panacea journal of medical sciences 2021;11(2):305–308 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article deciphering the diagnostic dilemma of abdominopelvic tuberculosis and advanced ovarian cancer anitha gandhi1,*, sundaram shanmugasundaram1, deepa shunmugam1 1dept. of surgical oncology, tirunelveli medical college hospital, tirunelveli, tamil nadu, india a r t i c l e i n f o article history: received 08-09-2020 accepted 15-02-2021 available online 25-08-2021 keywords: peritoneal tuberculosis ascites ca 125 abdominopelvic tuberculosis a b s t r a c t background: abdominopelvic tuberculosis often poses a diagnostic challenge due to its bizarre clinical features and inconclusive imaging features. most such patients were categorized under advanced ovarian cancer and undergo radical cytoreductive surgery with its associated morbidity, which would otherwise resolve spontaneously with medical management. materials and methods: this is a retrospective study of ten patients referred to the department of surgical oncology between november 2015 to october 2018 in a tertiary care centre at south tamil nadu, india as advanced ovarian cancer and later diagnosed to have tuberculosis. results: in 10 patients, the mean age was 34 years; mean ca125 was 496.6 iu/ml. abdominal pain and distension, loss of weight were seen in 70% of cases, respectively. only one patient had a prior history of tuberculosis. the imaging findings were complex adnexal mass in 9 patients (90%), ascites in 6 patients (60%) and omental stranding in 6 patients (60%). abdominal paracentesis was done in 6 patients (60%) and all had lymphocyte rich effusion. the diagnosis is established by laparotomy and biopsy in seven patients (70%), diagnostic laparoscopy in two patients (20%) and image-guided trucut biopsy in one patient (10%) with histopathology revealing caseating granulomas. conclusion: with our patients’ experience, a high index of suspicion is always needed whenever we encounter young women presenting with ascites, adnexal mass and elevated serum ca125 even when the routine investigations for tuberculosis reveal negative findings. the biopsy is the gold standard for establishing the diagnosis and to commence therapy. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction tuberculosis (tb) is a major public health issue worldwide. in 2017, 10 million people had tuberculosis and twothirdsof the cases were from eight countries, among which india ranks first (27%). abdominal tuberculosis involving peritoneum, gastrointestinal tract, genitourinary tract, lymph nodes and viscera accounts for 12% of extrapulmonary tuberculosis. 1 abdominopelvic tuberculosis often presents with non-specific features, leading to a delay in diagnosis and therapy commencement. * corresponding author. e-mail address: chenduronco2014@gmail.com (a. gandhi). it is essential to differentiate between the two entities as the management and prognosis are diverse with increased morbidity and mortality and reduced 5-year survival in advanced ovarian cancer at one end and good outcomes with medical therapy alone at the other end in patients with abdominopelvic tuberculosis. though immunocompromised status is a common risk factor for abdominopelvic tuberculosis, 12% of patients do not have any risk factors, thus increasing the diagnostic dilemma. the clinical symptoms and signs of abdominopelvic tuberculosis include pain in the abdomen, abdominal fullness, loss of appetite and weight, imaging revealing adnexal masses with or without peritoneal https://doi.org/10.18231/j.pjms.2021.062 2249-8176/© 2021 innovative publication, all rights reserved. 305 306 gandhi, shanmugasundaram and shunmugam / panacea journal of medical sciences 2021;11(2):305–308 nodules, and ascites omental nodules, and elevated serum ca125 levels 2,3 often lead to an alarming diagnosis of advanced ovarian cancer. only 10-15%% of ovarian cancers occur in premenopausal women with a peak incidence of ovarian cancers occurring between 65-75 years. whereas abdominopelvic tuberculosis is more common in women of 20-40 years of age, as depicted in many studies in the literature, our study is also similar. 4 early diagnosis is mandatory as a study by chow et al. 5 reported a mortality rate of 53% due to delay in obtaining mycobacterial culture reports. our study aims to highlight the importance of diagnosing abdominopelvic tuberculosis and to differentiate it from advanced ovarian cancer to avoid patients undergoing radical surgery with increased morbidity 2. materials and methods this is a case series of ten patients analyzed retrospectively at the department of surgical oncology, regional cancer centre, tirunelveli medical college, tirunelveli, tamil nadu, india. the study sample included all patients who presented with an adnexal mass, ascites and elevated serum ca125 and diagnosed as advanced cancer ovary elsewhere between november 2016 to october 2018. ethical clearance was obtained from the institutional review board. after obtaining consent from the patients included in the study, the patients’ demographic details, clinical presentations, laboratory parameters including ascitic fluid analysis and serum ca125 levels, imaging findings, diagnostic procedure, and pathology reports were analyzed. the diagnosis was established by histopathological examination of the biopsy specimen. all patients completed antituberculous therapy and are on followup. follow up included clinical examination and imaging if symptomatic. 3. results the patients’ age range was 27 to 45 years (mean 34 years). all patients in our study are parous women. none of them was immunocompromised. one patient had a previous history of tuberculosis. all patients had elevated serum ca125 except one patient ranging from 30.1 to 1101 iu/ml (mean 496.6 iu/ml) [normal value being less than 35 iu/ml]. the clinical symptoms and signs with which patients presented to us include abdominal distension due to ascites in 7 patients (70%), abdominal pain in 7 patients (70%), loss of weight in 7 patients (70%), loss of appetite in 5 patients (50%), mass abdomen in 4 patients (40%), fever in 1 patient (10%), vomiting in 1 patient (10%) and umbilical sinus with an ulcer in 1 patient (10%). (figure 1) fig. 1: clinical symptoms and signs the contrast-enhanced ct scan findings were complex adnexal mass in 9 patients (90%), ascites in 6 patients (60%), omental stranding in 6 patients (60%), peritoneal nodules in 4 patients (40%), loculated ascites in 1 patient (10%), mass in the rectovaginal plane in 1 patient (10%). abdominal paracentesis was done in 6 patients (60%) and all had lymphocyte rich effusion. (figure 2) fig. 2: ct scan findings chest x-ray was normal in 90% of patients. one patient had fibrotic change involving the right lung. contrast-enhanced ct chest of the same patient revealed bronchiectasis changes in the right middle lobe and left upper lobe and fibrotic changes involving the right lung. her sputum was negative for afb. none of our patients had contact history. six patients underwent laparotomy and biopsy since it was not possible to clinch the diagnosis with the investigations. repeated ascitic fluid cytology and ultrasound-guided fine-needle aspiration cytology were inconclusive and laparoscopy was deferred because of dense adhesions. the laparotomy findings were diffuse peritoneal thickening, dense adhesions of omentum and small intestines to the parietal wall, tubercles involving parietal and visceral peritoneum, nodules in the mesentery gandhi, shanmugasundaram and shunmugam / panacea journal of medical sciences 2021;11(2):305–308 307 of the small intestine, abdominal cocoon appearance, bilateral hydrosalpinx, loculated ascites, enlarged ovaries studded with tubercles, ovarian mass, omental caking one patient underwent complete staging laparotomy and primary cytoreduction as she had complex adnexal mass with normal serum ca 125; two patients underwent diagnostic laparoscopy of which one was converted to mini-laparotomy and biopsy, due to dense adhesions where even entry via palmers point was not possible. one patient underwent image-guided trucut biopsy from mass in the rectovaginal plane. all patients had histological evidence of granulomatous inflammation or caseating granulomas in some patients and were started on att as per the guidelines. all had symptomatic improvement and are disease-free presently. 4. discussion despite advances in the diagnostic and therapeutic armamentarium, tuberculosis is still on the rise in developing countries due to the increased incidence of hiv and the lack of appropriate implementation of health resources. the common predisposing factors to abdominopelvic tuberculosis include diabetes, hiv, cirrhosis, peritoneal dialysis, underlying malignancy, use of systemic steroids. 5,6 about 12% of cases have no risk factors. the most common route of spread is by reactivation of latent tuberculous foci in peritoneum reached by hematogenous spread from the pulmonary source. other routes include transmural spread from the infected small intestine or retrograde spread from tuberculous salpingitis. there is also a possibility of transmission by sexual intercourse with male partners infected with tuberculosis. peritoneal tuberculosis occurs in three forms: wet type with ascites, encysted type with localized abdominal swelling, and fibrotic type with abdominal masses composed of mesenteric and omental thickening. diagnosis is often difficult due to the lack of effective diagnostic tests and usually, abdominopelvic tuberculosis is a diagnosis of exclusion. patients presenting with complex adnexal mass and limited peritoneal disease confined to pelvis diagnosed as advanced ovarian cancer have to undergo staging laparotomy and cytoreductive surgery associated with some morbidity. it is better avoided when a preoperative clinching diagnosis is made the present study is an addition to the existing literature on the experience of misdiagnosis of abdominopelvic tuberculosis as advanced ovarian cancers. only 10% -15% of ovarian cancer occurs in premenopausal women, whereas abdominopelvic tuberculosis is common in women between 20 and 40. most of the patients in our study were between 20-40 years and none of the patients was nulliparous, which is often a risk factor for ovarian cancer. although the prior history of tuberculosis or tuberculosis history for a family member helps pinpoint the diagnosis, only < 30% will have a positive history. 5 in our study, only one patient had a prior history of tuberculosis. the clinical features include ascites (93%) and abdominal pain (73%), fever (58%). in our patients also, 70% had ascites and 70 % had abdominal pain as illustrated in other studies. because of insidious onset and non-specific clinical features, it requires a high index of suspicion. moreover, laboratory investigations are also not helpful to clinch the diagnosis of abdominopelvic tuberculosis. patients who presented with ascites should have the ascitic fluid analysis for cell count, afb staining & mycobacterial cultures. all 7 patients had exudative effusion. there was lymphocytic rich effusion in 6 out of 10 patients and none of them stained positive for ’afb in accord with data from sanai et al. in their systematic review. 7 moreover, the afb smear’s sensitivity is <2% and mycobacterial culture is <20% in ascitic fluid. 8–10 the utility of ascitic fluid pcr to diagnose peritoneal tuberculosis has not been well studied. out of 7 patients who had ascites, 5 patients with low serum ascites albumin gradient and 3 patients had elevated adenosine deaminase levels of 35, 39, and 40 iu/l. many authors have illustrated the usefulness of serum ascites albumin gradient of <1.1g/d revealing high sensitivity but with low specificity because of underlying liver or renal disease. similarly, though adenosine deaminase levels in the ascitic fluid have a sensitivity and specificity of >90% using cut off values from 36-40 iu/l in the diagnosis of abdominopelvic tuberculosis, this further warrants confirmation. 11 elevated serum ca 125 is non-specific in differentiating between benign and malignant conditions especially in premenopausal women since elevated levels are seen in many benign conditions, including endometriosis and pelvic inflammatory disease, fibroid uterus and diseases involving peritoneum like tuberculosis. serum ca 125 values of even up to 1000 iu/ml can be detected in these benign conditions, especially in endometriosis and abdominopelvic tuberculosis. one of the patients in our study had serum ca125 value of 1101 iu/ml. 12 although ct abdomen and pelvis provide information like mesenteric stranding, omental and peritoneal nodules, loculated ascites, hydrosalpinx, mesenteric lymphadenopathy, they are not pathognomonic. rather they are useful for directing the biopsy rather than confirming the diagnosis. to establish the diagnosis in patients with negative ascitic fluid analysis should undergo biopsy by either invasive or non –invasive technique. it is always preferable to do imageguided core needle biopsy whenever possible as it avoids unnecessary surgery and related morbidity in such patients. laparoscopy and biopsy are useful for establishing the diagnosis in abdominopelvic tuberculosis by visualization and biopsy for histopathological confirmation. 10,13–18 308 gandhi, shanmugasundaram and shunmugam / panacea journal of medical sciences 2021;11(2):305–308 presently, laparoscopy is becoming the choice method for differentiating tuberculosis from advanced ovarian cancer. but laparoscopy maybe sometimes difficult due to dense adhesions of the small intestine and omentum with parietal peritoneum. in such instances, mini-laparotomy has to be done. the preferable biopsy sites include enlarged mesenteric nodes, nodules in parietal or visceral peritoneum and omental nodules. moreover, port site tb’s risk is also a concern, though only case reports exist in the literature favouring port site tb. histopathological examination revealed caseating granulomas in all of our patients. the diagnostic criteria for abdominal tuberculosis as suggested by paustian include histology showing tubercles with caseating necrosis, suggestive operative findings, consistent histology from mesenteric lymph nodes, animal inoculation, or culture growth of mycobacterium tuberculosis, or histology showing acid-fast bacilli in the lesion. 19 but the applicability of these criteria is difficult for all cases. our study patients were started antituberculous therapy based on operative findings and histopathology evidence of granulomas. all patients completed the antituberculous regimen as per the guidelines and are disease-free presently, as evidenced by negative imaging and clinical improvement. 5. conclusion it is mandatory to have a high index of suspicion in young females presenting with ascites, adnexal mass and elevated serum ca 125. it is better to establish the diagnosis by non-invasive methods like core needle biopsy under image guidance whenever possible. early diagnosis and commencement of therapy will avoid unnecessary morbidities associated with misdiagnosis. 6. conflict of interest the authors declare that there are no conflicts of interest in this paper. 7. source of funding none. references 1. wu ch, changchien cc, tseng cw, chang hy, ou yc, lin h, et al. disseminated peritoneal tuberculosis simulating advanced ovarian cancer: a retrospective study of 17 cases. taiwan j obstet gynecol. 2011;50(3):292–6. doi:10.1016/j.tjog.2011.07.006. 2. wu dc, averbukh ld, wu gy. diagnostic and therapeutic strategies for peritoneal tuberculosis: a review. j clin transl hepatol. 2019;7(2):140–8. doi:10.14218/jcth.2018.00062. 3. elmore rg, li aj. peritoneal tuberculosis mimicking advancedstage epithelial ovarian cancer. obstet gynecol. 2007;110(6):1417–9. doi:10.1097/01.aog.0000295653.32975.4a. 4. djuwantono t, permadi w, septiani l, faried a, halim d, parwati i, et al. female genital tuberculosis and infertility: serial cases report in bandung, indonesia and literature review. bmc res notes. 2017;10(1):683. doi:10.1186/s13104-017-3057-z. 5. chow k, chow v, hung l, wong s, szeto c. tuberculous peritonitisassociated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. clin infect dis. 2002;35(4):409–13. 6. mehta jb, dutt a, harvill l. mathews km epidemiology of extrapulmonary tuberculosis. a comparative analysis with preaidsera. chest. 1991;99(5):1134–8. doi:10.1378/chest.99.5.1134. 7. sanai fm, bzeizi ki. systematic review: tuberculous peritonitise presenting features diagnostic strategies and treatment. aliment pharmacol ther. 2005;22(2):685–700. doi:10.1111/j.13652036.2005.02645.x. 8. debi u, ravisankar v, prasad kk. abdominal tuberculosis of the gastrointestinal tract: revisited. world j gastroenterol. 2014;20(40):14831–40. doi:10.3748/wjg.v20.i40.14831. 9. marshall jb. tuberculosis of the gastrointestinal tract and peritoneum. am j gastroenterol. 1993;88(7):989–99. 10. hillebrand dj, runyon ba, yasmineh wg, rynders gp. ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the united states. hepatology. 1996;24(6):1408–12. doi:10.1002/hep.510240617. 11. riquelme a, calvo m, salech f, valderrama s, pattillo a, arellano m, et al. value of adenosine deaminase (ada) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis. j clin gastroenterol. 2006;40(8):705–10. doi:10.1097/00004836200609000-00009. 12. bast rc, badgwell d, lu z, marquez r, rosen d, liu j, et al. new tumor markers: ca125 and beyond. int j gynecol cancer. 2005;15(3):274–81. 13. chow km, chow vc, hung lc. tuberculous peritonitisassociated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. clin infect dis. 2002;35(4):409–13. doi:10.1086/341898. 14. manohar a, simjee ae, haffejee aa, pettengell ke. symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period. gut. 1990;31(10):1130–2. doi:10.1136/gut.31.10.1130. 15. bhargava dk, shriniwas, chopra p. peritoneal tuberculosis: laparoscopic patterns and its diagnostic accuracy. am j gastroenterol. 1992;87(1):109–12. 16. tandon rk, sarin sk, bose sl. a clinico-radiological reappraisal of intestinal tuberculosis–changing profile? gastroenterol jpn. 1986;21(1):17–22. doi:10.1007/bf02775935. 17. singh mm, bhargava an, jain kp. tuberculous peritonitis. an evaluation of pathogenetic mechanisms, diagnostic procedures and therapeutic measures. n engl j med. 1969;281(20):1091–4. doi:10.1056/nejm196911132812003. 18. ribera e, vásque jmm, ocaña i, ruiz i, jimínez jg, encabo g, et al. diagnostic value of ascites gamma interferon levels in tuberculous peritonitis. comparison with adenosine deaminase activity. tubercle. 1991;72(3):193–7. doi:10.1016/0041-3879(91)90007-f. 19. harshal s, mandavdhare h, singh. vishal sharma recent advances in the diagnosis and management of abdominal tuberculosis. emj gastroenterol. 2017;6(1):52–60. author biography anitha gandhi, assistant professor sundaram shanmugasundaram, professor and head deepa shunmugam, assistant professor cite this article: gandhi a, shanmugasundaram s, shunmugam d. deciphering the diagnostic dilemma of abdominopelvic tuberculosis and advanced ovarian cancer. panacea j med sci 2021;11(2):305-308. http://dx.doi.org/10.1016/j.tjog.2011.07.006 http://dx.doi.org/10.14218/jcth.2018.00062 http://dx.doi.org/10.1097/01.aog.0000295653.32975.4a http://dx.doi.org/10.1186/s13104-017-3057-z http://dx.doi.org/10.1378/chest.99.5.1134 http://dx.doi.org/10.1111/j.1365-2036.2005.02645.x http://dx.doi.org/10.1111/j.1365-2036.2005.02645.x http://dx.doi.org/10.3748/wjg.v20.i40.14831 http://dx.doi.org/10.1002/hep.510240617 http://dx.doi.org/10.1097/00004836-200609000-00009 http://dx.doi.org/10.1097/00004836-200609000-00009 http://dx.doi.org/10.1086/341898 http://dx.doi.org/10.1136/gut.31.10.1130 http://dx.doi.org/10.1007/bf02775935 http://dx.doi.org/10.1056/nejm196911132812003 http://dx.doi.org/10.1016/0041-3879(91)90007-f panacea journal of medical sciences 2021;11(3):503–506 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article thyroid disorders in patients with dysfunctional uterine bleeding ajit kumar nayak1,* 1dept. of obstetrics & gynaecology, fakir mohan medical college & hospital, balasore, odisha, india a r t i c l e i n f o article history: received 12-07-2021 accepted 06-09-2021 available online 24-11-2021 keywords: dysfunctional uterine bleeding hypothyroidism hyperthyroidism thyroid disorder a b s t r a c t thyroid hormone plays an important role in the regulation of menstrual cycle in women. thyroid dysfunctions are frequently associated with dysfunctional uterine bleeding which is a type of abnormal uterine bleeding in absence of organic disease of the genital tract. this hospital based prospective study was carried out on 150 women in different age groups who presented with dysfunctional uterine bleeding in the department of obstetrics & gynecology, f.m. medical college & hospital, balasore, odisha over a period of one year. thyroid function test was done and was correlated with abnormal bleeding patterns and endometrial histopathological study. out of 150 patients with dysfunctional uterine bleeding, 27 (18%) had hypothyroidism, 2(1.33%) had hyperthyroidism and 121(80.67%) were euthyroid. majority i.e. 96 (64%) were in the age group of 26-35 years, out of which 21(21.87%) had hypothyroidism and one (1.04%) was hyperthyroid. menorrhagia and metrorrhagia were the most common pattern of menstrual irregularities noticed among the patients having hypothyroidism (81.48%) . 52.04%, 30.62% and 17.34% patients had proliferative pattern, secretory pattern and endometrial hyperplasia respectively. 21.5% of proliferative endometrium, 23.33% of secretory endometrium and 17.64% of endometrial hyperplasia were seen in histopathological study of patients having hypothyroidism. most of the patient with hypothyroidism i.e. 70.37% had normal endometrial thickness found during pelvic ultrasonography. prevalence of thyroid disorders particularly hypothyroidism is quite common in patients having dysfunctional uterine bleeding. therefore, thyroid function test should be done in all patients with menstrual irregularities to avoid unnecessary hormonal treatment and surgical intervention. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction dysfunctional uterine bleeding (dub) is a quite common gynecological problem. menorrhagia, metrorrhagia, polymenorrhoea, polymenorrhagia and oligomenorrhoea are the common menstrual pattern seen in patients with dub. thyroid dysfunction in women has been implicated in broad spectrum of menstrual disorders. 1 both hypothyroidism and hyperthyroidism may result in menstrual disturbances. increased menstrual flow found to be the most common reproductive system manifestation * corresponding author. e-mail address: ajitnayak_og@yahoo.co.in (a. k. nayak). of hypothyroidism. the menstrual irregularities in hypothyroidism are attributed to multiple factors like high tsh levels or altered gnrh pulses from hypothalamus causing decrease in pituitary gonadotropin secretion or defect in luteinizing hormone secretion with persistent follicle-stimulating hormone secretion. this results in chronic anovulation in hypothyroidism or luteal phase defects in less severe cases. hypothyroidism also alters the peripheral metabolism of estrogen and decreases shbg production, causing rise in serum estrogen level. this, in turn, causes abnormal feedback at the pituitary level. aim and objective of the study was to find out prevalence of various thyroid disorders in patients with dysfunctional https://doi.org/10.18231/j.pjms.2021.098 2249-8176/© 2021 innovative publication, all rights reserved. 503 504 nayak / panacea journal of medical sciences 2021;11(3):503–506 uterine bleeding and to correlate with abnormal bleeding patterns and histopathological study of endometrium. 2. materials and methods this hospital based, prospective study was carried out in the department of obstetrics & gynaecology, f.m. medical college & hospital, balasore, odisha over a period of one year from december 2019 to november 2020. 150 patients with dub in the age group of 15 to 40 years were enrolled in the study. dub was diagnosed among cases of abnormal uterine bleeding on the basis of history, clinical examination including abdomino-pelvic examination, relevant laboratory investigations and ultrasonography. detail menstrual history was taken and the menstrual abnormalities like menorrhagia, metrorrhagia, polymenorrhagia and puberty menorrhagia were noted. pelvic ultrasonography including measurement of endometrial thickness was done in all cases. histopathological study of endometrium was done in indicated cases. women on intrauterine contraceptive device or with organic lesion in genital tract like polyp, fibroid, blood dyscrasias, etc., or with history of taking steroid medication were excluded from the study. also, patients on drugs that raise the thyroid hormone concentration like tamoxifen, amiodarone, propranolol, glucocorticoids, lithium and potassium iodide were exempted from the study. after obtaining informed written consent, blood samples were collected and sent to the central laboratory for estimations of thyroid profile i.e. serum tsh, t3 and t4. thyroid function tests were done by chemiluminescence assay. thyroid function test results were correlated with menstrual irregularities and histopathological study of endometrium. statistical analysis of the data was performed by using microsoft excel software. 3. results out of 150 patients with dysfunctional uterine bleeding (dub), 29 patients (19.33%) found to have thyroid disorders. 27 patients(18%) had thyroid profile in hypothyroid range and 2 patients(1.33%) had hyperthyroidism. 121 patients (80.67%) with dub had normal thyroid function test [table 1]. majority i.e. 96 patients (64%) with dub were in the age group of 26-35 years, out of which 21 patients (21.87%) had hypothyroidism and one patient (1.04%) had hyperthyroidism. out of 12 patients (8%) who were in the age group of 36-40 years, 3 patients (25%) had hypothyroidism and one patient (8.34%) had hyperthyroidism. 42 patients (28%) were in the age group of 16-25 years, out of which 3 patients(7.14%) were found to be in hypothyroid state [table 2]. out of 150 patients with dub, 81 patients (54%) had menorrhagia, 25(16.67%) had polymenorrhagia, 36(24%) had metrorrhagia and 8(5.33%) had pubertal menorrhagia. among the patients having menorrhagia 17(20.99%) had hypothyroidism and 1(1.23%) had hyperthyroidism. among the patients having polymenorrhagia, thyroid profile of 3 patients (12%) revealed hypothyroidism. among patients having metorrhagia type of bleeding 5(13.88%) were found to have hypothyroidism and 1(2.78%) had hyperthyroidism. among patients presented with puberty menorrhagia 2(25%) were found to have hypothyroidism and no one had hyperthyroidism [table 3]. out of 150 patients presented with dub, d & c with endometrial biopsy was done for 98 cases. histopathological examination (hpe) study of endometrium revealed proliferative pattern in 51 patients (52.04%), secretory pattern in 30 patients (30.62%) and endometrial hyperplasia in 17 patients (17.34%). out of 51 patients with proliferative endometrium, 11 (21.57%) had hypothyroidism. among 30 patients with secretory endometrium, 7 (23.33%) were in hypothyroid state and 1 (3.33%) had hyperthyroidism. among 17 patients with endometrial hyperplasia, 3 (17.64%) had hypothyroidism and 1 (5.88%) had hyperthyroidism [table 4]. during pelvic ultrasonography, an endometrial thickness was measured for all patients having dub. out of 108 patients who had normal endometrial thickness (8-14mm), 19 (17.59%) were having hypothyroid range of thyroid profile and 1(0.93%) with hyperthyroid range.42 patients were having thickened endometrium (>14mm), among them 8(19.04%) had hypothyroidism and 1 (2.39%) had hyperthyroidism [table 5]. 4. discussion present study revealed out of 150 patients with dysfunctional uterine bleeding (dub), 29 patients (i.e. 19.33%) found to have thyroid disorders. whereas, kattel p et al reported dub accounted for 30.4% of thyroid dysfunction. 2 in the present study, thyroid profile of 18% of patients with dub revealed hypothyroidism, 1.33% had hyperthyroidism and 80.67% were euthyroid. ajmani n.s. et al reported hypothyroidism in 34% and hyperthyroidism in 8% of women with menstrual disorders. 3 jinger s k et al found that 39% of patients with dub were hypothyroid, 8% had hyperthyroidism and 53% were euthyroid. 4 thakur m et al found that 13.9% patients with abnormal bleeding were hypothyroid, 1.2% had hyperthyroidism and 84.9 % were euthyroid. 5 subedi s et al reported hypothyroidism in 9.3% patients and hyperthyroidism in 1.3% patients with dub. 6 in this study, 64% patients with dub were in the age group of 26-35 years, 28% were in the age group of 16-25 years and 8% were between 36 40 years of age. subedi s et al reported 53.33% of patients with abnormal bleeding were between the age group of 35-45 years followed by 33.33% between the age group of 25-34 years. 6 patel s b nayak / panacea journal of medical sciences 2021;11(3):503–506 505 table 1: thyroid profile among patients with dub (n=150) no of patients hypothyroidism hyperthyroidism euthyroid 150 27(18%) 2(1.33%) 121(80.67%) table 2: age distribution of patients with dub in relation to thyroid profile age (years) no of patients (%) hypothyroidism hyperthyroidism euthyroid 16-20 12(8%) 2(16.66%) 0 10(83.34%) 21-25 30(20%) 1(3.33%) 0 29(96.67%) 26-30 51(34%) 11(21.56%) 0 40(78.44%) 31-35 45(30%) 10(22.23%) 1(2.22%) 34(75.55%) 36-40 12(8%) 3(25%) 1(8.34%) 8(66.66%) total 150 27 2 121 table 3: analysis of abnormal bleeding pattern in relation to thyroid status patterns of dub no of patients hypothyroidism hyperthyroidism euthyroid menorrhagia 81(54%) 17(20.99%) 1(1.23%) 63(77.78%) polymenorragia 25(16.67%) 3(12%) 0 22(88%) metrorrhagia 36(24%) 5(13.88%) 1(2.78%) 30(83.34%) pubertal menorrhagia 8(5.33%) 2(25%) 0 6(75%) total 150 27 2 121 table 4: correlation between endometrial hpe study and thyroid dysfunction (n=98) endometrial histopathology no of patients hypothyroidism hyperthyroidism euthyroid proliferative 51(52.04%) 11(21.57%) 0 40(78.43%) secretory 30(30.62%) 7(23.33%) 1(3.33%) 22(73.34%) endometrial hyperplasia 17(17.34%) 3(17.64%) 1(5.88%) 13(76.48%) table 5: endometrial thickness in relation to thyroid disorders endometrial thickness no of patients hypothyroidism hyperthyroidism euthyroid 8-14 mm (normal) 108 19(17.59%) 1(0.93) 88(81.48%) >14mm (thickend) 42 8(19.04%) 1(2.39%) 33(78.57%) total 150 27 2 121 et al reported 46% patients with abnormal bleeding were in the age group of 21 to 30 years. 7 whereas, doifode and fernandes reported maximum number of patients belonged to age group of 31 to 40 years. 8 in the present study, majority i.e. 21 out of 27 patients (77.8%) having dub suffering from hypothyroidism were between the age group of 26-35 years. according to gouri m et al most common age group for dub was 26-30 years (22%). 9 verma s k et al reported 38.4% of dub with hypothyroidism were between the age group of 31-40 years. 10 in the present study, menorrhagia was the most common complaint among the patients with dub. majority of patients i.e. 17 out of 27 (62.96%) having dub with hypothyroidism had menorrhagia, followed by metrorrhagia (18.51%). verma s k et al reported menorragia and metrorrhagia combinedly constituted 58.95% of the abnormal menstrual pattern in patients with hypothyroidism. 10 according to krishnaveni m the type of menstrual abnormality commonly seen in hypothyroidism was menorrhagia (63.33%). 11 jadab k p et al reported that most common menstrual abnormality was menorrhagia (48%) followed by metrorrhagia and polymenorrhoea (14% each). 12 singh l et al found that 44.4% cases with hypothyroidism presented with menorrhagia. 13 douglas et al observed that 22.3% cases with menorrhagia had subclinical hypothyroidism. 14 among two of our dub patients with hyperthyroidism one had menorragia and other had metrorrhagia. our study revealed 21.57% of proliferative endometrium, 23.33% of secretory endometrium and 17.64 % of hyperplastic endometrium in patients with dub having hypothyroidism.3.33% of secretory endometrium and 5.88% of hyperplastic endometrium were seen among our hyperthyroid patients. sharma et al reported 36.36% of proliferative endometrium, 36.36% of secretory 506 nayak / panacea journal of medical sciences 2021;11(3):503–506 endometrium and 27.27% of atrophic endometrium in women with abnormal bleeding having hypothyroidism. 15 he also reported 42.84% of proliferative endometrium, 28.56% of secretory endometrium and 14.28% hyperplastic endometrium in his histopathological examination study in hyperthyroid patients. 15 kaur t et al observed that 64.3% of dub with hypothyroidism had proliferative endometrium, 14.3% had secretory endometrium and 21.4% had endometrial hyperplasia. 16 5. conclusion to conclude our study, we found thyroid disorder particularly hypothyroidism is a common endocrine problem in patients with dysfunctional uterine bleeding. most common age group affected was in between 26-35 years. menorrhagia, metrorrhagia and polymenorragia were the common menstrual irregularities encountered in patients with dub. so all patients presenting with dub should be subjected to thyroid function test in addition to routine hematological investigations, ultrasonography of pelvis and endometrial histopathology study in indicated cases. timely diagnosis and treatment of thyroid disorders in patients with dub can prevent unnecessary surgical intervention and its complications. 6. acknowledgement i am very much thankful and highly obliged to all the doctors and staffs of the department of obstetrics & gynaecology, f.m medical college & hospital, balasore, odisha for their active involvement while conducting this research study. 7. sources of funding no financial support was received for the work within this manuscript. 8. conflicts of interest no conflicts of interest. references 1. pahwa s, gupta s, kaur j. thyroid disorder in dysfunctional uterine bleeding. j adv res med sci. 2013;5(1):78–83. 2. kattel p, baral g. thyroid function test in abnormal uterine bleeding. nepal j obstet gynecol. 2018;12(2):74–8. 3. ajmani ns, sarbhai v, yadav n, paul m, ahamad a, ajmani ak, et al. role of thyroid dysfunction in patients with menstrual disorders in tertiary care centre of walled city of delhi. j obstet gynecol india. 2016;66(2):115–9. 4. jinger sk, verma a, dayma i, talreja t. to study the thyroid profile in menstrual disorder at tertiary care hospital in north west rajasthan. int j res med sci. 2017;5(5):2212–4. 5. thaku m, maharjan m, tuladhar h, dwa y, bhandari s, maskey s, et al. thyroid dysfunction in patients with abnormal uterine bleeding in a tertiary care hospital: a descriptive cross-sectional study. j nepal med assoc. 2020;58(225):333–7. 6. subedi s, banerjee b, manisha c. thyroid disorders in women with dysfunctional uterine bleeding. j pathol nepal. 2016;6(12):1018–20. doi:10.3126/jpn.v6i12.16253. 7. patel sb, delvadia jl, desai da. clinicopathological and endocrinal correlation in cases of menstrual disturbances. nhl j med sci. 2012;1(1):14–7. 8. doifode cd, fernandes k. study of thyroid dysfunction in patients with dysfunctional uterine bleeding. j obstet gynaecol india. 2001;51(2):93–5. 9. gouri m, radhika bh, harsini v, ranajaha r. role of thyroid function tests in women with abnormal bleeding. int j reprod contracept obstet gynecol. 2014;3(1):54–7. 10. verma sk, pal a, jaswal s. a study of thyroid dysfunction in dysfunctional uterine bleeding. int j reprod contracept obstet gynecol. 2017;6(5):2035–9. 11. krishnaveni m. evaluation of thyroid disorder in abnormal uterine bleeding with ovulatory dysfunction (aub-o). int j sci stud. 2019;7(9):69–75. 12. jadab kp, gautam ks, rohini g. thyroid status in patients with dysfunctional uterine bleeding in a tertiary care hospital of assam. indian j med biochem. 2016;20(1):11–5. 13. singh l, agarwal cg, choudhury sr, mehra p, khare r. thyroid profile in infertile patients. j obstet gynaecol india. 1990;40:248–53. 14. douglas lw, bernard g. early hypothyroidism in patients with menorrhagia. am j obstet gynecol. 1990;163(2):697–2. doi:10.1016/0002-9378(90)91261-a. 15. sharma n, sharma a. thyroid profile in menstrual disorders. jk sci. 2012;14(1):14–7. 16. kaur t, aseeja v, sharma s. thyroid dysfunction in dysfunctional uterine bleeding. webmed central obstet gynaecol . 2011;2(9):1–7. author biography ajit kumar nayak, associate professor & unit head cite this article: nayak ak. thyroid disorders in patients with dysfunctional uterine bleeding. panacea j med sci 2021;11(3):503-506. http://dx.doi.org/10.3126/jpn.v6i12.16253 http://dx.doi.org/10.1016/0002-9378(90)91261-a panacea journal of medical sciences 2021;11(2):326–330 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article antibiotic susceptibility of bacterial strains and bacteriological profile from patients with lower respiratory tract infections in a teaching hospital ritu vaish1,* 1dept. of microbiology, prathima institute of medical sciences, nagunuru, karimnagar, telangana, india a r t i c l e i n f o article history: received 12-12-2020 accepted 29-12-2020 available online 25-08-2021 keywords: lrti bacteriological profile antibiotic susceptibility a b s t r a c t background: lower respiratory tract infections (lrti) are one of the commonest health problems demanding frequent consultation and hospitalization. unnecessary and inappropriate initial antibiotic therapy is a potentially modifiable factor that is associated with increased mortality in patients with serious infections. aim of the study: to study bacterial profile and susceptibility pattern of lower respiratory tract infections in a teaching hospital. materials and methods: prospective study done in the department of microbiology at prathima institute of medical sciences, nagunuru, karimnagar, telangana., tover a period of 18 months ie from january 2019 to july 2020. a total of 120 samples from respiratory tract were studied for bacterial isolates and antibiotic susceptibility. results: a total of 120 cases were studied. the male to female ratio was 2:1. among the bacterial isolates, 76.6% were gram negative bacilli and 23.3% were gram positive cocci. among gram negative bacteria, the predominant bacterial isolate was klebisella. pneumoniae (45.8%) followed by pseudomonas. aeruginosa (28.3%.) conclusion: present study, was based on the pattern of resistance to commonly used antibiotics by organisms causing lower respiratory tract infections (lrtis) in our institute. this may help us to study the more susceptible group of drugs in our institute which would help prepare an antibiogram and develop a policy for rational antibiotic prescription. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction lower respiratory tract infections (lrtis) are one of the serious communicable diseases and the 3rd leading cause of death globally, after ischaemic heart and cerebrovascular diseases. 1 in developing countries management of lrtis is difficult in both children 2 and adults, 3 especially due to the issues associated with identification of the etiological agents and selection of appropriate antibiotics. lrtis in adults include lower respiratory tract infections, acute bronchitis, influenza, * corresponding author. e-mail address: rituvaish@gmail.com (r. vaish). suspected or definite community-acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease (copd) and bronchiectasis. 4 the etiological agents of lrtis cannot be determined clinically and differ from area to area. 5 gram-positive bacteria such as staphylococcus aureus, streptococcus pneumonia, etc. as well as gramnegative bacteria such as haemophilus influenzae, pseudomonas, acinetobacter, and klebsiella species are recovered from lrtis. 5,6 https://doi.org/10.18231/j.pjms.2021.066 2249-8176/© 2021 innovative publication, all rights reserved. 326 vaish / panacea journal of medical sciences 2021;11(2):326–330 327 2. aim of the study to study the bacteriological profile and susceptibility pattern of lower respiratory tract infections in a teaching hospital in karimnagar, telangana 3. materials and methods the study was approved by the institutional ethics committee. written informed consent was obtained from all the cases included in the study. a written informed consent was obtained from all the participants included in the study. there were no ethical issues involved prospective study done in in the department of microbiology at prathima institute of medical sciences, nagunuru, karimnagar, telangana. over a period of 18 months from january 2019 to july 2020. there were a total of 220 cases of suspected lrti of which 120 were studied. 3.1. inclusion criteria 1. patients who were willing to participate in the study. 2. age from 5 year to 75 years. 3. both genders 4. patients clinically suspected for lrtis. 5. positive culture. 3.2. exclusion criteria 1. patients who were unwilling to participate in the study. 2. patients suffering from tuberculosis. 3. patients who had received antibiotics before sputum could be sent for culture and sensitivity. 3.3. methodology the patients with lower respiratory tract infections visiting the department of pulmonology were selected based upon the above criteria. a proper detailed clinical history was taken. all the relevant investigations were done including routine investigations such as hemogram, complete urine examination, and relevant biochemical investigations. findings were recorded in a predesigned proforma. the procedure for collection of sputum samples was instructed to the patients in the department of microbiology. the sputum samples were collected into well labelled sterile, wide mouthed glass bottles with screw cap tops. tracheal and bronchial alveolar fluid samples were sent from the department of pulmonology immediately without any delay, to the microbiology laboratory. bacterial culture and antimicrobial susceptibility testing were done. the sputum samples were inoculated onto blood agar plates, chocolate agar plates and macconkey agar plates. blood agar plates and macconkey agar plates were incubated aerobically at 37-degree celsius for 24 hours. the inoculums on the plate were streaked with a sterile wire loop and observed for growth of colonies while chocolate agar plates were incubated in an atmosphere containing extra carbon dioxide in candle jar. all the bacteria were isolated and identified using morphology, microscopy. 3.4. antimicrobial susceptibility testing antimicrobial susceptibility testing was performed by modified kirby bauer method as per the clinical laboratory standards institute (clsi) guidelines. 7,8 for gram negative organisms, antibiotics tested were ampicillin (amp), piperacillin (pc), amoxycillin-clavulanic acid (amc), ampicillin-sulbactam (as), ceftriaxone (ctr), cefotaxime (ctx), ceftazidime (caz), cefoxitin (cn), cefepime (cpm), piperacillintazobactam (pt), gentamicin (gm), amikacin (ak), imipenem (imp), meropenem (mrp), ciprofloxacin(cip) and trimethoprimsulphamethoxazole (cot). for gram positive organisms, antibiotics tested were penicillin (p), amoxycillin-clavulanic acid (amc), ceftriaxone (ctr), cefoxitin (cn), erythromycin (er), clindamycin (cd), vancomycin (va), linezolid (lz), gentamicin (gm), amikacin (ak), ciprofloxacin (cip). the antibiogram of each confirmed isolate was studied and the susceptibility results were compiled. 4. observations and results a total of 220 samples were collected and screened, of which 120 were pathogenic. data was made for these120 cases. table 1: age distribution age distribution in years no. of cases percent (%) 5-15 02 1.6% 16-25 03 2.5% 26-35 08 6.6% 36-45 24 20% 46-55 41 34.1% 56-65 27 22.5% 66-75 15 12.5% total 120 100% in the present study age distribution ranged from 5 years to 75 years. most common age group affected was between 46-55 years, followed by 22.5% among 56 – 65 years. in the present study males 66.6% (80/120) were predominant when compared to females 33.3% (40/120) and the male to female ratio was 2:1. 328 vaish / panacea journal of medical sciences 2021;11(2):326–330 4.1. distribution of clinical features the common clinical features were fever in 25 (20.8%) cases, cough in 30 (25%) cases, fever and cough in 40 (33.3%) cases, breathlessness in 10 (8.3%) cases, chest pain in 5 (4.1%) cases, and myalgia in 10 (8.3%) cases. pneumonia 54.1% (65/120) cases was the most common clinical diagnosis in our study followed by bronchiectasis in 29.1% (35/120) cases and 16.6% (20/120) constituted bronchial asthma. fig. 1: types of samples in the present study, sputum swabs constituted 45% (54/120), pleural fluid 8.3% (10/120), tracheal aspirate 25%(30/120), bronchoalveolar fluid 16.6% (20/120) and endotracheal tube secretions constituted 5%(06/120) samples. table 2: distribution of bacterial isolates bacterial isolates no. of cases percent (%) klebsiella pneumoniae 55 45.8% pseudomonas aeruginosa 34 28.3% e.coli 03 2.5% staphaloccocus aureus 10 8.3% streptococcus pneumoniae 18 15% total 120 100% in the present study, among the bacterial isolates76.6% (92/120) were gram negative bacilli and 23.3% (28/120) were gram positive cocci. among gram negative bacteria, the predominant bacteria isolated was k.pneumoniae 45.8% followed by p.aeruginosa 28.3% and 2.5% e.coli. among gram positive bacteria, streptococcus pneumoniae 12.5% were predominant cooci isolated and s.aureus constituted 8.3%, followed by enterococci 5%. in the present study, k. pneumoniaewas the most common prevalent bacteria with a susceptibility of 90% to ceftazidime+clavulanate, 82% to ceftriaxone, ciprofloxacin 56%, gentamicin 76%, imipenem 80%, piperacillin+tazobactum 90%, vancomycin 68%, erythromycin 72%, linezolid 66%, cot 70%, tetracyclines 66%. p.aeruginosa showed a susceptibility of 92% to ceftazidime+clavulanate, 88% to ceftriaxone, ciprofloxacin 60%, gentamicin 80%, imipenem 92%, piperacillin+tazobactum 92%,ampicillin; 78%, linezolid 68%, cot 70%, tetracyclines 72%. amongst the gram-positive cocci, streptococcus pneumoniae showed susceptibility of 90% to ceftriaxone, ciprofloxacin 72%, gentamicin 70%, imipenem 88%, piperacillin+tazobactum 78%, vancomycin 78%, erythromycin 80%, ampiciilin 78% linezolid 70%, cot 76%, tetracyclines 60%. v staphylococcus aureus strains had susceptibility of 92% to ceftazidime+clavulanate, 86% to ceftriaxone, ciprofloxacin 70%, cefoxitin 82%, gentamicin 76%, imipenem 80%, piperacillin+tazobactum 90%, vancomycin 80%, erythromycin 82%, ampicillin 80%, linezolid 82%, cot 78%, tetracyclines 80%. 5. discussion 5.1. comparative studies related to age distribution in the present study, age distribution varied from 5 to 75 years. most common age group was between 46-55 years with a mean age of 48 years, followed by 22.5% among 5665 years. this was compared with other studies. in the study by tchatchouang s et al 9 the patient age ranged from 18 to 94 years with a median age of 50 years. in the study by nurahmed n et al 10 the mean age of was 38±14 years, and the highest proportion of participants was in the age range of 18–27 years (31.1%), followed by the age range 28–37 years (22.1%). 5.2. comparative studies related to gender distribution in the present study, males were predominant when compared to females and the male: female ratio was 2:1. similar findings were observed by tchatchouang s et al 9 where they also observed the male predominance and male/female sex ratio of 1.8. nurahmed n et al 10 noted slight female predominance in their study with 112 males and 128 females. 5.3. comparative studies related to clinical features in our study, the most predominant clinical symptom was cough with fever that constituted about 33.3%, next common was only cough 25%, then fever 20.8%, chest pain in 4.1%, breathlessness in 8.3% and myalgia in 8.3% cases. tchatchouang s et al 9 in their study observed the most predominant symptoms as cough (87.2%), dyspnoea (85.8%), breathlessness (83%), asthenia (75.9%), fever (63.8%), chest pain (60.3%), and myalgia (42.6%). 5.4. comparative studies related to site of swabs in the present study, among 120 samples collected, sputum swabs constituted 45%, pleural fluid 8.3%, tracheal aspirates 25%, bronchoalveolar fluid 16.6%, and endotracheal tube secretions were 5%. in a study done vaish / panacea journal of medical sciences 2021;11(2):326–330 329 table 3: distribution of antibiotic susceptibility of bacterial isolates antibiotics klebsiella pneumonia psuedomonas aeruginosa streptococcus pneumonia staphylococcus aureus ceftazidime+clavulanate 90% 92% na 92% ceftriaxone 82% 88% 90% 86% ciprofloxacin 56% 60% 72% 70% cefoxitin na na na 82% gentamicin 76% 80% 70% 76% imipenem 80% 92% 88% 80% piperacillin+tazobactum 90% 92% 78% 90% vancomycin 68% na 78% 80% erythromycin 72% na 80% 82% ampicillin; na 78% 78% 80% linezolid 66% 68% 70% 82% cot 70% 70% 76% 78% tetracyclines 66% 72% 60% 80% by sarmahn et al 11 among the 1376 samples included, there were tracheal aspirate (87), sputum (1101), throat swabs (168) and bronchoalveolar lavage (20). whereas manikandan et al 12 included 225 (90.7%) sputum samples and 112 (33.2%) throat swab samples. 5.5. comparative studies related tobacterial isolates in the present study, among the bacterial isolates 74.1% (89/120) were gram negative bacilli isolatedand 25.8% (31/120) were gram positive cocci. among gram negative bacteria (gnb), the predominant bacterial isolated was k.pneumoniae 45.8% followed by p.aeruginosa 28.3%. among gram positive bacteria streptococcus pneumoniae 12.5% were predominant cooci isolated and s.aureus constituted 8.3%,followed by enterococci 5%. in the study by regha ir et al 13 among the bacterial isolates 244 (84.7%) were gnb and remaining 44 (15.3%) were gram positive cocci. the predominant pathogen isolated was k.pneumoniae (31.1%) followed by p.aeruginosa (30.2%). among gram positive bacteria, s.aureus (4.5%) and strp.pyogenes (4.5%) were predominant organisms followed by enterococci (4.2%). in manikandan et al study 12 the most common organism isolated was streptococcus pneumoniae (36%), klebsiella pneumoniae (28.4%), staphylococcus aureus (24%), pseudomonas aeruginosa (11%) and escherichia coli (0.6%).the gram positive cocci constituted 202 (60%) while gram negative bacilli constituted 135 (40%) of the total isolates. nurahmed n et al 10 reported the prevalence of k. pneumoniae was the highest [32 (39.5%)], followed by s. pneumoniae [15(18.5%)], ecoli [13(16%)], and citrobacter [7(8.6%)]. 5.6. comparative studies related to antimicrobial sensitivity in the present study, k. pneumonia was the most common prevalent bacteria with a susceptibility of 90% to ceftazidime+clavulanate. streptococcus pneumoniae showed susceptibility of 90% to ceftriaxone, staphylococcus aureus strains showed susceptibility of 92% to ceftazidime+clavulanate andvancomycin 80%. regha ir et al 13 observed gram positive organisms with highest sensitivity towards vancomycin followed by linezolid. all (100%) of strp.pyogenes and strp.pneumoniae were sensitive to penicillin. sarmah n et al 11 observed that k. pneumoniae exhibited a higher sensitivity towards polymixin b and tigecycline. gram positive organisms on the other hand showed 100% susceptibility to vancomycin and linezolid followed by high susceptibility to teicoplanin. nurahmed n et al 10 noted most effective antibiotic for k. pneumoniae to be meropenem, with 100% sensitivity (32/32). manikandan et al 12 observeds. pneumoniae was the most prevalent bacteria with a susceptibility of 98% to amikacin. the susceptibility profile of s. aureus was 97% to amikacin.k. pneumoniae was the second most prevalent bacteria with a susceptibility of 95% to amikacin. p. aeruginosa had a susceptibility profile of 87% to amikacin. 6. conclusion present study, was based on the pattern of resistance to commonly used antibiotics by organisms causing lower respiratory tract infections (lrtis) in our institute. this may help us to study the more susceptible group of drugs in our institute which would help to prepare an appropriate antibiogram for rational antibiotic prescription. 7. limitations the present study has a number of limitations, and to appreciate the findings, some issues need to be addressed as small sample size of the study. a distinction between community-acquired and hospital-acquired infections could not be made. resultant morbidity and mortality was not 330 vaish / panacea journal of medical sciences 2021;11(2):326–330 analysed in study. 8. conflict of interest the authors declare that there are no conflicts of interest in this paper. 9. source of funding none. references 1. world health organization (who). the top 10 causes of death. geneva: who; 2017. available from: http://www.who.int/ mediacentre/factsheets/fs310/en/. 2. niederman ms, krilov lr. acute lower respiratory infections in developing countries. lancet. 2013;381(9875):1341–42. 3. khan s, priti s, ankit s. bacteria etiological agents causing lower respiratory tract infections and their resistance patterns. iran biomed j. 2015;19(4):240–6. 4. woodhead m, blasi f, ewig s, garau j, huchon g, ieven m, et al. guidelines for the management of adult lower respiratory tract infections. eur respir j. 2005;26:1138–80. doi:10.1183/09031936.05.0005570. 5. ozyilmaz e, akan oa, gulhan m, ahmad k, nagatake t. major bacteria of community-acquired respiratory tract infections in turkey. jpn j infect dis. 2005;58(1):50–2. 6. erling v, jalil f, hanson la, and sz. the impact of climate on the prevalence of respiratory tract infection in early childhood in lahore. pakistan j pub health. 1999;21(3):331–9. doi:10.1093/pubmed/21.3.331. 7. bauer aw, kirby wm, sherris jc, turck m. antibiotic susceptibility testing by a standardized single diskmethod. am j clin pathol. 1966;45(4):493–6. 8. clinical and laboratory standard institute 2012: performance standard for antimicrobial susceptibility testing: twenty second informational supplement. clsi document m100. 2012;32(3):22. 9. tchatchouang s, nzouankeua, kenmoe s, ngando l, penlap v, fonkoua mc, et al. bacterial aetiologies of lower respiratory tract infections among adults in yaoundé, cameroon. biomed res int. 2019;doi:10.1155/2019/4834396. 10. nurahmeda n, kedira s, fantahunb s, getahunc m, mohammedd a, mohammeda a, et al. bacterial profile and antimicrobial susceptibility patterns of lower respiratory tract infection among patients attending selected health centers of addis ababa, ethiopia . egypt j chest dis tuberc. 2020;doi:10.4103/ejcdt.ejcdt_68_19. 11. sarmah n, sarmah a, das dk. a study on the microbiological profile of respiratory tract infection (rti) in patients attending gauhatimedical college & hospital. aimdr ann int med dental. 2016;available from: https://pesquisa.bvsalud.org/portal/resource/pt/ sea-177811. 12. manikandan c, amsath a. antibiotic susceptibility of bacterial strains isolated from patients with respiratory tract infections. int j pure appl zool. 2013;1(1):61–9. 13. regha ir, sulekha b. bacteriological profile and antibiotic susceptibility patterns of lower respiratory tract infections in a tertiary care hospital, central kerala. int j med microbiol tropical dis. 2018;4(4):186–90. author biography ritu vaish, associate professor cite this article: vaish r. antibiotic susceptibility of bacterial strains and bacteriological profile from patients with lower respiratory tract infections in a teaching hospital. panacea j med sci 2021;11(2):326-330. http://www.who.int/mediacentre/factsheets/fs310/en/ http://www.who.int/mediacentre/factsheets/fs310/en/ http://dx.doi.org/10.1183/09031936.05.0005570 http://dx.doi.org/10.1093/pubmed/21.3.331 http://dx.doi.org/10.1155/2019/4834396 http://dx.doi.org/10.4103/ejcdt.ejcdt_68_19 https://pesquisa.bvsalud.org/portal/resource/pt/sea-177811 https://pesquisa.bvsalud.org/portal/resource/pt/sea-177811 panacea journal of medical sciences 2021;11(2):357–359 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ case report pulmonary hydatidosis presenting as pyopneumothorax in a 15 year old male gaurang aurangabadkar1,*, saood ali1, ulhas jadhav1, ajay lanjewar1 1dept. of respiratory medicine, jawaharlal nehru medical college, wardha, maharashtra, india a r t i c l e i n f o article history: received 10-11-2020 accepted 06-02-2021 available online 25-08-2021 keywords: hydatid cyst pyopneumothorax albendazole pleural effusion a b s t r a c t pulmonary hydatid cyst is an exceptional cause of pyopneumothorax6 that should be considered in countries where hydatid disease is endemic. the documented rates of simple pneumothorax in patients with pulmonary hydatidosis ranges from 2.4-6.2%. hydatidosis is a parasitic zoonosis of the genus echinococcus that infects herbivores and humans in its larvae stage(hydatid) and in paediatric population, generally presents as pulmonary hydatidosis. misdiagnosis of this condition as tubercular in origin can cause treatment and prognostic delays for the patient. we report a case of a 15 year old male presenting with complaints of breathlessness (grade 2 mmrc) since 3 months and dry cough, low grade fever with chills since 3 months. he had previously received akt therapy and iv antibiotics. his blood investigations were normal. his sputum for afb, cbnaat was negative. his initial chest xray was suggestive of right sided hydropneumothorax. cect thorax revealed features suggestive of hydatid cyst in right posterobasal segment lower lobe with loculated pyopneumothorax with collapsed and consolidated right lung with mediastinal lymphadenopathy. after admission, intercostal chest drainage tube was inserted on the right side and connected to underwater seal and pleural fluid was drained. pleural fluid investigations revealed exudative effusion by lights criteria, ada was 150, culture and sensitivity revealed no growth and cytology revealed features of empyema. the patient was started on iv piperacillin+tazobactam, iv metronidazole and tab albendazole for 14 days along with akt considering raised pleural fluid ada levels as suggestive of tubercular pleural effusion. the patients hydatid serology (echinococcus igg antibody elisa0.88) came out to be positive which confirmed our diagnosis of hydatidosis. after repeat chest x ray, there was resolution noted in effusion and icd tube was removed and the patient was discharged on oral antibiotics for 14 days and tab albendazole for 3 months. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction pulmonary hydatid cyst is a rare cause of pneumothorax with the incidence of simple pneumothorax in the paediatric population as a result of pulmonary hydatidosis is around 2.4 to 6.2% of the patients. due to the presence of chest xray findings, it has the potential of being misdiagnosed as a case of tubercular pleural effusion or empyema. pulmonary * corresponding author. e-mail address: gaurangabadkar712@gmail.com (g. aurangabadkar). hydatid cyst (phc) may rupture into the pleural cavity or bronchus. in such cases, phc may be misdiagnosed with other common pulmonary diseases like tuberculosis and thus patients may not be receiving appropriate treatment. for example, misdiagnoses of phc may even lead to major lung resection or pneumonectomy. 2. case history we present a case of a 15 year old male who presented to the respiratory medicine opd in avbrh, sawangi, wardha https://doi.org/10.18231/j.pjms.2021.071 2249-8176/© 2021 innovative publication, all rights reserved. 357 358 aurangabadkar et al. / panacea journal of medical sciences 2021;11(2):357–359 in view of possible surgical intervention and pulmonologist opinion with chief complaints of fever, breathlessness, right sided chest pain and history of loss of weight and appetite. the initial chest x ray was done which was suggestive of hydropneumothorax and icd tube insertion was done after which approximately 500ml of yellowish purulent pleural fluid was drained along with air removed. the patient was initially suspected to be suffering from tubercular pleural effusion and was started on akt from outside. his blood investigations were normal and pleural fluid analysis revealed exudative effusion by lights criteria, pleural fluid ada levels were 150 and culture/sensitivity revealed no growth, pleural fluid cytology revealed empyema like nature of effusion with pleural fluid tlc/dlc suggestive of lymphocytic effusion, pleural fluid afb and cbnaat were negative for mycobacterium tuberculosis. the patients sputum for afb and cbnaat were also negative. the patient had significant history of contact with dogs and cattle as the family was in the dairy business and hence to investigate further echinococcus igg antibody elisa was sent which came to be positive (value0.88reference values >0.5positive) which confirmed the diagnosis of pulmonary hydatidosis. 2.1. general examination on examination, the patient was afebrile, pr110/min, rr24/min, bp110/60 mm hg, spo298% on room air, pallor/icterus/cyanosis and clubbing was absent. there was no palpable lymphadenopathy present. 2.2. on respiratory examination on inspectionchest wall bilaterally symmetrical, trachea appears central in position, on palpationtrachea central in position, no deviation noted, on percussionright sided dull notes heard, on auscultationright sided decreased breath sounds, right sided succussion splash was heard. 2.3. other systems cardiovascular system-heart sounds normal, no murmurs heard, gastrointestinal systemp/a soft, non-tender, no hepatosplenomegaly, central nervous systemno focal neurological deficit noted, all reflexes normal 2.4. provisional diagnosis on the basis of history and clinical examination, a provisional diagnosis of right sided pyopneumothorax was made. 2.5. routine investigations the patients routine blood investigations were within normal limits fig. 1: followup chest x rays showing resolution of pleural effusion and consolidation fig. 2: cect thorax suggestive of multiple cavities with air fluid levels after much diagnostic deliberations, pulmonary hydatidosis was considered as a possible diagnosis and the patients echinococcus igg antibody elisa was sent which came to be positive (value0.88reference values >0.5positive) and the patient was started on tab albendazole 200mg bd for 3 months. the patient was later discharged after 1 month after removal of icd tube and was advised to continue anti-echinococcal therapy for 3 months and regular reviews every month in the opd. his serial chvest x rays were done at every opd visit, which clearly showed resolution of the pleural effusion and consolidation. 3. discussion hydatid cyst is a parasitic infection caused by the larval form of echinococcus granulosis complex, e. multilocularis aurangabadkar et al. / panacea journal of medical sciences 2021;11(2):357–359 359 or e. vogeli. 1 canines are the definitive hosts and humans are the accidental hosts and infection is acquired after consumption of food contaminated with eggs. 2 e. granulosus causes cystic echinococcosis and is the most common species to cause the human disease. although e. multilocularis is rare, it is the most virulent species and causes alveolar echinococcosis. e. vogeli and e.oligarthrus cause polycystic echinococcosis. 2 hydatid disease involves the lungs by various mechanisms. humans acquire the infection by ingestion of eggs mixed with uncooked or contaminated food, drinking water or direct contact with animals. gastric and enteric digestion of eggs facilitates the release of embryos. embryos subsequently attach to the duodenal or jejunal wall by their hooklets and penetrate the intestinal wall after which they reach the liver via the portal circulation. most of the embryos are stuck in the liver sinusoids but embryos with diameters less than 0.3 mm may pass through the hepatic sinusoids and through the hepatic vein and ivc, enter the right heart and finally settle in the lungs. embryos can also enter the thoracic duct via lymphatics of the small intestine and then through the ijv enter the right side of the heart and finally the lungs. 3–5 the most common sites of these cysts are the liver and the lungs. pulmonary cysts can rupture into the mediastinum, bronchial tree or peritoneal cavity and can present with cough, abdominal pain, hemoptysis or chest pain. rupture is the most frequent complication of pulmonary hydatid disease occurring in 49% patients. 1 the cyst may rupture intrabronchially or into the pleural cavity. 6 surgical intervention is the treatment of choice in selected patients. 7 medical therapy for pulmonary hydatid cyst includes benzimidazoles group of drugs (mebendazole, albendazole). indications for chemotherapy includes smaller cysts and patients with contraindications for surgery. albendazole is preferred as it has better bioavailability, requires a minimum contact period of 11 days to have a significant response and should be given for a minimum period of 3-6 months. continuous therapy is more efficacious as it achieves higher drug levels on a sustained basis and do not allow the metacestodes to gradually recover. 4. conclusion hydatid cysts in lung are common in endemic area. in the present report, we described details of ruptured pulmonary hydatid cyst in a boy with fever and breathlessness, as the most prominent symptoms. the disease was misdiagnosed clinically, as pulmonary tuberculosis but hydatid serology gave us the diagnosis of pulmonary hydatidosis in this case. after definitive diagnosis, the patient was given antiechinococcal therapy with tab albendazole for 3 months. patient was discharged with good and stable vital signs. this report emphasizes that the ruptured pulmonary hydatid cyst should be considered in the differential diagnosis of tuberculosis especially in endemic areas for both infections. 5. conflict of interest the authors declare that there are no conflicts of interest in this paper. 6. source of funding none. references 1. sebit s, tunc h, gorur r, isitmangil t, yildizhan a, us mh, et al. the evaluation of 13 patients with intrathoracic extrapulmonary hydatidosis. j int med res. 2005;33(2):215–21. doi:10.1177/147323000503300209. 2. eckert j, deplazes p. biological, epidemiological, and clinical aspects of echinococcosis, a zoonosis of increasing concern. clin microbiol rev. 2004;17(1):107–35. doi:10.1128/cmr.17.1.107-135.2004. 3. sarkar m, pathania r, jhobta a, thakur br, chopra r. cystic pulmonary hydatidosis. lung india. 2016;33(2):179–91. doi:10.4103/0970-2113.177449. 4. zhang w, li j, mcmanus dp. concepts in immunology and diagnosis of hydatid disease. clin microbiol rev. 2003;16(1):18–36. doi:10.1128/cmr.16.1.18-36.2003. 5. özkan s, erer o, yalçın y, yuncu g, aydoğdu z. hydatid cyst presenting as an eosinophilic pleural effusion. respirology. 2007;12(3):462–4. doi:10.1111/j.1440-1843.2007.01054.x. 6. pfefferkorn u, viehl ct, barras jp. ruptured hydatid cyst in the right thorax: differential diagnosis to pleural empyema. thorac cardiov surg. 2005;53(4):250–1. doi:10.1055/s-2005-837643. 7. agha ra, fowler aj, saetta a, barai i, rajmohan s, orgill dp, et al. for the scare group the scare statement: consensus-based surgical case report guidelines. int j surg. 2016;34:180–6. author biography gaurang aurangabadkar, junior resident saood ali, assistant professor ulhas jadhav, professor and hod ajay lanjewar, associate professor cite this article: aurangabadkar g, ali s, jadhav u, lanjewar a. pulmonary hydatidosis presenting as pyopneumothorax in a 15 year old male. panacea j med sci 2021;11(2):357-359. http://dx.doi.org/10.1177/147323000503300209 http://dx.doi.org/10.1128/cmr.17.1.107-135.2004 http://dx.doi.org/10.4103/0970-2113.177449 http://dx.doi.org/10.1128/cmr.16.1.18-36.2003 http://dx.doi.org/10.1111/j.1440-1843.2007.01054.x http://dx.doi.org/10.1055/s-2005-837643 panacea final 2014 78 pjmsvolume 4 number 1: case report jan june 2014 the urinary analysis showed the presence of plenty of rbcand few pus cells. haemogram, kidney function test, blood sugar were in the normal range. the status and the nature of intravesical foreign body (ivfb)was confirmed by x-ray andultrasonography (usg) of kidney urethra and bladder (kub). they confirmed the presence of a long, obliquely lying foreign body in the urinary bladder (fig. 2, 3). figure 2:plain radiograph pelvis ap and lateral view: obliquely lying linear lucent shadow with metal tip figure 3: ultrasonography kub showing a long echogenic foreignbody lying obliquely in bladder introduction: the urinary bladder can be the site of various types of foreign bodies (1), which otherwise would seem to be a more inaccessible site for introduction. they find their way in bladder by accident, iatrogenic, migration during masturbation or from neighboring organs. a rare case of a complete ball pen in the urinary bladder is reported and its unusual presentation and management are discussed. case history: a 24-year-old, unmarried female presented in an emergency with a history of self insertion of ball pen into the urethra and bladder at around midnight. she disclosed that as the pen was being used for masturbation, it suddenly disappeared and went in the bladder. since then she was having increased frequency of micturition, severe dysuria, hematuria once, suprapubic pain and incomplete evacuation of bladder. past history revealed that she had a habit of frequent masturbation with pen & hematuria off & on.general examination revealed normal temperature, pulse, blood pressure parameters. the abdominal examination revealed palpable, tender bladder (around 3 centimeters). rest of the abdomen was scaphoid, soft & non-tender. the local examination showed a significantly patulous external urethral meatus and absent hymen (fig.1). figure 1: patulous external urethral meatus and absent hymen intravesical foreign body (a complete ball pen) a rare case report 1 chaudhary swanand abstract : the lower urinary tract is the recipient of a variety of foreign bodies which almost defies imagination. they include all types of objects. the frequency of such cases and the nature of objects are an important addition to the diseases of the urinary organs. intravesical foreign bodies provide a challenge to the urologist in both diagnosis and management. keywords : intravesical foreign bodies, urinary bladder, foreign bodies. 1 associate professor, consultant urologist, department of surgery, nkpsims&rc, digdoh hills, hingna road, nagpur – 440019. drswanandchaudhary_80961@y ahoo.co.in 79 grasping of the ball point with the biopsy forceps or stone crushing forceps was tried so as to bring it out. all the efforts were unsuccessful because the ball point frequently slipped out. after trying for 45 minutes, we thought of abandoning the endoscopic procedure and to proceed for open surgical extraction. cystoscope was taken out and immediately the pen came out partially through the external meatus (fig. 7) (possibly due to vertical lie of pen from dome of bladder to urethra). figure 7: pen lying in urethra pen was grasped and removed completely (fig. 8). site of impaction re-visualized by cystoscopy and it showed no active bleeding (fig. 9). indwelling catheter kept in bladder for 48 hours and then removed. she voided satisfactorily and discharged after 3 days. figure 8:completely removed ball pen from bladder the kidneys and the rest of the abdomen were normal. ball pen was removed cystoscopically under general anaesthesia. in lithotomy position cystoscopy was done. external urethral meatus was significantly patulous. bladder was distended and showed an obliquely lying reynold's ball pen (fig. 4) and ball point impacted in the left lateral wall (fig.5). rest of the bladder was normal. subsequently, the pen was disimpacted from the bladder wall (fig. 6). figure 4: cystoscopy showing obliquely lying reynold's ball pen figure 5: cystoscopy showing pen impacted in wall figure 6: cystoscopy showing disimpacted from the bladder wall pjmsvolume 4 number 1: jan june 2014 case report figure 9: site of impaction re-visualized by cystoscopy showing no active bleedi 80 pjmsvolume 4 number 1: jan june 2014 case report discussion: foreign body lodged in the body orifices is not unusual and the incidence is increasing. french et al reported an increase with respect to rectal foreign bodies (2). the urinary bladder, however, would seem a more inaccessible site for the introduction of foreign bodies. in view of the above, our case report is quite rare, where a complete ball pen as gone in the bladder. the possible explanation is, because the patient gave the history of frequent masturbation with pen resulting into patulous urethra which allowed the sudden and complete self insertion into bladder (during masturbation). the diagnosis was easy based on exact history, x-ray and usg of kidney urethra and bladder. the radiological investigations corroborated with the history and showed the ivfb consistent with the ball pen. the problem we had was how to inform the parents about the diagnosis, the necessity of emergency procedure and consent. the patient had initially told us not to explain anything about the pen and associated events to her parents and relatives (for obvious reasons). she herself was convinced about the necessity of emergency procedure and gave the consent. but, because parents knew nothing, it was difficult for us to convince them about the diagnosis and the necessity emergency procedure. after some perseverance, the patient relented and confided everything to her mother, then consent was given and the procedure was done. the classification of ivfb based on method of deposition in bladder is(1): self-inserted – sexual gratification, pediatric, psychiatric, senility, drug intoxication iatrogenic – bladder drainage, bladder surgery, adjacent surgery migratory – uterus, rectum, vagina, penetrating trauma, and migration could be of intrauterine device (iud), appendicoliths, perforated enteric foreign body, surgical sponges, and bone fragments from hip and pelvic bones. foreign bodies presenting acutely(1): foreign bodies delayed presentation(1): myriad of foreign bodies are mentioned in the literature like light bulbs, plastic beans (3), thermometer(4), wax candle(5), wrist watch, insects, snakes (decapitated), worms, squirrel tails, french fried potato, tooth brush(6), crayons, shoelace, chewing gum mould. the diagnosis is based on history of self-admission, alcoholism, drug addiction, psychiatric disturbances, previous bladder / pelvic surgery, symptomatology and also supported by examination and investigations like xray, usg, computed tomography (ct)and cystoscopy. the principles of management are: 1) aimed at complete extraction of foreign body with minimal trauma to bladder and urethra. 2) prevention. majority can be treated with transurethral extraction, but a few would require suprapubic cystostomy (7) or perineal urethrostomy. occasionally foreign body is voided spontaneously e.g. bullets (8). some innovative procedures are described in literature likepercutaneous instruments, fogarty catheter, magnetic retrievers for galvanic objects (9), air insufflation of bladder (10). preventive measures include use of absorbable sutures in bladder surgery, routine examination of all catheters after removal and if incomplete to check with cystoscopy, and psychiatric evaluation in relevant cases. ivfb are prone for complications like bladder perforation, pelvic abscess, fistula, chronic irritation, chronic sepsis and carcinogenesis. conclusion: there is a noticeable increase in incidence of foreign bodies lodged in body orifices (more in rectum than urinary bladder).ivfb provide a challenge to the urologist in both the diagnosis and management. object mode of introduction hair grip eroticism with partner match stick eroticism with partner drinking straw erotic games pipe cleaner attempted clearance of urethral blockage 2.5 cm nail psychiatric disturbance piece of string psychiatric disturbance cotton bud self hygiene. object time interval mode of presentation catheter tip 5 years recurrent urinary abdominalpain tract infection (uti), pipe cleaner 7 years recurrent uti (calcified) calcified stitch 18 months recurrent uti after stamey procedure iud 9 years recurrent uti, chronic abdominal pain suprapubic 6 months recurrent uti catheter tip 81 pjmsvolume 4 number 1: jan june 2014 case report references: 1) eckford sd, persad ra, brewster sf, gingell jc. intravesical foreign bodies: five year review. brit j urol 1992; 69: 41-45. 2) french gwg, sherlock dj, holl-allen rtj.problems with rectal foreign bodies. br j surg 1985; 72:243-244. 3) abdulla mm. foreign body in the bladder. brit j urol 1990; 65: 420. 4) yiu mk, yiu tf, chan ay. extraction of an intravesical thermometer using a flexible cystoscope. brit j urol 1995; 76: 143. 5) moon wk, kim sh, lee sj.paraffinoma in the urinary bladder: ct findings. j comput assist tomogr 1992; 16:308. 6) grandos ea, riley g, rios gj. self-introduction of urethrovesical foreign bodies. eur urol 1991; 19:259. 7) saunders ms, bitonte ag, mcelroy jb. the improbable intravesical foreign body. south med j 1992; 85: 653. 8) sankari br, parra ro. spontaneous voiding of a bullet after a gunshot wound to the bladder: a case report. j trauma 1993; 35:813. 9) wise kl, king lr. magnetic extraction of intravesical foreign body. urology 1989; 33:62. 10) wear jb jr. cystoscopy with carbon dioxide irrigation. j urol 1966; 96:828. page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 case report panacea journal of medical science, january – april 2015:5(1);47-49 47 giant true splenic epithelial cyst: a case report barhate m1, thakur s2, kamble m3 abstract: splenic cysts are rare lesions in daily surgical practice. these are classified as true or pseudocyst based on presence or absence of epithelial lining. most of these are asymptomatic until they regain significant size, at this time they are detected incidentally on ultrasonography or ct scan. we report a case of 45-year-old male with giant epithelial splenic cyst with about 2500 ml of brownish fluid was collected from the cyst. the specimen measured 180 mm ×160 mm ×120 mm and weighted 3500 g. laparotomy with splenectomy has been the method of choice for giant epithelial cysts. keywords: epithelial cyst, splenic cyst, pseudocyst. 1junior resident-3, 2prof. and head, 3associate prof., dept. of general surgery, b. j. govt. medical college, pune. mayur_rn2006@yahoo.co.in introduction: primary splenic cysts are even rarer lesions. they have presence of epithelial lining either simple squamous or cuboidal epithelium. various haematological and radiological investigations are required to confirm the diagnosis. decision about the type of surgical procedure is based on the size of the cyst, its relationship to the splenic hilum and amount of normal remnant splenic tissue and whether cyst is symptomatic. case history: a 45-year-old patient presented with complaints of sensation of fullness in left upper abdomen, atypical pain and mild dyspeptic symptoms. on examination, a lump was palpable in left upper abdomen. usg abdomen revealed giant cystic lesion with irregular cystic pattern in upper abdomen. computarized tomography confirmed evidence of 17cm ×15cm ×12 cm cystic lesion with thin enhancing septae arising from spleen (fig. 1). all laboratory tests were normal and serological tests gave no evidence of parasitic infection with echinococcus granulosus. at laparotomy, a huge splenic cyst of approximately 20 cm of maximum diameter was found with almost total displacement of remaining splenic parenchyma (fig. 2 and 3). however due to cyst size and location, preservation of spleen was considered impossible and total splenectomy was carried out. histopathology report revealed spleen with a cyst having fibro collagenous wall lined by cuboidal epithelium with focal calcification which is a rare presentation (fig. 4). generally epithelial splenic cysts are lined by simple squamous epithelium. aspirated cystic fluid showed no evidence of malignancy. thus the diagnosis of primary true splenic cyst was established. figure 1: ct scan showing cystic lesion in spleen barhate m et al. giant true splenic epithelial cyst: a case report panacea journal of medical science, january – april 2015:5(1);47-49 48 figure 2: intraoperative image of splenic cyst after separation of adhesions figure 3: resected specimen of spleen with giant cyst figure 4: histopathology image showing fibro collagenous wall lined by cuboidal epithelium results: postoperative clinical course was uneventful. patient received pneumococcal, meningococcal and haemophilus influenza vaccination and antibiotic prophylaxis post op. patient was discharged on postoperative day 7. patient continues to be followed up and is in good clinical condition and asymptomatic. discussion: giant true splenic cysts are rare findings. based on presence or absence of epithelial lining, they barhate m et al. giant true splenic epithelial cyst: a case report panacea journal of medical science, january – april 2015:5(1);47-49 49 are classified as true cysts (primary) or pseudocysts (secondary) (1). splenic cyst may also be classified as parasitic and non-parasitic cysts. taenia echinococcus infection is the most common cause of parasitic cyst. parasitic cysts commonly occur in areas of endemic hydatid disease. splenic cysts other than those of hydatid disease are extremely rare. the clinical presentation may vary based on the size and location of the cyst. patient with splenic cyst may complain of asymptomatic mass in left hypochondrium or symptomatic mass with symptoms like dyspepsia, early satiety, left hypochondrial pain and abdominal fullness. patient may also complain of pleuritic chest pain, shortness of breath and/or shoulder or back pain. patient may also experience renal symptoms from compression of the left kidney (2). splenic epithelial cysts occur predominantly in children and young women (3). patient with a giant splenic cyst present with palpable mass in anterior abdominal wall. on physical examination, an abdominal lump may be palpable. rarely splenic cyst present with acute abdomen related to rupture, hemorrhage or infection. diagnosis is best made by ct scan of abdomen. ct scan or mri gives information regarding the morphology of cyst, composition of cystic fluid, the location of cyst in spleen and its relationship with surrounding tissues (4). ultrasonography may show whether the cyst is anechoic or hypoechoic and whether they have smooth cyst wall (5). solid tumors are usually either hypoechoic or isoechoic. calcifications are frequently found in primary cysts or pseudocysts. cystic fluid may contain protein particles, breakdown products of hemorrhage or cholesterol crystals. histologically, epithelial cysts have a squamous epithelial lining with intracellular bridges and a thick collagenous wall. the interior cyst wall may be composed of thick trabeculated fibrous bands covered by epithelium. in our case the epithelial cyst was lined with cuboidal epithelium which is also rare presentation. differential diagnosis of cystic lesion in spleen may include parasitic echinococcal cyst, intrasplenic pancreatic cyst, pseudocysts from splenic trauma, congenital cyst, splenic abscess, metastatic disease and cystic lymphangioma/ hemangioma (rare) (6). splenic cyst with a diameter larger than 4-5 cm should be managed surgically, due to increase risk of complications (7). various surgical options range from percutaneous aspiration, sclerotherapy to partial or complete splenectomy. these options depend upon the size of cyst, its relationship with surrounding structures and its relationship with splenic hilum. we recommend, giant symptomatic splenic cysts should be managed by complete open splenectomy. conservative and minimal surgical approach should be employed for smaller sized and peripherally located splenic cysts. references: 1. williams rj, glazer g. splenic cysts: changes in diagnosis, treatment and aetiological concepts. ann r coll surg engl 1993;75(2):87–89. 2. trompetas v, panagopoulos e, priovoloupapaevangelou m, ramantanis g. giant benign true cyst of the spleen with high serum level of ca 19-9. eur j gastroenterol hepatol 2002;14(1):85–88. 3. sakamoto y, yunotani s, edakuni g. laparoscopic splenectomy for a giant splenic epidermoid cyst: report of a case. surg today 1999;29(12):1268–1272. 4. robertson f, leander p, ekberg o. radiology of the spleen. eur radiol 2001;11:80-95. 5. siniluoto tm, paivansalo mj, lahde st, alavaikko mj, lohela pk, typpo ab, et al. nonparasitic splenic cysts. ultrasonographic features and follow-up. acta radiol 1994;35:447-451. 6. sardi a, ojeda hf, king d, jr. laparoscopic resection of a benign true cyst of the spleen with the harmonic scalpel producing high levels of ca 19-9 and carcinoembryonic antigen. am surg 1998; 64:1149-54. 7. till h, schaarschmidt k. partial laparoscopic decapsulation of congenital splenic cysts. surg endosc 2004;18; 626-628. panacea journal of medical sciences 2022;12(1):91–96 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article varying zinc levels in pediatric nephrotic syndrome patients and its correlation with remission and relapse: an observational study rahul jaiswal1, anubha shrivastava1, a d tiwari1, r k yadav1, manisha maurya1, nandita mishra1,* 1dept. of pediatrics, moti lal nehru medical college, prayagraj, uttar pradesh, india a r t i c l e i n f o article history: received 20-07-2021 accepted 06-09-2021 available online 30-04-2022 keywords: zinc levels nephrotic syndrome remission relapse a b s t r a c t background: zinc deficiency, common in children of developing countries, leads to susceptibility to infections. relapses in nephrotic syndrome are precipitated mostly by infections. most of morbidity and mortality in nephrotic patients is during nephrotic range proteinuria. management of factors which reduce duration of relapse, can decrease morbidity in pediatric nephrotic patients. we aimed to study serum zinc levels, in patients of nephrotic syndrome, at onset/relapse and at remission and tried to find out correlation between serum zinc levels and time to achieve remission. materials and methods: observational study was conducted in tertiary centre of north india over 12 months. consecutive pediatric patients, with initial episode/relapse of ns were enrolled. patients were treated as per standard protocol. time taken for remission was noted. serum zinc level was estimated first at confirmation of initial episode/relapse and then at remission. data were summarized as mean ± standard deviation. groups were compared by paired t test. pearson correlation analysis was done to assess association between initial zinc level and time to attain remission. results: 68 patients were screened for inclusion in the study but only 49 qualified for final analysis. serum zinc level was statistically different in all patients at enrolment and at remission. pearson correlation analysis showed an insignificant and inverse correlation between time to remission and serum zinc level (r=0.14, p>0.05) suggesting that, as serum zinc level at enrolment decreases, the time to remission lengthens. conclusion: zinc level at initial episode/relapse was found to have negative correlation with time to attain remission. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction: the annual incidence of nephrotic syndrome (ns) is 1.216.9 per 100,000 children. 1 the pathogenesis of minimal change disease (mcd) is unclear, but there is a strong evidence of immune dysregulation, chiefly involving cell mediated immunity (cmi). 2 abnormalities in function of t cell subset (especially regulatory t cells) have been variably reported in mcd. lymphocyte adenosine * corresponding author. e-mail address: drnandita19@gmail.com (n. mishra). deaminase activity (as a marker of cmi), demonstrated changes both in active and remission stage of ns. 3 finding of increased plasma levels of ige, relatively normal igg4 with decreased igg1 and igg2 and association with atopy suggest type 2 cytokine bias in mcd. 4 ns is also associated with abnormal immunoglobulin levels. there are reports regarding involvement of complement system and b lymphocytes in pathophysiology of ns, although none of the immunological biomarkers evaluated were undeniably linked to changes in glomerular permeability and proteinuria. 3 some studies also suggest link between https://doi.org/10.18231/j.pjms.2022.018 2249-8176/© 2022 innovative publication, all rights reserved. 91 92 jaiswal et al. / panacea journal of medical sciences 2022;12(1):91–96 urinary chemokines (such as il-8/cxcl8 and mcp1/ccl2) and changes in glomerular permeability and/or the deterioration of glomerulopathies. 5 in recent years, evidence of mcd to be a podocytopathy has emerged and role of a circulating permeability factor is also postulated. 6 zinc deficiency is associated with high mortality in developing country. low zinc level has been described in children with severe malnutrition, malabsorption and nephrotic syndrome due to either lack of intake, decreased absorption or loss of zinc in stool and urine. 7 zinc has pivotal role in immune regulation. due to its deficiency, oxidative defence is weakened. excessive generation of reactive oxygen species is one of the incriminated mechanisms in pathogenesis of progression of renal injury. 8 basis for infection triggered relapse are still unclear but dysregulation of immune mechanism may have some role. evidence of perturbed cmi, its association with atopy, elevated levels of ige and upregulated gene expression for interleukin (il-4, il-13) suggest t helper 2 (th2) cytokine bias. 9 zinc deficiency probably leads to down-regulation of t-helper 1 (th1) cytokines, a relative th2 bias and increased risk of infection. zinc supplementation leads to decreased episode of infections, presumably due to augmentation of gene expression for il 2 and interferon, thereby restoring th1-th2 imbalance. 10 decreased infections lead to lower chances of relapses, hence lower morbidity and mortality, due to augmentation of immune response. but zinc supplementation as preventive strategy for ns has not been found strongly in cochrane. 11 we aimed to measure levels of zinc during initial episode/relapse and during remission in nephrotic patients and find correlation between initial zinc level and time to remission. this may give a hint to involvement of immune response in pathogenesis of ns and requirement of zinc supplementation to shorten the duration of relapse. 2. materials and methods this observational study was conducted in department of pediatrics of a tertiary care centre of north india over 12 months, which included enrolment, analysis and documentation. ethical clearance was obtained from institutional ethical committee. consecutive patients, in the age group of 1-14 years, with generalized edema, who were admitted to emergency department or attending out patient department of department of pediatrics were screened for the study. the procedure of the study was explained to parents/caretakers in their own language. written and informed consent was taken from parents/guardian before enrolment. bedside urinary protein heat coagulation test (bsup) was done to look for proteinuria. those with nephrotic range proteinuria i.e., bsup 3+/4+ underwent biochemical analysis (24-hour urinary protein >1000 mg/m2/d, hypoalbuminemia ≤ 2.5 g/dl and hypercholesterolemia >200 mg/dl) to confirm first episode of ns. those patients who were already known case of ns, their home bsup record was revised to confirm relapse. relapse was defined as bsup 3+/4+ for three consecutive days, having being in remission previously; it was further divided into twoinfrequent relapse and frequent relapse. patients having frequent relapses were those, who had two or more relapses in initial six months or four or more relapses in any twelve months. all the patients were grouped in three categories; patients with initial episode (ie), infrequent relapsers (ifr) and frequent relapsers (fr). patients with clinical evidence of systemic disease (e.g., tuberculosis, diabetes, chronic liver disease, malabsorption syndrome), congenital ns, infantile ns, those taking zinc and zinc containing supplement within three months prior to study period, or already on steroid, those with episodes of acute respiratory infections (ari) and diarrhea three months prior to study and those with history of recurrent attacks of ari & diarrhea were excluded from the study. detailed history, anthropometry and physical examination of each case was recorded systematically on a standard proforma. patients with first episode of ns were treated with prednisolone at 2mg/kg/day in two divided doses daily for six weeks, followed by 1.5mg/kg/day single dose every alternate day for six weeks. relapse patients were treated with prednisolone at 2mg/kg/day in two divided doses daily till remission, followed by 1.5 mg/kg/day single dose every alternate day for four weeks. remission was defined as bsup nil or trace for three consecutive days. patients who did not remit on prednisolone at 2mg/kg/day for four weeks were labelled as steroid resistant ns and were excluded from study. time taken for remission was noted in each patient. those patients who did not complete treatment, were excluded from final analysis. serum zinc level was done initially at confirmation of initial episode/relapse and was repeated at remission. two millilitre sample was collected in plain vial for it. sample was centrifuged and serum was separated for zinc level analysis by atomic absorption spectrophotometry. other relevant blood investigations e.g., lipid profile, kidney function test and serum albumin were also done. data were entered into microsoft excel spreadsheet and then analysed by spss 24.0. and graph pad prism version 5. data were summarized as mean ± standard deviation. groups were compared by paired t test. a two-tailed paired t-test was used at α=5% and considered p<0.05 as statistically significant. pearson correlation analysis was done to assess association between initial zinc level and time to attain remission. 3. results all 68 patients were screened for inclusion in the study but only 49 got qualified for final analysis (figure 1). baseline characteristics of the enrolled patients is in table 1. various jaiswal et al. / panacea journal of medical sciences 2022;12(1):91–96 93 table 1: baseline characters of children with nephrotic syndrome ie(n=19) ifr(n=20) fr(n=10) total(n=49) age (in years) number % number % number % number % <5 12 63.16% 5 25% 0 0 17 34.7% 5-10 5 26.32% 15 75% 8 80% 28 57.1% >10 2 10.53% 0 0 2 20% 4 8.2% gender male 12 63.16% 14 70% 7 70% 33 67.3% female 7 36.84% 6 30% 3 30% 16 32.7% residence rural 10 52.6% 18 90% 5 50% 33 67.3% urban 9 47.4% 2 10% 5 50% 16 32.7% ie = initial episode; ifr = infrequent relapse; fr = frequent relapse table 2: biochemical findings at enrolment and at remission (initial episode) p-value <0.05 = statistically significant; sd = standard deviation n=19 assessed at mean sd minimum maximum median p-value vdrl (mg/dl) enrolment 100.52 45.18 7.83 186.0 95.0 0.32 remission 85.76 44.73 7.96 179.0 90.0 hdl (mg/dl) enrolment 58.70 17.59 26.80 82.72 65.43 0.63 remission 62.02 24.0 25.60 105.58 60.30 tg (mg/dl) enrolment 469.46 170.59 231.79 931.20 443.20 <0.0001 remission 158.63 84.89 79.20 447.84 132.30 cholesterol (mg/dl) enrolment 437.64 144.48 272.00 777.00 453.13 <0.0001 remission 155.15 94.99 46.20 409.50 110.00 serum urea (mg/dl) enrolment 43.83 25.41 17.13 117.90 36.64 0.39 remission 37.57 18.94 22.48 96.80 29.29 serum creatinine (mg/dl) enrolment 0.70 0.27 0.18 1.07 0.71 0.72 remission 0.73 0.20 0.34 0.96 0.78 serum albumin (g/dl) enrolment 2.59 0.58 1.65 3.89 2.40 <0.0001 remission 3.36 0.36 2.86 4.48 3.24 serum zinc (µg/dl) enrolment 49.32 33.25 4.00 165.00 43.00 0.0002 remission 104.00 47.61 29.00 213.00 98.00 vldl= very low-density lipoprotein; hdl= high density lipoprotein; tg = triglyceride table 3: biochemical findings at enrolment and at remission (infrequent relapse) p-value <0.05 = statistically significant; sd = standard deviation n=20 assessed at mean sd minimum maximum median p-value vldl (mg/dl) enrolment 73.64 40.57 4.59 132.20 82.50 0.44 remission 84.01 42.90 16.00 178.00 80.30 hdl (mg/dl) enrolment 57.52 18.80 9.91 90.00 58.40 0.68 remission 55.21 16.65 22.67 80.15 54.30 tg (mg/dl) enrolment 281.22 128.50 104.20 531.92 261.68 0.0002 remission 135.40 94.87 36.20 412.00 109.20 cholesterol (mg/dl) enrolment 286.95 140.85 76.20 612.00 235.45 0.0002 remission 139.96 78.13 41.20 380.37 116.20 serum urea (mg/dl) enrolment 33.96 22.52 14.34 102.40 25.20 0.70 remission 31.79 11.04 16.27 53.50 28.99 serum creatinine (mg/dl) enrolment 0.84 0.31 0.34 1.60 0.86 0.43 remission 0.78 0.20 0.43 1.10 0.78 serum albumin (g/dl) enrolment 2.79 0.70 1.30 4.41 2.75 0.0021 remission 3.55 0.76 2.32 5.87 3.39 serum zinc (µg/dl) enrolment 46.75 27.58 4.00 127.00 43.00 <0.00001 remission 144.90 74.95 20.00 369.00 134.00 vldl= very low-density lipoprotein; hdl= high density lipoprotein; tg = triglyceride 94 jaiswal et al. / panacea journal of medical sciences 2022;12(1):91–96 fig. 1: patient recruitment. aki = acute kidney injury ie = initial episode; ifr = infrequent relapse; fr = frequent relapse fig. 2: pearson correlation graph between zinc level at enrolment and time to attain remission. jaiswal et al. / panacea journal of medical sciences 2022;12(1):91–96 95 table 4: biochemical findings at enrolment and at remission (frequent relapse) p-value <0.05 = statistically significant; sd = standard deviation n=10 assessed at mean sd min. max. median p-value vdrl (mg/dl) enrolment 71.17 44.78 3.39 132.20 68.00 0.97 remission 71.87 28.00 42.00 108.70 67.10 hdl (mg/dl) enrolment 50.99 20.93 9.40 90.52 48.00 0.59 remission 56.08 20.35 32.20 102.00 55.19 tg (mg/dl) enrolment 276.45 113.20 145.65 427.00 262.60 0.0025 remission 133.25 61.49 92.20 291.15 107.60 cholesterol (mg/dl) enrolment 244.56 86.52 139.56 452.08 222.20 0.0050 remission 138.77 59.02 75.00 244.38 115.20 serum urea (mg/dl) enrolment 38.27 11.22 22.75 54.60 36.25 0.96 remission 38.52 9.70 26.42 59.90 36.95 serum creatinine (mg/dl) enrolment 0.72 0.17 0.44 0.98 0.69 0.29 remission 0.82 0.25 0.32 1.10 0.93 serum albumin (g/dl) enrolment 2.78 0.69 1.80 3.93 2.66 0.08 remission 3.22 0.34 2.64 3.70 3.32 serum zinc (µg/dl) enrolment 44.30 17.83 21.00 78.00 43.50 <0.00001 remission 104.30 29.50 52.00 151.00 104.50 vldl= very low-density lipoprotein; hdl= high density lipoprotein; tg = triglyceride biochemical parameters in all the three categories of patients at enrolment and at remission are enumerated in tables 2, 3 and 4. in patients with initial episode and infrequent relapses, levels of triglyceride, cholesterol and albumin was statistically different at enrolment and at remission. in frequent relapsers, only levels of triglyceride and cholesterol was statistically different at enrolment and at remission. serum level of zinc was statistically different in all patients at enrolment and at remission. correlation between serum zinc level at enrolment and time to remission is summarized graphically in figure 2. pearson correlation analysis showed an insignificant and inverse correlation between time to remission and serum zinc level (r=0.14, p>0.05) suggesting that as serum zinc level at enrolment decreases, the time to remission increases. however, the correlation was statistically not significant. on subgroup analysis; correlation between initial serum zinc level and time to remission showed a significant and negative correlation (r=6.082, p<0.05) in patients with initial episode suggesting that as serum zinc level decreases, time to remission increases and vice versa. correlation in ifr showed, insignificant and positive correlation between serum zinc level and time to remission (r=0.862, p>0.05). correlation in fr patients also showed an insignificant and positive correlation between initial serum zinc level and time to remission (r=2.225, p>0.05). 4. discussion in present study, there was significant difference in mean value of serum zinc during relapse and remission (p value<0.05). it was low at relapse but normal at remission. correlation study do point out that low serum zinc level at relapse led to greater time required to attain remission, however the values were not statistically significant. the serum for assessment of zinc level was stored (at -20◦c) for an average of one month before analysis as samples needed to be transported to another centre for analysis. changes, if any, brought about by this storage is not accounted for, in the analysis. zinc level at remission was considered to be representative of normal baseline level for individual patients, which may not be true in all scenarios. almosawi concluded hypozincemia can occur in chronic renal problem like ns. low serum zinc level was commoner in frequent relapsers. 12 asim mumtaz found that there was high prevalence of zinc and copper deficiency in patients suffering from ns. causes of hypozincemia and hypocuperemia were hypoalbuminemia and raised 24hour urinary protein losses. other probable factors were decreased dietary intake and increased loss of trace metals in urine. 13 lindeman also studied serum zinc concentrations and found it to be decreased in patients with a variety of clinical disorders including nephrotic syndrome, cirrhosis and renal insufficiency. he found that symptoms of acute zinc deficiency (anorexia, dysfunction of smell and taste, mental and cerebellar disturbances) and chronic zinc deficiency (growth retardation, anemia, testicular atrophy and impaired wound healing) are common in these patients. 14 however, to our knowledge there is no study that found out correlation between the low zinc status and persistence of proteinuria. 5. conclusion overall zinc level was found to have negative correlation with remission time. therefore, it can be concluded that zinc supplementation with standard steroid therapy can 96 jaiswal et al. / panacea journal of medical sciences 2022;12(1):91–96 be tried to decrease relapse duration. characterization of profile of immune response might help in development of specific and individualized therapies, leading to clinical improvement and better prognosis. however, large scale, well designed, prospective studies across different setting are needed to substantiate the recommendation of zinc along with standard steroid therapy in idiopathic nephrotic syndrome. 6. sources of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest references 1. noone dg, iijima k, parekh r. idiopathic nephrotic syndrome in children. lancet. 2018;392(10141):61–74. doi:10.1016/s01406736(18)30536-1. 2. bagga a, mantan m. nephrotic syndrome in children. indian j med res. 2005;122(1):13–28. 3. mishra op, garg r, z a, usha. adenosine deaminase activity in nephrotic syndrome. j trop pediatr. 1997;43(1):33–7. doi:10.1093/tropej/43.1.33. 4. culver el, sadler r, bateman ac, makuch m, cargill t, ferry b, et al. increases in ige, eosinophils, and mast cells can be used in diagnosis and to predict relapse of igg4-related disease. clin gastroenterol hepatol. 2017;15(9):1444–52. 5. wde fp, brito-melo ge, guimarães ft, carvalho tg, mateo ec. simões e silva ac. the role of the immune system in idiopathic nephrotic syndrome: a review of clinical and experimental studies. inflamm res. 2014;63(1):1–12. 6. vivarelli m, massella l, ruggiero b, emma f. minimal change disease. clin j am soc nephrol. 2017;12(2):332–45. 7. javed f, asghar a, sheikh s, butt ma, hashmat n, malik ba, et al. comparison of serum zinc levels between healthy and malnourished children. ann punjab med coll (apmc). 2009;3(2):139–43. 8. dwivedi j, sarkar pd. study of oxidative stress, homocysteine, copper & zinc in nephrotic syndrome: therapy with antioxidants, minerals and b-complex vitamins. j biochem tech. 2009;1(4):104–7. 9. mathieson pw. immune dysregulation in minimal change nephropathy. nephrol dial transplant. 2003;18(s6):26–9. 10. prasad as. effects of zinc deficiency on th1 and th2 cytokine shifts. j infect dis. 2000;182(1):62–8. doi:10.1086/315916. 11. wu hm, tang jl, sha zh, cao l, li yp. interventions for preventing infection in nephrotic syndrome. cochrane database syst rev. 2004;(2):3964. doi:10.1002/14651858.cd003964. 12. almosawi qm. serum zinc level in children with relapsing nephrotic syndrome. int j curr res. 2016;8(11):42328–30. 13. mumtaz a, anees m, fatima s, ahmed r, ibrahim m. serum zinc and copper levels in nephrotic syndrome patients. pak j med sci. 2011;27(5):1173–6. 14. lindeman rd, baxter dj, yunice aa, king rw, kraikit s. zinc metabolism in renal disease and renal control of zinc excretion. prog clin biol res. 1977;14:193–209. author biography rahul jaiswal, junior resident anubha shrivastava, associate professor a d tiwari, professor r k yadav, assistant professor manisha maurya, associate professor nandita mishra, assistant professor cite this article: jaiswal r, shrivastava a, tiwari ad, yadav rk, maurya m, mishra n. varying zinc levels in pediatric nephrotic syndrome patients and its correlation with remission and relapse: an observational study. panacea j med sci 2022;12(1):91-96. http://dx.doi.org/10.1016/s0140-6736(18)30536-1 http://dx.doi.org/10.1016/s0140-6736(18)30536-1 http://dx.doi.org/10.1093/tropej/43.1.33 http://dx.doi.org/10.1086/315916 http://dx.doi.org/10.1002/14651858.cd003964 panacea journal of medical sciences 2021;11(2):280–283 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article alloimmunisation in sickle cell patients of western odisha: a tertiary care centre study chitta ranjan prasad1, susmita behera2, yespal sharma3,* 1dept. of transfusion medicine, veer surendra sai institute of medical sciences and research, burla, odisha, india 2dept. of transfusion medicine, mkcg medical college and hospital, brahmapur, odisha, india 3dept. of pathology, veer surendra sai institute of medical sciences and research, burla, odisha, india a r t i c l e i n f o article history: received 07-01-2021 accepted 22-01-2021 available online 25-08-2021 keywords: alloantibody sickle cell thalassemia a b s t r a c t rbc carries numerous protein and carbohydrate antigens on their surface. out of 347 red cell antigens recognized by international society of blood transfusion, 308 antigens are clustered in 36 blood group systems. except naturally occurring anti-a and anti-b antibodies all others are unexpected. out of these some like duffy, kell, kidd, mns, p and certain rh types are considered clinically significant. only few studies for prevalence of irregular red cell alloantibody have been done. those studies were done either in general population or in thalassemia patients. few studies were done on sickle cell disease patients but all are outside india and those are significant. but no studies have been done till now on prevalence of alloantibody in sickle cell disease patients in india. again the western part of odisha is with high patient load of sickle cell disease. this study is very useful for this part of odisha as complication due to the alloantibody can be managed properly. both the patients and the clinician will be benefited by this study. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction sickle cell disease is a hereditary haemoglobinopathy, characterised by chronic anaemia, recurrent painful episodes and irreversible organ damage. transfusion of red cells is a common intervention to treat and prevent the complication. patients with sickle cell disease have high risk of alloantibody formation. alloantibody may cause haemolytic transfusion reaction (acute or delayed) or decrease in the survival of transfused rbcs. red blood cell alloimmunization results from the genetic red blood cell antigen disparity between donor and recipient or from mother and fetus. the first reports on alloimmunization date from the 17th century describing hydropic stillborns. this disease, today known as hemolytic disease of the fetus or newborn (hdfn), is caused by * corresponding author. e-mail address: yespal1983@gmail.com (y. sharma). immune igg antibodies from the mother directed against the red blood cells of the fetus a red blood cell unit contain red cells that express an array of multiple alloantigens, each of which can potentially induce an antibody response. it is therefore surprising that humoral alloimmunisation to red cell is rare. indeed, when abo compatible, d matched red blood cells are used, only approximately 3% of transfused patients become alloimmunized, even following multiple red blood cell transfusion. the alloimmunisation frequency varies with both the blood group antigen and the underlying genetics and pathophysiology of the recipient. alloimmunisation rate are substantially higher in sickle cell anemia. 1 the reasons for this are 1. disparity of donor/recipient demography. https://doi.org/10.18231/j.pjms.2021.057 2249-8176/© 2021 innovative publication, all rights reserved. 280 prasad, behera and sharma / panacea journal of medical sciences 2021;11(2):280–283 281 2. alteration in immunobiology due to sickle cell disease. 3. lickage disequilibrium with immunoregulatory genes close to the globin gene. 2 the red cell alloantibodies are not equally distributed among transfused patients. rather patients who have made an alloantibody against one blood group antigen are more likely to make additional antibody often subsequent transfusion. those not responding to antigen in initial transfusion are unlikely to develop the antibody. the two groups are responder and non-responder. these observations are practical ramification for management of patients requiring chronic transfusion therapy as sickle cell disease. matching blood for multiple antigens (e.g. kell, kidd &duffy) is both costly and time consuming. so many places matching for abo & d is done during initial treatment and later on once the patient makes one red cell alloantibody, extensively matched blood is provided for subsequent transfusion, patient who does not make alloantibody continue to receive red blood cell matched only for abo & d. this saves the resources but results in development of at least one red cell alloantibody in responder, which would have been avoided. 1.1. potential mechanisms 1. the recipient genetically negative for the antigens. 2. the transfused donor red cell carries the antigen. 3. the recipient mhc class-ii molecules are capable of presenting a red cell allogenic peptide containing a variant amino acid found in the donor but not in the recipient. 1.2. additional factors 1. genetic determinants other than red cell antigen and mhc class-ii. 2. environmental factors affecting the donor limit. 3. environmental factor s affecting the transfusion recipient. 1.3. other genetic determinants rs660 polymorphism in the ro52 gene is associated with kinetics of alloimmunisation in sickle cell disease patients, 2 although the function of ro52 (also called ssa1 and trim21) is only practically characterised. it appears to be immunoregulatory gene products. thus, a role for ro52 in regulating alloimmunisation is logical; however correctly the association is only correlative and causal role is yet to be tested. the risk of alloimmunisation can be reduced by choosing blood matched for rh and kell groups in scd. 3 patients who are already alloimmunised should undergo extended red cell phenotypic matching (c, c, d, e, e, k, k, jka, jkb, fya, fyb, kpa, kpb, mns, lewis) with some centres also employing red cell genotyping to increase the accuracy of rh typing, and in locating compatible units. 2. materials and methods all the tests are done by gel card method. liss/coombs card (matrix), card centrifuge (85g), incubator (370c), workstation, pipettes (10, 25 & 50µl), screening cell pane, isotonic saline solution (liss), bottle top dispenser reagents: -the matrix ahg (coombs) test card contains six microtubes, prefilled with a gel in a suitable buffer containing anti-human igg and monoclonal antic3d. the matrix ahg (coombs) test card is suitable for direct coombs test, indirect coombs test including compatibility testing, antibody screening and antibody identification. 2.1. methods the study was conducted in the department of transfusion medicine and department of pathology vssimsar, burla from november 2017 to august 2019 and the study was prospective and observational study. the study was conducted on the sickle cell disease patients coming for red cell transfusion to blood bank, vssimsar, burla. principle:as the matrix gel card containing red blood cells is centrifuged under specific conditions, the red blood cells sensitized with antibody will agglutinate in presence of the anti-human globulin reagent in the gel matrix and will be trapped in the gel column. the red blood cells, which do not get trapped in the gel matrix, are palleted at the bottom of the column. the reaction is then read and graded according to their reactivity pattern. 2.2. inclusion criteria 1. age 5-30 yrs. 2. sickle cell patients with more than two transfusions. 2.3. exclusion criteria 1. patients with multiple transfusions due to any other haemoglobinopathy or any other medical or surgical causes. 2. sickle cell patients with no history of transfusions. 3. limitations 1. small sample size. 2. non availability of specific antibody identification facility. 3. high cost and short expiry of reagent. 4. study included only patients coming to blood bank for transfusion of red cell. 282 prasad, behera and sharma / panacea journal of medical sciences 2021;11(2):280–283 4. observation veer surendra sai institute of medical science and research is a tertiary care institute situated at burla in the state of odisha. this institute has its own blood bank in the department of transfusion medicine. in view of high load of sickle cell disease patients a separate sickle cell unit is there with all high end tests for sickle cell patients. 1. screening of total 110 patients was done in the department of transfusion medicine for alloantibodies. 2. all patients were confirmed for sickle cell disease by hplc test done in our sickle cell unit. 3. proper history of all the patients was collected in a preprepared format attached later. 4. all the history related to transfusion and transfusion related complications were collected carefully. 5. three panel screening cell supplied by tulip and matrix ahg gel card were used for the entire test. 6. auto-control & dat was done for all the patients. 7. quality control was done every day at the starting and end of the testing. a total of 110 patients with sickle cell disease were included in the study after careful consideration of all the exclusion and inclusion criteria. then all the patients were included in the study were screened for alloantibodies. all the observations were done visually and photograph of the gel-cards were kept for future reference. all the patients with screening test positive were sent to other higher centre where specific antibody detection facility was available. those who were severely ill were transfused with extensively cross matched blood as life saving measure. demographic data of sickle cell disease patients who received regular blood transfusion: 1. out of 110 patients 59 were male patients and 51 were female patients. 2. 53.63% are male of total patients. 3. 46.37% are female of total patients. 4. all the sickle cell disease patients as diagnosed by sickle cell institute. 5. distribution of patients as per age: 6. out of 110 patients maximum no of patients are of age group 16yr-20yr i.e. 30 out of 110 patients. it is 27.27% of total patients screened. distribution of patients among different blood groups: 1. maximum numbers of patients are of o+ve blood group i.e. 44 out of 110. 2. it is around 40% of the total patients screened. 5. results out of total 110 patients screened for alloantibody 15 patients were found to be positive for alloantibody. that is 13.64% of patients developed alloantibodies. which is significant and requires immediate attention. 1. among the 15 patients 7 were males and 8 were females. so the alloantibody distribution shows little female predominance. table 1: association between alloantibody and gender gender present of alloantibody absent of alloantibody % male 7 52 11.86% female 8 43 15.68% total 15 95 13.64% 6. discussion till now there are no published data on incidence of alloimmunisation among sickle cell disease patients in western part of odisha and india. thus, study was aimed to investigate the frequency of alloimmunisation among these patients. the rate of alloimmunisation observed in present study is 13.64% which is comparable to study done by l.a.m. bashawri, damman, soudi arbia, 4 who found it to be 13.7%. study done by j sin et al, amsterdom 5 and wendell f. rosse et al, chicago 6 found it total 22% and 18.6% respectively, which is little higher than the present study. another study done by fekri samarah et al, palestine 7 found 7.76%, which is much lower than the present study. except the last study all other study found higher frequency of alloantibody formation in sickle cell disease as mentioned in different literatures and books. these differences in the rate of rbc alloimmunization among scd patients support the importance of ethnic/genetic differences between patients and donors. although the cost of antigen matching is high, further studies are needed to investigate the influence of this factor on the rate of alloimmunization. another factor that could contribute to the relatively low rate in the last study is that scd patients are not checked for rbc alloantibodies after each transfusion which may lead to missing the detection of transitory alloantibodies. 7 mean age of alloantibody production in present study is 22.2yrs. which is 28.8yrs in study by l.a.m. bashawri and 23.4yrs in study by j sin et al. study by wendell f. rosssr et al and f. samarah also show similar result i.e. patients with older age (>20yrs) show highest rate of production of alloantibody. 8 two patients out of 15 patients in present study were of paediatric age groups. this is quite similar to most of the other studies. it is reported that scd children who were first transfused at the age of 10 years and older had a higher rate of alloantibodies compared to those who were transfused before that age. 9 prasad, behera and sharma / panacea journal of medical sciences 2021;11(2):280–283 283 eight out of 15 patients are female in present study, showing slight female predominance. this is similar to the study by l.a.m. bashawri and most of other studies. only the study by f. samarah found no difference in gender. it has been suggested in many literatures that the rate of alloimmunisation was greater for women than for men. the reason for this is more need of red cell transfusion and complications related to pregnancy. 10 the predominant blood group in present study is o+ve followed by b+ve, a+ve and ab+ve. the study shows result similar to the study done by l.a.m. bashawri and most of the other studies available. 11,12 comparison of different studies with present study table 2: comparison of different studies with present study study total no of patients no of patients positive % of positive patients l.a.m. bashawri 350 48 13.7% j sins et al 250 54 22% wendell f. rosse et al 200 36 18.6% fekri samarah et al 116 9 7.76 % present study 110 15 13.64% 7. conclusion clinically red cell alloantibody is associated with:1. hemolytic dis of fetus & new born(hdfn 2. hemolytic transfusion reaction 3. decrease in survival of transfused red cells 4. some cause destruction of incompatible red cells within hours, minutes to days it is found in this study that in the sickle cell disease patients, the prevalence of alloantibodies is higher than in the general population and is associated with many complications. as sickle cell disease patients require multiple transfusions in their lifetime they should always be screened for alloantibody. the red cell transfused to them should be screened so that development of alloantibody can be avoided. as this part of odisha has high incidence of sickle cell disease and many people died due to complications of this disease, this study is an eye opener. screening of alloantibody should be made mandatory for these patients and for the donor‘s blood. moreover, while transfusing red blood cells to these patients, leukofiltration should be used. 8. conflict of interest the authors declare that there are no conflicts of interest in this paper. 9. source of funding none. references 1. garratty g. severe reactions associated with transfusion of patients with sickle cell disease. transfusion. 1997;37(4):357–61. 2. tatari-calderon z, minniti cp, kratovil t. rs660 polymorphisim in ro52 (ssa1;trim21) is a marker for age-dependent tolerance induction and efficiency of alloimmunisation in sickle cell disease. mol immunol. 2009;47(1):64–70. doi:10.1016/j.molimm.2008.12.027. 3. garratty g. autoantibodies induced by blood transfusion. 2004;44(1):5–9. doi:10.1111/j.0041-1132.2004.00658.x. 4. bashawri la. m : red cell alloimmunisation in sickle-cell anaemia patients. eastern mediterranean health jurnal. 2007;13(5):1181– 1189. 5. sins j, riel wv, aj van lersel l w. alloantibody formation in patients with sickle cell disease. blood. 2013;122(21):2395. doi:10.1182/blood.v122.21.2395.2395. 6. rosse wf, gallagher d, kinney tr, castro o, dosik h, mooh j, et al. transfusion and alloimmunization in sickle cell disease. the cooperative study of sickle cell disease. blood. 1990;76(7):1431–7. 7. samarah f, srour ma, yaseen d, dumaidi k. frequency of red blood cell alloimmunisation in patient with sickle cell disease in palestine. adv hematol. 2018;doi:10.1155/2018/5356245. 8. red cell immunogenetics and blood group terminology. available from: https://www.isbtweb.org/working-parties/redcell-immunogenetics-and-blood-group-terminology. 9. daniels g, castilho l, flegel wa, fletcher a. international society of blood transfusion committee on terminology for red cell surface antigens: macao report. vox sang. 2009;96(2):153–6. doi:10.1111/j.1423-0410.2008.01133.x. 10. smart e, armstrong b. blood group systems. int soc blood transfus sci ser. 2008;3(2):68–92. 11. kar bc. sickle cell disease in india. j assoc phys india. 1991;39(12):954–60. 12. ullatil v, patel dk, patel s, das k, bag s, meher s, et al. hepatitis-b and c in sickle cell hemoglobinopathies of western odisha, india. int j pharm sci invention;2015(5):21–6. author biography chitta ranjan prasad, associate professor susmita behera, assistant professor yespal sharma, senior resident cite this article: prasad cr, behera s, sharma y. alloimmunisation in sickle cell patients of western odisha: a tertiary care centre study. panacea j med sci 2021;11(2):280-283. http://dx.doi.org/10.1016/j.molimm.2008.12.027 http://dx.doi.org/10.1111/j.0041-1132.2004.00658.x http://dx.doi.org/10.1182/blood.v122.21.2395.2395 http://dx.doi.org/10.1155/2018/5356245 https://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-blood-group-terminology https://www.isbtweb.org/working-parties/red-cell-immunogenetics-and-blood-group-terminology http://dx.doi.org/10.1111/j.1423-0410.2008.01133.x panacea journal of medical sciences 2021;11(2):197–203 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article outcome of neonates born to mothers with premature rupture of membranes ratikanta mahala1, jyoti ranjan champatiray1, madhusmita pradhan2, mangal charan murmu1,* 1dept. of pediatricts, s.c.b. medical college and hospital, cuttack, odisha, india 2dept. of obstetrics and gynecology, bhima bhoi medical college and hospital, balangir, odisha, india a r t i c l e i n f o article history: received 10-11-2021 accepted 06-02-2021 available online 25-08-2021 keywords: differential leucocytes count (dlc) premature rupture of membranes (prom) a b s t r a c t introduction: premature rupture of membranes (prom) is a syndrome characterized by rupture of the fetal membranes before labour. acute chorioamnionitis complicates 0.5% 10% of all pregnancies but the incidence may be as high as 3-25% in pregnancies complicated by prom of more than 24 hours duration. intrauterine infection specially chorioamnionitis is one of the most serious problems found by the practicing obstetrician and subsequently by the pediatrician. the incidence of neonatal infection for infants born to women with prom range from 1 – 2.6%. aims & objectives: to know the incidence, clinical course, outcome of early onset sepsis following prom more than 18 hours. materials & methods: this is a prospective study conducted from december 2018 to september 2020 in scb medical college and hospital and svppgip cuttack. all neonates born to healthy mothers with prom more than 18 hours during their hospital stay were studied. results: 53.3% of the cases had premature rupture of membranes of 18-24 hours duration,38.3% cases had premature rupture of membranes of 24 to 72 hour and 8.4 % cases had premature rupture of membranes of more than 72 hr. rds was the most common clinical manifestation (37.5%) followed by septicemia (10%), meningitis (1.7%) and pneumonia 1.7%. most common organisms isolated in blood culture were staphylococcus followed by klebsiella, e. coli, pseudomonas. the incidence of neonatal infection in neonates born to mothers with prom was 10%. conclusion: premature rupture of membranes is responsible for increased perinatal morbidity among preterm neonates & directly proportional to duration of prom. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction premature rupture of membranes (prom) is one of the most common problems in obstetrics complicating approximately 5-10% of term pregnancies. preterm premature rupture of membranes (pprom) occurs approximately in 1% of all pregnancies. 1 the fetal and neonatal morbidity and mortality are significantly affected by duration of latency and gestation at prom. the primary complication for the mother is risk of infection, * corresponding author. e-mail address: mangal74murmu@gmail.com (m. c. murmu). complications for the newborn consists of prematurity, fetal distress, perinatal asphyxia, cord compression, deformation and altered pulmonary development. 2 the most significant maternal risk of term prom is intrauterine infection the risks of which increases with the duration of membrane rupture. 3 for patients with pprom the most likely outcome is preterm delivery within one week with its associated morbidity and mortality risks such as respiratory distress, necrotizing enterocolitis, intraventricular haemorrhage and sepsis. 4 neonatal sepsis can be divided into two main sub types depending on whether the onset is during the first https://doi.org/10.18231/j.pjms.2021.043 2249-8176/© 2021 innovative publication, all rights reserved. 197 198 mahala et al. / panacea journal of medical sciences 2021;11(2):197–203 72 hours of life or later. early onset septicemia is caused by organism prevalent in the genital tract or in the labour room. early onset bacterial infections occur either due to ascending infection following rupture of membranes or during the passage of baby through infected birth canal. 5 prom of duration more than 18 hours is the appropriate cut off for increased risk of neonatal infection. 6 there are recommendations of antenatal antibiotic administration in pregnant women who had prom ≥ 18 hours the regimen to prevent neonatal infection postnatally still varies among institutions. 7 the key to the management is an accurate assessment of gestational age, pulmonary maturity and presence or absence of sepsis. however the management is special in preterm patient in whom the risk of fetal and maternal infection that can accompany expectant treatment has to be weighed against potential improvement in neonatal outcome that comes with greater maturity of fetal lungs. currently most authorities accept a plan of active management which includes prevention of infection, delay of delivery until fetal maturity is achieved and active intervention by induction if labour is no longer preventable or if early infection is suspected. the knowledge of incidence of early onset sepsis in relation to prom and its effect on neonatal outcome is essential in order to prevent the neonatal morbidity and mortality. diagnosis of early onset sepsis close observation for early signs of sepsis, aggressive evaluation and early treatment has decreased the incidence of early onset sepsis associated with prom. the present study was undertaken to evaluate newborns born to mothers with prom for early onset sepsis. neonatal outcome has also been evaluated in the prospective study. 2. aims & objectives to know the incidence, clinical course, outcome of early onset sepsis following prom more than 18 hours and compare risks of individual outcomes among neonates according to the latency periods from membrane rupture until the time of delivery. 3. materials and methods this is a prospective study conducted from december 2018 to september 2020 in scb medical college and hospital and svppgip cuttack. this has been approved by institutional ethical committee clearance vide letter no452/14-10-2020. all neonates born to healthy mothers with prom more than 18 hours during their hospital stay were studied. total neonates included in the study were 120, who have qualified for the study as per criteria described. a detailed history of mother was taken including age, parity, socioeconomic history, occupation, history of previous pregnancy loss, history of antepartum haemorrhage, obstetric history with emphasis on exact time of rupture of membranes, duration history and antibiotics before labour were evaluated. detailed birth history including resuscitation details, apgar score and gestational age assessment were evaluated. in examination of the neonate the pulse, respiratory rate, crt and temperature were noted followed by systemic examination. required investigations are done for the neonate and followed during their hospital stay. 3.1. inclusion criteria all neonates born to healthy mothers with prom more than 18 hours. 3.2. exclusion criteria 1. antepartum haemorrhage. 2. medical disease in mother other than infection. 3. neonates with major congenital malformation. 4. neonates born with meconium stained liqour. 3.3. methods following investigations were carried out: 1. hb%, tlc was estimated by automated analyzer. 2. differential leucocytes count (dlc), band cell count, toxic granules was done by peripheral smear. 3. crp semi quantitative estimation by latex agglutination technique. 4. blood culture and sensitivity. 5. chest x-ray (if required). 6. csf analysis and head ultrasound (if required). 3.4. statistical analysis all observational data was tabulated and analyzed by appropriate statistical method to draw final inference and conclusion. statistical methods like descriptive methods (graphs, numerical summaries), inferential methods (confidence interval, significance tests) are used. p-value in statistics: the p-value is the probability of obtaining results at least as extreme as the observed results of a statistical hypothesis test, assuming that the null hypothesis is correct. the p-value is used as an alternative to rejection points to provide the smallest significance at which null hypothesis is rejected. smaller p-value means that there is stronger evidence in favor of alternate hypothesis. 4. observation the analysis of the present study shows that out of 120 neonates 64(53.3%) were males and 56(46.7%) were females, 9(7.5%) cases weighing <1500gms, 32(26.6%)cases were weighing between1500 and 2500gms and 79(65.9%) cases weighing >2500 gms, 25(37.5%) mahala et al. / panacea journal of medical sciences 2021;11(2):197–203 199 table 1: distribution of cases according to different parameter (n=120) parameters number percentage sex male 64 53.3 female 56 46.7 birth weight in grams <1500 9 7.5 1500-2500 32 26.6 >2500 79 65.9 gestational age <37 weeks 45 37.5 >37 weeks 75 62.5 mode of delivery normal 84 70 caesarean section 36 30 prom in hours 18-24 hours 64 53.3 24-72 hours 46 38.3 >72 hours 10 8.4 cry history immediately after birth 114 95 delayed cry 6 5 type of morbidity r.d.s 45 37.5 septicemia 12 10 meningitis 2 1.7 pneumonia 2 1.7 n e c 0 0 ivh 0 0 asymptomatic 59 49.1 maternal age in years <22,>18 42 35 >22-<27 61 52.2 >28 17 14.8 parity primi 78 64.8 multi 42 35.2 socio-economic status lower 62 51,6 middle 50 41.6 higher 8 6.8 were of<37weeks and 75cases (62.5%) were of gestational age more than 37 weeks, 84(70%) neonates are delivered by normal vaginal delivery and36 (30%) were delivered by caesarean section, 64(53.3%) had prom of 18-24hrs duration, 46(38.3%) had 24-72 hrs and 10(8.4%) had >72 hrs of duration. 114(95%) neonates cried immediately after birth and 6(5%) babies have history of delayed cry. morbidity was seen in 61(50.9%) out of which rds being most common 37.5%.prom is more in primipara cases (64.8 %) and more common in lower socioeconomic status (51.6 %).table 1 out of 120 cases 61 cases (50.8%) had morbidity. in that 61 cases (50.8%) 45 cases were born before 37 weeks. so neonatal morbidity was common in preterm babies. out of 45 cases of rds (37.5%), 31cases (25.8%) were of preterm gestation. there was highly significant difference in morbidity among preterm (<37 weeks) and term (>37 weeks).table 2 chi-square tests shows p-value < 0.001 which is statistically significant. neonatal morbidity like rds ,septicemia are more common in preterm premature rupture of membrane cases.table 3 as duration of prom increases incidence of septicemia also increases. thus if duration of prom is more than 24hours, the incidence of septicemia was 10% in comparison to zero incidence when it is less than 24hours. r.d.s was more common when duration of prom was less than 24hours. morbidity is more in the neonates with longer duration of prom.table 4 chi-square test shows p-value <0.001, which is statistically significant. the risk of septicemia increases with longer duration of prom.table 5 analysis how that out of 120neonates with history of prom two cases (1.7%) died who had prom duration of > 72 hours.table 6 the analysis shows that out of 60 cases 25 (20.8%) had leucopenia and leucocytosis was observed in 22 cases (18.4%), c-reactive protein was positive in 35 cases (29.2%) and negative in 85 cases (70.8%), 12 cases (10%) had growth in blood culture.table 7 staphylococcus was most common organisms causing sepsis 7 cases (58.3%) out 12 cases. out of 12 cases 2 cases (16.7%) died due to staphylococcal septicemia.table 8 200 mahala et al. / panacea journal of medical sciences 2021;11(2):197–203 table 2: distributions of cases according to gestational age and neonatal morbidity morbidity gestational age in weeks total cases <34 34-37 >37 r d s 12 (10%) 19(15.8%) 14(11.7%) 45(37.5%) septicemia 6(5%) 4(3.3%) 2(1.7%) 12(10%) meningitis 0 2(1.7%) 0 2(1.7%) pneumonia 0 2(1.7%) 0 2(1.7%) nec 0 0 0 0 ivh 0 0 0 0 total 18(15%) 27(22.5%) 16(13.3%) 61(50.8%) table 3: morbidity v/s gestational age cross tabulation morbidity gestational age in weeks 32 33 34 35 36 37 38 39 40 42 total no morbidity 1 1 1 0 5 1 28 7 11 6 63 r d s 7 3 2 4 12 2 7 1 4 2 45 septicemia 3 2 2 0 2 0 0 0 3 0 12 total 11 6 5 4 19 3 35 8 18 8 120 table 4: neonatal morbidity in relation to duration of prom complications p r o m 18-24 hours 24 -72 hours >72 hours r d s 25(20.8%) 17(14.2%) 3(2.5%) septicemia 0 5(4.2%) 7(5.8%) meningitis 0 0 2(1.7%) pneumonia 0 0 2(1.7%) total 25(20.8%) 22(18.4) 14(11.7%) table 5: neonatal morbidity & prom duration cross tabulation morbidity prom duration in hours 18 20 22 23 24 26 28 30 32 36 40 48 >72 nil 14 15 5 0 2 1 4 7 2 4 0 6 0 r d s 8 8 8 1 3 0 2 3 0 3 4 5 3 septicemia 0 0 0 0 0 0 0 0 0 0 0 5 7 total 22 23 13 1 5 1 6 10 2 7 4 16 10 table 6: distribution of neonatal death according to duration of prom duration in hours live cases death cases total no % no % no % 18-24 64 53.3 0 0 64 53.3 24-72 46 38.3 0 0 46 38.3 >72 8 6.7 2 1.7 19 8.3 total 118 98.3 2 1.7 120 100 table 7: distribution of cases in relation to different parameter (n=120) variable number of cases percentage w b c (cell/cmm) <5000 25 20.8 5000-20000 73 60.8 >20000 22 18.6 c r p positive 35 29.2 negative 85 70.8 blood culture positive 12 10 negative 108 90 mahala et al. / panacea journal of medical sciences 2021;11(2):197–203 201 table 8: organism isolated in blood culture organism isolated live death total no % no % no % staphylococcus 5 41.6 2 16.7 7 58.3 klebsiella 2 16.7 0 0 2 14.2 e.coli 2 16.7 0 0 2 14.2 pseudomonas 1 8.3 0 0 1 14.2 total 10 83.3 2 16/7 12 100 5. discussion this was a prospective observational study conducted from december 2018 to september 2020. total of 120 neonates were included in this study, born in scb medical college and hospital, cuttack during the study period. 0ut of 120 neonates 64 (53.3%) cases were males 56 (46.7%) cases were females. in wornart et al 8 study out of 5182 cases 53.96% cases were males and 46.04% cases were females which was similar to our study. 79(65.9%) babies born with birth weight more than 2500 grams and 41(34.1%) babies with birth weight less than 2500 grams. woranart et al 8 study shows 28.84 % babies were less than 2500 grams and 71.15% babies were more than 2500 grams. shubeck f et al study 9 incidence of prom was more in babies weighing less than 2500 grams (24.8%) and incidence of prom in babies weighing more than 2500 grams was only 2%. in the present study the incidence of prom was more in babies weighing more than 2500 grams. this is due to fact that the total number of babies weighing >2500 grams were more in the sample. similar results were observed in woranart et al 8 study. 25(37.5%) cases born before 37 weeks and 75(62.5%) cases born after completion of 37 weeks. kifah al-q qa & fatin al-awayshah 3 study found that incidence of prom was more in preterm gestation (62%)45. in woranart et al 8 study incidence of prom was 42.3% cases in preterm geststion and 57.7% cases occurred at term. according to danforth 1 70% of cases of prom occurred at term and 30% of prom occurred at preterm. the present study results are consistent with woranart et al 8 study. in our study out of 120 newborns 84(70%) were born by normal vaginal delivery and 36(30%) born by lscs. vaginal delivery found to be commonest mode. in sanyal and mukherjee study 1087% cases are delivered by vaginal route and 13% are delivered by lscs .kodkany and telang 11 study 81% are delivered by vaginal route and 19% are delivered by lscs. out of 120 cases table 5 analysis shows 110(91.6%) cases had prom of less than 72 hours duration and 10 (8.4%) case had longer duration of prom(>72 hours). in kifah al-q qa & fatin al-awayshah 3 study 74% cases had prom of <72hrs duration and 26% had prom of >72 hrs.woranart et al 8 study had 92.3 % cases had prom less than 72 hrs duration and 7.69% cases had prom of more than 72 hrs. our study results are consistent with woranart et al 8 study in terms of duration of prom. in this present study 114 (95%) babies cried immediately after birth and 6 (5%) cases had history of delayed cry with apgar score <4 at 1 minute. in begum and roy 12 study 91.4% of babies cried immediately after birth and 8.6% cases had history of delayed cry. hassan and shahin 13 study had incidence of birth asphyxia in 4.8% cases1.so with 5% cases of birth asphyxia our study is consistent with hassan and shahin 13 study. analysing morbidity in the present study 45(37.5%) cases had rds, septicemia was seen in 12(10%) cases, pneumonia in 2(1.7%) cases, meningitis in 2(1.7%) cases. anjanadevi and reddy devi et al 14 found neonatal infection in 53.8% cases and rds in 18.3%.nili and aa shams ansari 2 found rds in 33.3% cases and septicemia in 5.5% cases and pneumonia in 2.5% cases. anjana devi et al 14 found septicemia in 11.5%, pneumonia in 5.8% and meningitis in 2.9% cases121.the present study results are consistent with observations made by f. nili and aa shams ansari. 2 in the present study 1.7% of cases had meningitis. in the present study there is highly significant difference in morbidity among preterm and term babies. out of 61 cases having morbidity 45(73.7%) cases were preterm, among 45 cases of rds 31(68.8%) cases ware premature and out of 12 cases of septicemia 10(83.3%) cases were preterm. analysis showed out of 120 mothers 78(64.8%) cases were primipara and 62(51.6%) mothers are of lower socioeconomic status. sharma sk et al 15 study had also similar results with 62.5% primipara cases and 37.5% are of lower socioeconomic status. merenstein gb and weisman le 16 observed that when prom is accompanied with prematurity the incidence of proven sepsis is 4-6%. miller hc and jekel f 17 observed that neonatal morbidity is affected mainly by prematurity itself, rather than by the occurrence of prom. we found that morbidity was more among preterm babies which was statistically significant, p-value less than 0.001. the complications are more as the duration of prom increases. all 12 cases of septicemia were of prom duration more than 24 hours but out of 45 cases of rds 25 (55.5%) cases had duration of prom less than 24 hours. f nili and aa shams ansari 2 observed that the risk of 202 mahala et al. / panacea journal of medical sciences 2021;11(2):197–203 pneumonia were much higher in group with > 24 hrs of prom and rds was more common if prom duration is less than 24 hrs. taylor claimed that as latent period increased from 12 hours to more than 24 hours neonatal infection rate also increase from 1.3% to 13.3%124. in our study septicemia was seen in 10% cases with prom more than 24 hrs which is consistent with taylor study. rds was more common in prom duration less than 24 hrs consistent with f nili and aa shams ansari 2 study. in the present study crp positive in 29.2% of cases. these results are consistent with observations made by kifah alqa qa and fatin al-awayshah 3 in their study. staphylococcus (58.3%) was the most common organism causing sepsis followed by klebsiella (14.2%) cases, e.coli in (14.2%) cases, pseudomonas in (14.2%) cases. shubeck et al 9 observed growth of staphylococcus in 50% of cases followed by klebsiella in 14% of cases and pseudomonas in 4% of cases. j.a. fayaz also found that preterm with leaking has less rds as compared to those without leaking because of prom the fetus is exposed to stress which leads to more secretion of glucocorticoids which accelerate lung maturation. gluck et al 18 explained the acceleration of pulmonary maturity documenting the following observations. 1. prom of more than 24 hours duration was associated with more mature l:s ratio of amniotic fluid than normally expected for that gestation. 2. phosphatidyl glycerol (pg) appeared in the amniotic fluid at an earlier period in gestation following prom. 3. trachea or pharyngeal aspirates from preterm infants born following prom of more than 24 hours showed a mature phospholipids pattern at gestation ranging from 29 to 33 weeks. that out of 120 cases with prom duration more than 18 hours 2 cases (1.7%) died who had prom duration of more than 24 hours and both deaths occurred due to septicemia. f. nili and a.a. shams ansari 2 observed that mortality is more with prom more than 24 hours. the present study analysis showed 20.8% of the neonates had leucopenia. 60.8% cases had leucocyte count between 5000 to 20000 cells/cumm. leucocytosis was observed in 18.4% cases. kifah al-q qa & fatin al-awayshah 3 observed leucopenia in 41.7% cases and 58.3% cases had leucocyte count between 5000 – 20000 cells/cumm and crp was positive in 21.7% cases in their study. 6. summary the present prospective study includes 120 cases of neonates born to mothers with prom of more than 18 hours duration delivered in scb medical college and hospital, cuttack from december 2018 to september 2020. out of 120 newborns 53.3% were males and 48.3% were females 70% of the total neonates were born by normal vaginal delivery and 30% were delivered by cesarean section 53.3% of the cases had premature rupture of membranes of 18-24 hours duration,38.3% cases had premature rupture of membranes of 24 to 72 hour and 8.4 % cases had premature rupture of membranes of more than 72 hr. rds was the most common clinical manifestation (37.5%) followed by septicemia (10%), meningitis (1.7%) and pneumonia 1.7%. out of 120 cases 49.1% neonates were asymptomatic and 50.9% were symptomatic. neonatal morbidity was more common in preterm babies. rds was the commonest clinical presentation in these babies. the incidence of septicemia was found to be 10 %. the incidence of septicemia was more in premature rupture of membranes of longer duration. there is a significant increase in the incidence of early onset sepsis in preterm with premature rupture of membranes. the incidence of neonatal deaths was 1.7% out of 120 neonates born to mothers with prom of more than 18 hours duration. incidence of mortality among neonates with early onset sepsis was 16.7%. crp was positive in 29.2% of cases. out of 120 cases 20.8% had leucopenia and 18.4% had leucocytosis. most common organisms isolated in blood culture were staphylococcus followed by klebsiella, e. coli, pseudomonas. prom is more common in primipara and women of lower socioeconomic status. 7. conclusion premature rupture of membranes is a high-risk obstetric condition. active management is needed to enable delivery within 18 hours of premature rupture of membranes as it offers better neonatal outcome. premature rupture of membranes though common in term patients, is not responsible for increased maternal and fetal morbidity and mortality in them. premature rupture of membranes is responsible for increased perinatal morbidity among preterm neonates. morbidity increases as the duration of premature rupture of membranes increases. advances in care of preterm babies may reduce the perinatal mortality following premature rupture of membranes, the ultimate solution lies in prevention of premature rupture of membranes before term. 7.1. what this study adds great attention to maternal risk factors like previous prom, addiction, lower socioeconomic status, maternal uti etc may decrease the incidence rate and severity of maternal and neonatal complications associated with prom. appropriate antibiotic coverage for prom mother in appropriate time will reduce neonatal mortality and morbidity. early diagnosis of neonatal sepsis using a protocol that utilizes mahala et al. / panacea journal of medical sciences 2021;11(2):197–203 203 multiple methods and follow up for the clinical condition of these neonates are the key factors to avoid missing neonates with true sepsis and decreasing the use of antibiotics in those without infection. 8. conflict of interest the authors declare that there are no conflicts of interest in this paper. 9. source of funding none. references 1. scott jr, gibbs rs, karlan by, haney af. danforth’s obstetrics and gynecology. in: 9th edn. philadelphia, lippincott williams & wilkins; 2003. 2. nili f, ansari s. neonatal complications of premature rupture of membrane. acta med iranica. 2003;41(3):176–8. 3. al-qa’qa k, al-awaysheh f. awayshih neonatal outcome and prenatal antibiotic treatment in premature rupture of membranes. pak j med sci. 2005;21(4):441–4. 4. down sb, yasin s. premature rupture of membranes before 28 weeks: conservative management. am j obstet gynecol. 1986;155(3):471–9. doi:10.1016/0002-9378(86)90257-7. 5. davies pa. bacterial infection in the fetus and newborn. arch dis child. 1971;46(245):1–27. doi:10.1136/adc.46.245.1. 6. kliegman rm. nelson text book of pediatrics . in: 21st edn.. vol. 1; 2019. p. 995–1005. 7. egarter c, leitich h, karas h, wieser f, husslein p, kaiderb a, et al. antibiotic treatment in preterm premature rupture of membranes and neonatal morbidity: a metaanalysis. am j obset gynaecol. 1996;174(2):589–97. doi:10.1016/s0002-9378(96)70433-7. 8. ratanakorn w, srijariya w, chamnanvanakij s, saengaroon p. incidence of neonatal infection in newborn infants with a maternal history of premature rupture of membranes (prom) for 18 hours or longer by using phramongkutklao hospital clinical practice guideline (cpg). j med assoc thai. 2005;87(7):973–8. 9. shubeck f, benson rc, clark ww. fetal hazard after rupture of the membranes. a report from the collaborative project. obstet gynecol. 1966;28(1):22–31. 10. sanyal mk, mukherjee tn. premature rupture of membrane; an assessment from a rural medical college of west bengal. j obstet gynecol india. 1990;40(4):623–8. 11. kodkany bs, telang ma. premature rupture of membranes. a study of 100 cases. j obstet gynecol india . 1991;41(4):492–6. 12. begum h, roy m, shapla nr. perinatal outcome of premature rupture membrane in pregnancy. j dhaka med coll. 2018;26(2):135– 9. doi:10.3329/jdmc.v26i2.38831. 13. boskabadi h, maamouri g. shahin mafinejad neonatal complications related with prolonged rupture of. maced j med sci. 2011;4(1):93–8. doi:10.3889/mjms.1857-5773.2011.0159. 14. devi a, devi r. premature rupture of membrane a clinical study. j obstet gynecol india. 1996;46:63–8. 15. sharma sk, dey m. maternal and neonatal outcome in cases of premature rupture of membranes beyond 34 weeks of gestation. int j reprod contracept obstet gynecol . 2017;6(4):1302–5. 16. merenstein gb, weisman le. premature rupture of the membranes: neonatal consequences. semin perinatal . 1996;20(5):375–80. doi:10.1016/s0146-0005(96)80004-8. 17. miller hc, jeker jf. epidemiology of spontaneous premature rupture of membranes: factors in preterm births yale. yale j biol med. 1989;62(3):241–51. 18. gluck l, kulovich mv. lecithin/sphingomyelin ratios in amniotic fluid in normal and abnormal pregnancy. am j obstet and gynecol. 1973;115(4):539–46. doi:10.1016/0002-9378(73)90404-3. author biography ratikanta mahala, resident jyoti ranjan champatiray, associate professor madhusmita pradhan, associate professor mangal charan murmu, associate professor cite this article: mahala r, champatiray jr, pradhan m, murmu mc. outcome of neonates born to mothers with premature rupture of membranes. panacea j med sci 2021;11(2):197-203. http://dx.doi.org/10.1016/0002-9378(86)90257-7 http://dx.doi.org/10.1136/adc.46.245.1 http://dx.doi.org/10.1016/s0002-9378(96)70433-7 http://dx.doi.org/10.3329/jdmc.v26i2.38831 http://dx.doi.org/10.3889/mjms.1857-5773.2011.0159 http://dx.doi.org/10.1016/s0146-0005(96)80004-8 http://dx.doi.org/10.1016/0002-9378(73)90404-3 panacea final 2014 1 learning depends on several factors but a crucial step is engagement of the learner. medical students experience a variety of learning activities in the environment of the medical school/ college. the environment is usually complex and unique & its most important determinant is curriculum. the learning environment is primarily affected by curriculum. the learning environment is not only an important determinant of curriculum but is also a striking index of the behaviour of both students & the trainers because teaching is not only related to giving information & sharing experiences but producing a contextually or /and environmentally related learning as well. curriculum's most significant manifestation is the environment both, educational & organisational, which includes everything that is happening in the medical school/college. a good learning environment is vital for the delivery of quality training. there has been a proven connection between the environment & the valuable outcomes of the students' achievement, satisfaction& success. positive environment & positive outcome appears to go together. as the learning environment affects students motivation & achievement it is important to get feedback from the students on how they are experiencing their learning environment on a regular basis & the results should be used to guide strategic planning & the institutional focus of optimum utilisation of available resources. the undergraduate mbbs curriculum in india is still in the traditional mode. generally it is teacher centred, discipline based, information gathering & hospital based with no option or elective module. but education is a dynamic process& it needs to change its pattern to suit the changing demands of the health care system of the society & the nation. a continous improvement in the educational environment of a curriculum is possible only by defining its strengths & weaknesses. thus monitoring the perception of students about the educational environment is critical as successful management of any change is only possible with systemic feedback. every now & then we cannot change the curriculum but the feedback obtained can also be used to optimise the same curriculum to suit majority of the students & to accommodate each & every student. for higher quality of learning it is required to enrich learning environment by identifying its weaknesses. so more importance should be given to perception of students to improve educational environment as perceptions are associated positively with learning approach, learning outcomes & attitude towards studying. so the principal areas for further development of educational environment could be teaching methods, teachers behaviour with students, the classroom atmosphere, the social & academic environment, support system during stress, commitment of the institute towards students with facilities like favourable accomodation, mentorship programmes etc. it is also the need of the hour to create a non threatening environment in the classroom teaching&to give more opportunities to the students for self learning by incorporating new methods of teaching learning and assessment. worldwide perception of students has been used to know the educational environment in variety of circumstances. to quote a few, in melaka manipal medical college manipal india, students' perception of the learning environment was studied and based on the feedback received. problem based learning sessions were implemented in the curriculum. also short term students research projects were introduced to make the students independent learners. personal and professional development sessions were implemented and the number of summative examinations were reduced to reduce stress (1). students' perception was also utilised to compare traditional curriculum with the early clinical exposure program in iran(2) & with problem based learning in saudi arabia (3). students perception was used in a medical school of uae experiencing curricular transition from discipline based to organ based curriculum and the students not only reinforced the justification of the course organisers about the new curriculum but also identified remedial interventions in the form of new strategies in assessment (4). in this issue of panacea we have included an original research article pjmsvolume 4 number 1: jan june 2014 editorial optimizing medical education 1 gade shubhada 1 asstt. professor, physiology faimer fellow, secretary met unit nkpsims & rc digdoh hills, hingna road nagpur 440019 shubhagade@gmail.com depicting educational environment of nkpsims & rc nagpur, the students' perception about the learning environment and to identify our strengths & weaknesses. references: 1. abraham r ,ramnarayan k, vinod p, torke s. students' perception of learning environment in an indian medical school, bmc medical education .2008;8:20. 2. ebrahim s, kojuri j. comparison of two educational environments in early clinical exposure program based on dundee ready educational environment measure j.adv med & prof 2013;1(1), 36-37. 3. rukban m, khalil m, al-zalabani a. learning environment in medical schools adopting different educational strategies.educational research and reviews.march 2010; vol 5 (3):126-129. 4. shahnaz syed ilyas,sreedharan jayadevan. students' perception of educational environment in a medical school experiencing curricular transition. united arab emirates. medical teacher. 2011; 33:e37-e42. pjmsvolume 4 number 4: jan june 2014 editorial 2 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 panacea final 2014 49 prevalence of dysmenorrhea among girl students in a medical college 1 2 dass ruhi , kulkarni meenal 1 2 iiimbbs student, associate professor, department of community medicine, nkpsims & rc, digdoh hills, hingana road, nagpur-440019. meenalkulkarni76@gmail.com abstract : menstruation is a phenomenon unique to the females. dysmenorrhea is the most common and least understood and addressed complaint. prevalence of dysmenorrhea was found to be 54 % to 87%. dysmenorrhea has its impact on academic performance, college, sports and social activities of girls. but very few girls seek health care for this problem. a cross-sectional descriptive study was conducted in a medical college attached to a tertiary care hospital to find out prevalence of dysmenorrhea among medical college girl students, to study its impact on various activities and to assess health care seeking behavior during dysmenorrhea.allgirl students (first to final mbbs) from a medical college who were willing to participate included in the study (n=150). data was analyzed in proportions, mean and standard deviation.prevalence of dysmenorrhea was found to be high (66%). premenstrual syndrome was present among 44% girls. nearly half of the girls reported dysmenorrhea every month rd and among 1/3 girls intensity of pain of dysmenorrhea was severe. common relieving factor was found to be rest. 45% girls reported absenteeism from colleges due to it. 87% girls reported limitations in various activities due to rd dysmenorrhea. only 1/3 girls were seeking health care for dysmenorrhea. maximum number of girls (89%) reported 'no need of treatment' during dysmenorrhea. hence it was concluded that dysmenorrhea was found to be common problem.there is need to increase awareness among girls regarding importance of health care seeking during dysmenorrhea. keywords : dysmenorrhea, impact, healthcare seeking. introduction: menstruation is a phenomenon unique to the females. the onset of menstruation is one of the most important changes occurring among girls .the first menstruation occurs between 11 and 15 years (1). although reproductive health in particular related to maternal health and reproductive tract infections is recognized as a health priority in developing countries,much less attention is paid to menstrual health and menstrual disorders.of all menstrual complaints dysmenorrhea is by far most common and arguably,the least understood and addressed complaints (2). primary dysmenorrhea is defined as painful menses in women with normal pelvic anatomy usually beginning during adolescence. it is characterized by crampy pelvic pain beginning shortly before or at the onset of menses and lasting 1 to 3 days. it not only disturbs their routine but also causes humiliating suffering (3). prevalence of dysmenorrhea was found to be 54 % to 87% from various studies (4-10). dysmenorrhea has its impact on academic performance, college, sports and social activities of girls. but very few girls seek health care for problem of dysmenorrhea. so the present study was designed to study the prevalence and impact of dysmenorrhea among medical college girls and to assess health care seeking behavior among them. material and methods: a cross-sectional descriptive study was conducted in nkp salve institute of medical sciences and research center, nagpur. the study was conducted from june 2011 to september 2011. all healthy girl students (first to final mbbs) from a medical college (nkpsims, nagpur) who were willing to participate were included in the study (n=150). after taking permission from iec, the project was started. girls from different semesters from the institute were contacted after finishing their classes or clinics in the college. after taking informed consent the data was collected in selfadministered predesigned pretested questionnaire. questionnaires were collected immediately in 1520 minutes. information regarding pattern of menstrual cycle, premenstrual syndrome (pre-menstrual syndrome-a change in mood or behavior or appearance of some abnormal vague symptoms noticed in second half of menstrual cycle), details of dysmenorrhea (dysmenorrhea-painful menstruation of sufficient magnitude so as to incapacitate day to day activities). during last 6 months, impact of dysmenorrhea on various activities and health care seeking behavior during dysmenorrhea was collected. data was analyzed by using epi info statistical package by calculating simple proportions, mean and standard deviation. results: the girls were in the age range of 18 to 22 years. mean age of menarche was found to be 12.98±1.44 maximum number of girls (84%) had attained menarche between 11 to 14 years of age. most of the girls (79.33%) reported mother as a source of information about menstrual cycle. 81.33% girls reported regular menstrual cycle. nearly 70% girls had duration of pjmsvolume 4 number 1: jan june 2014 original article menstrual cycle between 3-5 days and length of menstrual cycle between 28-32 days.18% girls reported excess and 7.34 % girls reported scanty blood flow during menstrual cycle. out of total 150 students, 99 students reported dysmenorrhea so prevalence of dysmenorrhea was found to be 66% (fig. 1). figure 1: prevalence of dysmenorrhea among medical students (n=150) 44% girls were having premenstrual syndrome. irritability, headache, constipation and nausea were common complaints present during premenstrual syndrome. out of total 99 girls, approximately half of the girls (n=49)were suffering from dysmenorrhea every month. more than half (63%) of girls were having dysmenorrhea of moderate or severe intensity(table 1). table1: frequency and intensity of dysmenorrhea(n=99) out of total 99 girls with dysmenorrhea, 45 (45.45%) girls h a v e r e p o r t e d a b s e n t e e i s m i n c o l l e g e d u e t o dysmenorrhea.among 45 girls who remained absent,25 girls (55%) reported absenteeism from college for one or more than one day (table2). table 2: duration of absenteeism from college (n=45) in most of the girls (68.75%) dysmenorrhea was relieved by rest and 27% girls were taking medicines for relief.86(87%) girls were having limitations due to dysmenorrhea (fig. 2). figure 2: limitations due to dysmenorrhea (n=99) limitations were present among 50(58.14%), 16(18.60%) and 13(15.20%) girls in daily activities, in sports and in academics respectively (table3). table 3: limitations in various activities due to dysmenorrhea (n=86) health care seeking behavior was found to be very poor and only 34% girls were seeking health care during dysmenorrhea. almost all girls (90%) reported no need of treatment as a reason for not seeking health care. discussion: in present study mean age of menarche was found 12.98±1.44.singh a et al (3) carried out study in 107 medical college students and found mean age of menarche 12.5 ±1.52 years which is similar to the present study. prevalence of dysmenorrhea was 66% in the present study. few authors (1, 5, 7) found prevalence of dysmenorrhea (85%,79.6%,83.2% respectively) higher than the present study. sc chan et al (6),sharma p, et al(8) and nabia tariq et al(10) reported similar prevalence (68.7%,67.2%,67%) like the present study. premenstrual syndrome is a prevalent menstrual morbidity among college girls next to dysmenorrhea. premenstrual syndrome was reported by 44% girls. sharma et al(8)reported premenstrual syndrome amongst 63.1% girls which is more than the present study. dysmenorrhea was the commonest cause of college absenteeism of girls . it also caused pjmsvolume 4 number 1: jan june 2014 original article 50 every month most of the times rarely dysme49(49.49%) 26(26.26%) 24(24.24%) norrhea frequency mild moderate severe of pain intensity 36(36.36%) 35(35.35%) 28(28.28%) of pain absenteeism number % few periods 20 44.44 1 day 19 42.22 2 days 3 6.67 >2 days 3 6.67 limitations due to number % dysmenorrhea daily activities 50 58.14 sports 16 18.60 academics 13 15.12 socialisation 7 8.14 total 86 100 limitations in various activities of girls. 45.45% girls remained absent from the college due to dysmenorrhea. agarwal a and venkat a(7)also reported school absentees among 24% girls. healthcare seeking behavior was found to be very poor. only 34.34% girls sought healthcare for dysmenorrhea. agarwal a and venkat a (7) conducted a study among secondary school and college girls in singapore and found that only 5.9% girls were seeking medical advice, which is poorer than the present study. conclusion: mother was found to be a common source of information about menstrual cycle. premenstrual syndrome was present among 44% girls. irritability and headache were found to be common complaints during premenstrual syndrome. prevalence of dysmenorrhea was found to be high (66%). nearly half of the girls reported dysmenorrhea every month rd and among 1/3 girls intensity of pain of dysmenorrhea was severe. common relieving factor was found to be rest. dysmenorrhea had impact on various activities of girls.45% girls reported absenteeism from colleges due to dysmenorrhea. 87% girls reported limitations in various activities due to dysmenorrhea and most of the girls were having limitations in daily activities. health care seeking behavior for dysmenorrhea was found poor among girls. only rd 1/3 girls were seeking health care for dysmenorrhea. maximum number of girls (89%) reported 'no need of treatment' as a reason for not seeking health care during dysmenorrhea. references: 1) banikarim c, chacko mr, kelder sh. prevalence and impact of dysmenorrhea on hispanic female adolescents.arch pediatradolesc med 2000 dec; 154(12):1226-9. 2) patel v, tanksalev,sahasrabhojaneem,gupte s, nevrekarp.the burden and determinants of dysmenorrhea: a population–based survey of 2262 women in goa, india. bjog:an international journal of obstetrics and gynaecology2006 apr;113(4):453-63. 3) singhmm,devi r, gupta ss.awareness and health seeking behavior of rural adolescent school girls on menstrual and reproductive health problems.indian journal of medical sciences.1999 oct; 53(10):439-43. 4) atchuta kra, saibhargavi p. dysmenorrhea in different settings.ijcm2008 oct;33(4):246-249. 5) agarwal a, agarwala. a study of dysmenorrhea during menstruation in adolescent girls. ijcm2010; 35(1):159-164. 6) ss chan,kw yiu, pm yuen, ds sahota, tk chung. menstrual problems and health care seeking behavior in hong kong chinese girls. hong kong med j2009; 15(1):18-23. 7) agarwal a, venkat a. questionnaire study on menstrual disorders in adolescent girls in singapore. j pediatr adolesc gynaec 2009 dec; 22(6):365-71. 8) sharma p, malhotra c, taneja dk, saha r problems related to menstruation among adolescent girls.ind j paediatr 2008 feb; 75(2):125-9. 9) hong-gui zhou. prevalence of dysmenorrhea in female students in a chinese university: a prospective study. health 2010; 2:311-314. 10) nabiat, jawad hashim m,jaffery t, sumairaijaz s, sana b, zainab a. impact and healthcare-seeking behavior of premenstrual symptoms and dysmenorrhea.bjmp 2009; 2(4):40-43. pjmsvolume 4 number 1: jan june 2014 original article 51 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 panacea journal of medical sciences 2021;11(2):231–235 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article prevalance and distribution of candidia species from diabetic foot ulcer in tertiary care centre, jamnagar, gujarat pushpa r kateshiya1, binita j aring1,*, dipali maganbhai gavali1 1dept. of microbiology, shri m p shah govt. medical college, jamnagar, gujarat, india a r t i c l e i n f o article history: received 23-03-2021 accepted 11-06-2021 available online 25-08-2021 keywords: dm foot c. albicans diabetes mellitus fungus culture. a b s t r a c t introduction: diabetes mellitus is a chronic disease which may cause diabetic foot ulcer, which is a major cause of morbidity and mortality, it may also lead to foot amputation due to gangrene, and may cause cellulitis, abscess etc. aims & objectives: to study prevalence of candidiasis in diabetic foot ulcer in a tertiary care centre, jamnagar. materials and methods: 32(10.66%) isolates that were recovered from wound discharge samples (300 samples tested) from november 2017 to september 2018. all isolates were visualized under direct microscopy, cultured, & sugar assimilation tests were performed. results: amongst 300 samples 32(10.66%) were positive for fungal culture, in which major isolates was c. albicans (50%), c. tropicalis (18.75%), c. dubliniensis (9.37%), c.krusei (9.37%), c. glabrata (6.25%), c. parapsilosis (6.25%). conclusion: this study shows that in diabetic foot ulcer most common fungal pathogens were c. albicans, c. tropicalis, c. dubliniensis, etc. early identification of organism can help in early treatment and early recovery. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction diabetes mellitus affect globally, about 463 million people had diabetes worldwide as of 2019. 1 diabetes mellitus have major 3 types (i) type i: insulin dependent diabetes mellitus (iddm), where pancreases produces decreased amount of insulin (insulin deficiency). (ii) type ii: noninsulin dependent diabetes mellitus (niddm) or adult diabetes mellitus, where body cells do not respond to insulin (insulin resistance). (iii) type iii: gestational diabetes occurs in pregnant women due to high sugar level. among these type 90% cases were type ii diabetes mellitus. diabetes mellitus has multi-system affliction and causes long term complications like cardiovascular diseases, * corresponding author. e-mail address: drbinitajosepharing@gmail.com (b. j. aring). diabetic retinopathy, nephropathy, neuropathy and diabeticrelated foot ulcers. 2–4 in the history of diabetes treatment there has been a wide range of modern treatments available to control it, in the near future we may expect a complete cure. 5,6 in nontraumatic lower limb amputation most common cause was diabetic foot ulcer. amputation leads to morbidity and disability or discomfort in routine physical activity. diabetic foot ulcer infection is poly-microbial and multidrug resistant. several studies and research which were conducted showed that aerobic and anaerobic bacterial infection were of primary importance. due to the lack of mycological importance, fungal infections were ignored to be a cause of diabetic ulcer. the present study was conducted to isolated the fungal pathogen from diabetic foot ulcer wound and in which https://doi.org/10.18231/j.pjms.2021.048 2249-8176/© 2021 innovative publication, all rights reserved. 231 232 kateshiya, aring and gavali / panacea journal of medical sciences 2021;11(2):231–235 candida species were more common. all fungi constituting the genus candida belongs to the yeast like fungi because they exhibit a mycelium as well as a yeast form. the yeast cells are unicellular, small, oval, 3-5 µm in diameter and exhibit budding forms called blastospores or blastoconidia. the mycelia forms are of two types, pseudo mycelium and true mycelia. 7,8 candida infections were most common in foot ulcers because of widespread use of empirical antibiotic and any medical devices. proper identification of fungi may help for the better outcome and prevents their complications. 2. aims and objectives 1. prevalence of candida species in diabetic foot ulcer. 2. identify non albicans candida species by using phenotyping methods. 2.1. ethics statements the study was approved by institute ethics committee, m. p. shah govt. medical college and guru gobindsingh hospital, jamnagar with ref. no. iec/certi/113/2017. 3. materials and methods in this retrospective study total 300 pus samples were collected from guru gobind singh government hospital, jamnagar. diagnosis of a yeast infection is done by direct microscopic examination, culturing, further diagnosis done with serological, molecular methods and other newer rapid diagnostic tests are available like flurogenic tests, platelia candida antigen test, rapid trehalose assimilation test, cand tec ramco labs. 9 3.1. collection of the specimen on the basis of clinical history and finding, samples were collected as per laboratory protocol. the ulcer site from diabetic foot exudate was collected by sterile thin cotton wool swabs, aseptically. then sample were immediately transported to laboratory for processing. 3.2. diagnostic methods all the samples were processed in the following manner: a. direct microscopy primary smear, including gram’s stain: yeast cells and pseudo hyphae are stained dark blue. b. culture 1. sabouraud dextrose agar (sda): within 2-3 days of incubation cream coloured, pasty and smooth colonies appear. 2. corn meal agar: at 25◦c large, highly refractile, thick walled, terminal chlamydospore were noted. 3. chrom agar: the medium consists of specially selected peptones and artificial substrates called chromogens, which release differently coloured compounds upon degradation by specific enzymes, permits the differentiation of different species of candida like c.albicanslight green to blusih green, c. dubliniensisdark green, c.parapisolosiscream coloured, c.kruseipinkish to purplish, c.glabratapink to purple. fig. 1: different species of candida on chrom agar) 3.3. germ tube test: 10,11 candida species treated with normal human serum and incubated at 37◦c for2-4 hours, shows long tube-like projection extending from mother yeast cells and no constriction at the point of attachment. only c. albicans and c.dubliniensis produce germ tube. 3.4. sugar assimilation test: 12 shows ability of yeast to use particular carbohydrate utilization by presence of halo zone around disc. fig. 2: sugar assimilation test kateshiya, aring and gavali / panacea journal of medical sciences 2021;11(2):231–235 233 3.5. sugar fermentation test: 13 gas production in durham’s tube with colourless to pink colour changes shows sugar fermentation test positive. fig. 3: gas production with carbohydrate assimilation 4. result in present study out of 300 samples 32 samples shows presence of yeast cells on direct smear examination, so the isolation rate of positive cases was about 10.67%, sex wise prevalence of positive cases showed that there is higher prevalence in male (59.38%) than female (40.62%). it is more common in patients of age group between 51-60yr (28.1%), followed by 61-70 yr (25%),41-50 yr (18.8%), 3140yr (12.6%), 21-30 yr & >70yr shows (6.2%)and 11-20yrs (3.1%). fig. 4: sex wise distribution of candida candida isolated among positive samples which include c.albicans (50%), c.tropicalis (18.75%), c.dubliniensis (9.37%), c.krusei (9.37%), c.glabrata (6.25%) & c.parapsilosis (6.25%). the chi-square statistic is 0.068. the p-value is 0.999434. the result is not significant at p < 0.05. table 1: age group wise distribution of candida age (year) total no. percentage 11-20 1 3.1% 21-30 2 6.2% 31-40 4 12.6% 41-50 6 18.8% 51-60 9 28.1% 61-70 8 25% >70 2 6.2% the chi-square statistic is 0.0098. the p-value is 0.999988. the result is not significant at p < 0.10. fig. 5: candida spp. differencing on chrom agar 5. discussion diabetes foot ulcer may be associated with some predisposing risk factors like smoking, alcoholism, trauma, previous ulcer, prior amputation, previous ulcer leading to amputation, neuropathy, etc. ulcer may be due to diabetes any of its complication, which may include fungal isolates may show different patterns, which may affect treatment. in fungal infection identification of the fungal agent species were most important than the isolation. in candida species chrom agar was used as a differential medium due to its ability to detect mixed culture of yeast from clinical specimens for presumptive identification. it is used for the definitive identification because the phenotypic method was time consuming and unable to discriminate c. albicans and c. dubliniensis. 18,19 in present study, we have tested 300 samples of pus. on direct microscopy, smears were examined for pus cells or any fungal elements (yeast cells). all the samples were tested for fungal culture & biochemical test. a study conducted by sanniyasi s et al 14 (72.4%), j nithyalakshmi et al 15 (67.6%), abhilash et al 16 (66.7%) showed prevalence of candida species more common in male than female which was same as present study (59.38%). in our study, among the positive samples the highest number of isolation were c.albicans (50%), c.tropicalis (18.75%), c.dubliniensis (9.37%), c.krusei 234 kateshiya, aring and gavali / panacea journal of medical sciences 2021;11(2):231–235 table 2: comparison of positive cases and sex wise distribution in different studies total sanniyasi s et al (2015) 14 j nithyalakshmi et al (2014) 15 abhilash et al (2015) 16 present study positive cases 15.23% 15.49% 18% 10.67% male 72.4% 67.6% 66.7% 59.38% female 27.6% 32.4% 33.3% 40.62% table 3: comparison of various isolates in different study organism j nithyalakshmi et al (2014) 15 abhilash et al (2015) 16 emilija m m et al (2005) 17 present study c.albicans 64% 49% 18.2% 50% c.tropicalis 18% 23% 22.7% 18.75% c.dubliniensis 4% 5% 9.1% 9.37% c.krusei 5% 5% 4.5% 9.37% c.parapsilosis 9% 18% 36.4% 6.25% (9.37%), c.parapsilosis (6.25%) which compared with j nithyalakshmi et al 15 (64%), abhilash et al 16 (49%), but study by emilija m m et al 17 shows c. parapsilosis (36.4%) followed by c.tropicalis (22.7%) as its highest isolation. 6. conclusion early diagnosis of the patients on clinical ground as well as diagnosis of the causative organism and to know its effective treatment is of much importance for the positive outcome. in this study non albicans candida species was found to be equally responsible for this clinical condition. treatment failure is common with candida non-albicans, because of its high resistance and low susceptibility to azoles. therefore accurate identification of different species of candida is essential. for prevention, proper personal hygiene along with awareness of cleanliness may help the situation. strict hospital ward and operation theatre cleanliness is also required. frequent changing of antiseptic solution bottles and judicious use of antibiotics are important. 7. limitation as candida albicans can be seen as normal flora it was difficult to differentiate both the pathogen and non pathogen forms. as we had only limited resources it was difficult to differentiate the candida non albicans upto species level. acknowledgments the author expresses their sincere gratitude to all the staff members of microbiology department for their help and support. references 1. idf diabetes atlas. in: 9th edn. (retrieved 18 may 2020); 2019. available from: www.diabetesatlas.org. 2. yerat rc, rangasamy vr. a clinic microbial study of diabetic foot ulcer infections in south india. int j public health. 2015;5(3):236–41. 3. sallam a, el-sharawy a. role of interleukin-6 il-6) and indicators of inflammation in the pathogenesis of diabetic foot ulcers. aust j basic appl sci. 2012;6(6):430–5. 4. ali o, ali ah, southy he, and sk. microbiological profile of diabetic foot ulcer and use of il6 as a predictor for diabetic foot infection. int j curr microbiol app sci. 2016;5(12):1–10. 5. dharod m. diabetic foot: microbiology, pathogenesis and glycan studies lydia francis. university of westminster; 2010. available from: https://core.ac.uk/download/pdf/161119986.pdf. 6. mihir v, butala. study of edinburgh university solution of lime (eusol) dressing in diabetic foot. saurashtra university; 2012. 7. moran gp, sullivan dj, coleman dc. emergence of non-candida albicans candida species as pathogens . in: calderone r, editor. candida and candidiasis. 4th edn.. vol. 4. washington: asm press; 2002. p. 37–53. 8. ajello l, george lk, kalpan w, kaufman l. cdc laboratory manual for medical mycology, public health service. vol. 25. washington: public health service; 1963. p. 1–28. 9. smitka cm, jackson sg. rapid flurogenic assay for differentation of the candida parapsilosis group from other candida species. j clin microbiol. 1989;27(1):203–6. 10. isibor jo, eghubare a, omoregie r. germ tube formation in candida albicans: evaluation of human and animal sera and incubation atmosphere. shiraz emed j. 2005;6(1&2). 11. konemen ew, allen sd, janda wm, schreckenberger p, winn w. mycology. in: color atlas and the textbook of diagnostic microbiology. 6th edn. lippincott, philadelphia; 1997. p. 1153–230. 12. hazen kc, howell sa. candida, cryptococcus and other yeast of medical importance. in: and others, editor. in manual of clinical microbiology. 8th edn.. vol. 2. american society for microbiology;. p. 1693–711. 13. mackie m. fungi in practical medical microbiology . in: 14th edn. churchill livingstone; 1996. p. 695–717. 14. saravanan s, jagan b, cunnigaiper d. fungal infection: a hidden enemy in diabetic foot ulcers. j foot ankle surg. 2015;2(2):74–6. 15. nithyalakshmi j, nirupa s, sumathi g. diabetic foot ulcers and candida co-infection: a single centered study. int j curr microbiol app sci. 2014;3(11):413–9. 16. abhilash s, kannan ns, rajan kv, pramodhini. clinical study on the prevalance of fungal infections in diabetic foot ulcers. int j cur res rev. 2015;7:8–13. 17. emilija mm, smilja k, milan v, drago ds, mladen b, verica v, et al. candida infection of diabetic foot ulcers. daibetologia croat. 2005;60(1):43–50. 18. baradkar vp, mathur m, kumarhichrom s. hichrom candida agar for identification of candida species. indian j pathol microbiol. www.diabetesatlas.org https://core.ac.uk/download/pdf/161119986.pdf kateshiya, aring and gavali / panacea journal of medical sciences 2021;11(2):231–235 235 2010;53(1):93–5. 19. nadeem sg, hakim st, kazmi su. use of chromagar candida for the presumptive identification of candida species directly from clinical specimens in resource-limited settings. j med. 2010;5. doi:10.3402/ljm.v5i0.2144. author biography pushpa r kateshiya, tutor binita j aring, associate professor dipali maganbhai gavali, assistant professor cite this article: kateshiya pr, aring bj, gavali dm. prevalance and distribution of candidia species from diabetic foot ulcer in tertiary care centre, jamnagar, gujarat. panacea j med sci 2021;11(2):231-235. http://dx.doi.org/10.3402/ljm.v5i0.2144 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2021;11(3):452–457 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a profile of acute kidney injury in eastern india: a cross sectional study amitava mazumdar1, sujata mazumdar1, ujjal kumar chakravarty1, tushar kanti pakira2, somnath maitra3,*, santa subhra chatterjee4 1dept. of general medicine, rkmsp, vivekananda institute of medical sciences, kolkata, west bengal, india 2chandannagar subdivisional hospital, chandannagar, west bengal, india 3dept. of general medicine, jagannath gupta institute of medical sciences and hospital, budge budge, kolkata, west bengal, india 4tata medical center, kolkata, west bengal, india a r t i c l e i n f o article history: received 05-03-2021 accepted 28-04-2021 available online 24-11-2021 keywords: aki rifle akin kdigo a b s t r a c t introduction: aki is an important cause of morbidity and mortality with mortality remaining unchanged in the last decade inspite of advances in treatment.it is classified as pre renal, renal and post renal categories with overlap. the classification criterias are rifle, kdigo and akin, based on which the present study has been conducted, as the new markers of aki such as ngal,il 18 and kim 1 are not sensitive and specific. aims and objectives: the purpose of the study is to determine the aetiologies, clinical features, risk factors and comorbidities associated with aki in a tertiary care hospital. materials and methods: this prospective observational study was conducted in rkmsp with 60 indoor patients after taking consent and applying the inclusion and exclusion criteria.after taking history and performing clinical examination,laboratory investigations were done and detailed statistical analysis was performed to obtain the results. results: study showed that with rise of age, aki increased. females were more commonly affected with sepsis being the commonest cause and dm is the commonest associated co morbidity.most of the patients were in risk stage according to rifle criteria and incidence of aki was more or less similar, according to different classification systems. conclusion: the importance of the study lies in the fact that study of risk factors, aetiology, clinical features and co morbities associated with aki will pave the path for larger studies so that the mortality and morbidity from aki may be modified. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction acute kidney injury(aki) is a heterogenous syndrome defined by a rapid decline in the gfr resulting in the retention of metabolic waste products and dysregulation of fluid, electrolytes, and acid base homeostasis. 1 * corresponding author. e-mail address: som_jeet@yahoo.co.in (s. maitra). aki represents a broad constellation of pathophysiologic process of varied severity and etiology, these includes decrease in gfr, partial or complete obstruction to urinary flow, and a spectrum of processes with characteristic patterns of glomerular, interstitial, tubular, or vascular parenchymal injury. decreased urine output is often a cardinal manifestation of aki, and patients are frequently classified based on urine flow rates as non oliguric (urine output https://doi.org/10.18231/j.pjms.2021.089 2249-8176/© 2021 innovative publication, all rights reserved. 452 mazumdar et al. / panacea journal of medical sciences 2021;11(3):452–457 453 >400ml/day), oliguric (urine output<400ml/day) or anuric (urine output<100ml/day). 2 multiple mechanisms may contribute to this increased susceptibility, including diminished renal functional reserve, impaired salt and water conservation predisposing to intravascular volume contraction, decreased activity of detoxification mechanism increasing susceptibility to cytotoxic injury etc. aki usually divided into three broad pathophysiologic categories based on cause. 1. prerenal disease characterised by effective hypoperfusion of the kidneys in which there is no parenchymal damage to the kidney. 2. intrinsic disease involving the renal parenchyma. 3. postrenal disease associated with acute obstruction of the urinary tract. although these categories are useful and help to inform the initial clinical assessment of patients with aki, there is often a degree of overlap among these categories. aki, previously called arf, was first described by the term ‘ischuria renalis’ by william herbeden in 1802. 3 the term aki was used for the first time by william mac naider in 1918 in a situation of mercury poisoning, but became the preferred term in 2004 when arf was redefined as aki by rifle criteria. 4 the latest classification of aki proposed by the acute kidney injury working group of kdigo definition and staging system is the most recent and preferred definition, is based on the previous two classification, and had the aim of unifying the definition of aki. 5 despite significant advances in both critical care and nephrology, the mortality rate of hospitalized aki cases has remained relatively unchanged at around 50% . despite its widespread use, however, serum creatinine has significant limitations as a tool for assessing gfr as age. gender, muscle mass and diet, mostly protein intake, are determinants of creatinine production. 6 some equations for e gfr account for some of these variables (such as age and gender in the mdrd equation), muscle mass and nutritional considerations are not reflected by these equations. so need of some alternative diagnostic molecules was evident and here comes the new biomarkers for early detection and monitoring outcome and prediction of mortality and morbidity in aki. the newer diagnostic biomarkers include ngal, urinary cystatin-c, kidney injury molecule-1 (kim-1) and il 18. in case of early post ischemia, up regulation of ngal transcription and translation, particularly in proximal tubular cells occurs. so, level of urinary as well as blood ngal increases well before (within 2 hours of injury) than rise in serum creatinine (12-24 hours). during any form of ischemic renal injury, il-18 increase well before rise of serum creatinine. following ischemic injury, kim-1 it is dramatically up regulated in regenerating proximal tubules. cystatin c, is produced by all nucleated cells. serum levels of cystatin c have been established as a reliable correlate of gfr, superior to serum creatinine in that cystatin c production is not influenced by muscle mass; its level is not affected by age, race, or gender; and its urinary clearance does not involve tubular secretion. however, while serum cystatin c level can be used as a surrogate marker of gfr, it is not a true biomarker of aki in that its levels are not a direct marker of renal injury. elevation in urinary cystatin c, on the other hand, is closer to a true biomarker of aki. cystatin c is freely filtered at the glomerulus and then nearly completely reabsorbed by the proximal tubules. recent human studies on urinary cystatin c have shown promise in using this measurement as a biomarker of aki, with cystatin c levels assayed by elisa. these markers have been evaluated in various studies either alone or in combination but the sensitivity and specificity data is lacking, hence these have not been included still in the classification criterias, i.e. rifle, akin and kdigo. this study is based on the rifle, akin and kdigo criterias. there are several studies all over the world and also in india but all of them points towards a particular etiology of acute kidney injury. so the main purpose of this study is to assess the etiology, clinical features, risk factors and co morbities associated with aki and to reduce the overall morbidity and mortality. 2. aims and objectives 1. to evaluate the different etiologies (sepsis, like pneumosepsis, urosepsis, intraabdominal sepsis; drugs like diuretics, heart failure, acute gastroenteritis, pancreatitis etc, cancer) of aki. 2. to study the different clinical presentation of aki (like dyspnea, oliguria, anasarca, uremic features like encephalopathy and vomiting, infection, postoperative presentation). 3. to evaluate the risk factors of aki (hypotension, dehydration). 4. to study the comorbid illness associated with aki (dm, hypertension, anemia, chronic obstructive lung disease, cld). 3. materials and methods after taking ethical consent, the study was conducted in rkmsp. it is a prospective, observational, cross sectional study with the patients admitted in medicine ward, icu(medicine) and post-operative hdu and the study was conducted for one and half years. 3.1. variables 1. diseases causing aki (sepsis, heart failure, over use of diuretics, acute gastroenteritis, acute pancreatitis). 454 mazumdar et al. / panacea journal of medical sciences 2021;11(3):452–457 2. clinical presentation of aki (dyspnea, fatigue, drowsiness, oliguria). 3. risk factors of aki (dehydration, postoperative, hypotension, dehydration). 4. co-morbidities with aki (diabetes mellitus, hypertension, chronic lung disease and cld). 3.2. inclusion criteria 1. patients willing to participate in this study. 2. all patients admitted in medical ward, medicine icu and post-operative hdu. 3.3. exclusion criteria 1. patients with back ground ckd. 2. patients on maintenance dialysis. 3. patients admitted here from other hospital(s) without proper documents. 4. age below 12 years. 3.4. sample size patients from above mentioned units. 3.5. nature of data collection 1. history 2. examination (a) general examination (b) gastro intestinal system (c) cardio vascular system (d) respiratory system (e) central nervous system (f) locomotor system (g) skin and appendages 3. laboratory parameters cbc (hematology analyser and manual technique), crp (latex agglutination test), rft (automated analyser), lft (automated analyser), electrolytes (automated analyser), chest x ray(digital), mp (thick and thin smear) and mp dual antigen test , dengue igm ab (elisa), scrub typhus igm ab (elisa),ecg, echocardiography, vasculitis and collagen vascular disease profile (rheumatoid factor, anf by hep2, ana profile, panca), blood culture and sensitivity (aerobic and anaerobic), urine re/cs (aerobic and anaerobic), test for other tropical illness, usg wa,kub, ct kub. 4. results and analysis for statistical analysis .data were entered into a microsoft excel spreadsheet and then analysed by spss (version 25.0; spss inc., chicago, il, usa) and graph pad prism version 5. data have been summarized as mean and standard deviation for statistical analysis: numerical variables and count and percentages for categorical variables. two-sample t-tests for a difference in mean involved independent samples or unpaired samples. paired t-tests were a form of blocking and had greater power than unpaired tests. p-value ≤0.05 was considered for statistically significant. table 1: distribution of age in years age in years frequency percent ≤30 3 5.0% 31-40 5 8.3% 41-50 4 6.7% 51-60 16 26.7% 61-70 10 16.7% 71-80 16 26.7% 81-90 6 10.0% total 60 100.0% 32 patients (53.4%), are of above 60 years. out of them, 16 patients (26.7%) were between 71 years and 80 years. fig. 1: showing sex distribution 40(66.7%) patients were female and 20(33.3%) patients were male. among total 60 patients 22(36.7%) patients had sepsis, 6(10.0%) patients had drugs, 2(3.3%) patients had obstructive uropathy, 8(13.3%) patients had heart failure, 4(6.7%) patients had surgery, 3(5.0%) patients had acute gastro enteritis/acute pancreatitis, 2(3.3%)patients had collagen vascular disease/vasculitis, one of systemic lupus erethymatosus and one of granulomatosis with polyangiitis; 4(6.7%) patients had malignancy, 1(1.7%) patient had lvf and 2(3.3%) patients had hepatic disease (cld, others).uro sepsis followed by pneumosepsis (5 cases, 20%). here, 31(51.7%) patients had t2dm followed by hypertension of 16(26.7%). among cardiac morbidities, 1(1.7%) patient had cad and 6(10%) patients dilated cardiomyopathy. bar diagram 1 the mean hospital stay (mean± s.d.) of patients was 11.4237 ± 5.4495 days so, all the three criterias showed similar and comparable results. it is clear from the above tabulation regarding the grading as per rifle criteria on the basis of mazumdar et al. / panacea journal of medical sciences 2021;11(3):452–457 455 table 2: distribution of etiology-sepsis, drugs, obstructive uropathy, heart failure, surgery, acute gastro enteritis/ acute pancreatitis, collagen vascular disease/vasculitis, malignancy and hepatic (cld) frequency percent sepsis no 35 58.3% yes 25 41.7% drugs no 53 88.33% yes 7 11.66% obstructive uropathy no 57 95% yes 3 5% heart failure no 51 85% yes 9 15% post-operative cases no 56 93.3% yes 4 6.7% acute gastro enteritis/acute pancreatitis no 57 95.0% yes 3 5.0% collagen vascular disease/vasculitis no 58 96.7% yes 2 3.3% malignancy no 55 91.66% yes 5 8.3% hepatic causes, chronic liver disease(cld) no 58 96.7% yes 2 3.3% table 3: distribution of sepsis cases among patients with sepsis causing acute kidney injury sepsis frequency percentage urosepsis 18 72 % pneumosepsis 5 20 % intra-abdominal sepsisappendicular abcess 1 4 % central nervous system infectionmeningitis 1 4% skin and bone infectioncellulitis and osteomyelitis 0 0% total 25 table 4: distribution of co-morbidities in patients of aki frequency percent t2dm no 29 48.3% yes 31 51.7% hypertension no 44 73.3% yes 16 26.7% cardiac disease cad 1 1.7% dcm 6 11.66% no 52 86.7% fig. 2: showing distribution of pre renal, renal, post renal causes of aki among study population table 5: comparison among rifle, akin and kdigo criteria staging criteria rifle akin kdigo risk (rifle) or stage 1 (akin/kdigo) 28(46%) 28(46%) 28(46%) injury (rifle) or stage 2 (akin/ kdigo) 21(35%) 21(35%) 21(35%) failure (rifle) or stage 3 (akin/kdigo) 10(16.6%) 11(19%) 11(19%) loss ( rifle) 1(1.66%) end stage renal disease (rifle) serum creatinine level that patients having in risk28(46%), injury 21(35%), failure-10 (16.6%), loss-1(1.66%), no patient entered into the end stage renal disease. the patient who was in “loss”, underwent maintenance dialysis. as per akin and kdigo criteria patients distribution are stage-128(46%), stage-2-21(35%), stage-3-11(19%) in total 60 patients. out of 60 patients 25 patients (41.66%) had sepsis, and among them 10 patients (16.66%) and 12 patients (20%) were in “injury” and “risk” category respectively. among 60 patients, 7 patients (11.66%) received diuretics (frusemide and torsemide) and developed aki and they were in “injury” and “risk” category. out of 60 patients, 9 patients (15%) had heart failure and developed acute kidney injury. 28 patients (46.66%) were in risk category and amongst them 8 patients (28.57%) had heart failure. in the study, most of the patients (46%) were in stage-1 as per akin criteria. out of 60 patients, 25 (41.66%) were in sepsis. amongst them, 12 (20% of total) and 10 (16.66% of total) were in 456 mazumdar et al. / panacea journal of medical sciences 2021;11(3):452–457 stage-1 and stage-2 respectively. in the present study, out of 60 patients, 9 patients (15%) had heart failure. most (8) of them were in stage-1 as per akin criteria. out of 60 patients, 7 (11.66%) patients had undergone aki due to diuretics use and most of them were is stage1 (3 no, 5% of total) and in stage-2(4 no, 6.66% of total) respectively as per akin criteria. most of the patients (46%) were in stage-1 as per kdigo criteria. 5. discussion in the study, we found that aki was more prevalent above age 50 years and it was 80%. in one study in 2007 by ali khan and simpson et al, 7 based on 223390 population median age group was found to be 76 years for aki. a study by istifanus bala bosan, abubakar ibrahim, sunday musa oguche et al 8 which is a nigerian study done in january 2016, shows 158 (49.4%) females out of 320 aki patients whereas slightly male preponderance of 162 (50.6%) male patients. but those who were admitted due to sepsis (119), there were female preponderance as 70/119 (58.8%). here also female preponderance was found. among 60 patients the etiological cause of aki was evaluated and it was found that sepsis was the most common cause 25 (41.7%). s a multicentric study done by sean m. bagshaw, shigehiko uchino, rinaldo bellomo et al 9 in 2007, sepsis was found to be the most common cause of oliguric renal failure among 1753 enrolled patients as 833 (47.5%) of patient developed acute kidney injury. in background of heart failure, aki is also an important predictors of adverse outcome. here, 9 patients (15%) developed aki who were cases of congestive heart failure. a study by butler j, wang y, abraham wt et al 10 on worsening renal failure among 1007 enrolled heart failure cases, worsening of renal failure was found in 27% of cases with arr 2.1; ci 1.5, 3.0 (significant). moreover worsening of renal function occurred on the day of admission. less number of patients with heart failure heres because of lower study population. among total sepsis patients (25, 41.7%) (table 3), it is seen that 18 patients (72%) is due to urosepsis, followed by pneumosepsis (5 number, 20%). a study by chih-yen hsiao, huang-yu yang, meng-chang hsiao, et al 11 showed 97 patients (12.3%) developing aki after admission with 4 patients (0.5%) necessitating dialysis therapy among 790 enrolled uti cases and upper uti (46.4% versus 35.5%, p = 0.037) is the most common cause. drugs are important cause of aki, while aki is also associated with cancer and 6.7% cases among post surgery patients. here, two (3.33%) age and one (1.66%) acute pancreatitis patient was diagnosed as aki. a study by atim e. pajai, kalpana s. mehta et al showed that incidence of aki due to diarrhea was 23%, and affecting males predominantly in 4th decade among 230 patients admitted with aki. but in our study it is low because of the fact that most of the patients with acute gastroenteritis are admitted in other designated centres. none of the patients developed severe acute pancreatitis during study period and also, pancreatitis patients were well resuscitated with fluid and supportive measures, hence, number of cases due to pancreatitis is low. in my study prevalence of aki in collagen vascular disease and vasculitis is 3.3%. in hepatic cause two (3.33%) cld patient were diagnosed here. it was seen here, that three co-morbidities, t2dm, hypertension, and cardiac disease are related with aki. among these t2dm is related in 51.7% cases and most of them had sepsis, and urosepsis was diagnosed mostly, that causes intrinsic aki. in this study 26.7% of cases were found to be hypertensive. the study by chih-yen hsiao, huang-yu yang et al 11 shows hypertension(54.6% versus 40.7%, p = 0.009) to be a significant comorbidity amongst aki patients. here, 60% of cases were of renal etiology and 31.66% were of pre renal etiology. in one study by santos wj, zanetta dm et al 12 88% of cases (524 cases out of 593) developed intrinsic renal aki. this data also corroborates with our study as the cases of renal causes of aki was more than those of pre renal and post renal. as per rifle classification risk-46%%, injury-35%, failure-16.6%, loss1.66%. in this study it was found in akin classification of aki, patients are in stage-1 46%, stage-2 35%, stage-3 19% with similar result and out come as in rifle classification. 5.1. comparison between rifle and akin classification from the analysis here, it is obvious that in spite of some theoretical benefit for diagnosis of aki practically akin classification does not provide any extra benefit than rifle classification and as per kdigo classification, it was found that the result was similar akin classification. 6. conclusion this study showed that increasing age increased the risk of aki with higher incidence in the female population and sepsis is the commonest cause. the commonest comorbidity is t2 dm. most of the patients as per rifle classification were in risk stage (46%) followed by injury stage (35%) followed by failure. also the incidence of aki as per different classification systems, i.e. rifle, akin, kdigo showed no significant difference. mazumdar et al. / panacea journal of medical sciences 2021;11(3):452–457 457 7. limitations however this study has its own limitations with low study population, lack of acute gastroenteritis cases(as they are admitted in government and infectious disease hospital) and no snake bite(admitted in government set up)patients or hiv cases. 8. abbreviations aki-acute kidney injury; rifle-risk, injury, failure, loss, end stage renal disease; akinacute kidney injury network criteria; kdigokidney disease improving global outcomes; gfr-glomerular filtration rate; ngalneutrophil gelatinase-associated lipocalin; kim 1kidney injury molecule-1; cld-chronic liver disease; ckd-chronic kidney disease; t2 dm/dm-type 2 diabetes mellitus. 9. conflict of interest the authors declare that there are no conflicts of interest in this paper. 10. source of funding none. references 1. leedahl dd, frazee en, schramm ge, dierkhising ra, bergstralh ej, chawla ls, et al. derivation of urine output thresholds that identify a very high risk of aki in patients with septic shock. cjasn. 2014;9(7):1168–74. 2. gottlieb ss, abraham w, butler j. the prognostic importance of different definitions of worsening renal function in congestive heart failure. j card fail. 2002;8(3):136–41. doi:10.1054/jcaf.2002.125289. 3. koza y. acute kidney injury: current concepts and new insights. j inj violence res. 2016;8(1):58–62. doi:10.5249/jivr.v8i1.610. 4. majumdar a. sepsis induced acute kidney injury. indian j crit care med. 2010;14(1):14–21. 5. bagshaw sm, uchino s, bellomo r, morimatsu h, morgera s, schetz m, et al. septic acute kidney injury in critically ill patients: clinical characteristics and outcomes. clin j am soc nephrol. 2007;2(3):431– 9. doi:10.2215/cjn.03681106. 6. bucuvic em, ponce d, balbi al. risk factors for mortality in acute kidney injury. rev assoc med bras (1992). 2011;57(2):158– 63. doi:10.1590/s0104-42302011000200012. 7. ali t, khan i, simpson w, prescott g, townend j, smith w, et al. incidence and outcomes in acute kidney injury: a comprehensive population-based study. j am soc nephrol. 2007;18(4):1292–8. doi:10.1681/asn.2006070756. 8. bosan ib, ibrahim a, oguche mt, tuko mt, abdulrasheed mm, et al. characteristics of acute kidney injury in adult patients in a tertiary health facility in northern nigeria. j curr res sci med. 2016;2(2):102–8. doi:10.4103/2455-3069.198377. 9. bagshaw sm, uchino s, bellomo r, morimatsu h, morgera s, schetz m, et al. septic acute kidney injury in critically ill patients: clinical characteristics and outcomes. clin j am soc nephrol. 2007;2(3):431– 9. doi:10.2215/cjn.03681106. 10. forman de, butler j, wang y, abraham wt, o’connor cm, gottlieb ss, et al. incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. j am coll cardiol. 2004;43(1):61–7. doi:10.1016/j.jacc.2003.07.031. 11. hsiao cy, yang hy, hsiao mc, hung ph, wang mc. risk factors for development of acute kidney injury in patients with urinary tract infection. plos one. 2015;10(7):133835. doi:10.1371/journal.pone.0133835. 12. santos wj, zanetta dm, pires ac, lobo sm, lima eq, burdmann ea, et al. patients with ischaemic, mixed and nephrotoxic acute tubular necrosis in the intensive care unit–a homogeneous population? crit care. 2006;10(2):68. doi:10.1186/cc4904. author biography amitava mazumdar, associate professor sujata mazumdar, associate professor ujjal kumar chakravarty, associate professor tushar kanti pakira, medical officer somnath maitra, associate professor santa subhra chatterjee, visiting consultant cite this article: mazumdar a, mazumdar s, chakravarty uk, pakira tk, maitra s, chatterjee ss. a profile of acute kidney injury in eastern india: a cross sectional study. panacea j med sci 2021;11(3):452-457. http://dx.doi.org/10.1054/jcaf.2002.125289 http://dx.doi.org/10.5249/jivr.v8i1.610 http://dx.doi.org/10.2215/cjn.03681106 http://dx.doi.org/10.1590/s0104-42302011000200012 http://dx.doi.org/10.1681/asn.2006070756 http://dx.doi.org/10.4103/2455-3069.198377 http://dx.doi.org/10.2215/cjn.03681106 http://dx.doi.org/10.1016/j.jacc.2003.07.031 http://dx.doi.org/10.1371/journal.pone.0133835 http://dx.doi.org/10.1186/cc4904 429 too many requests you have sent too many requests in a given amount of time. 59 1 2 senior resident, professor, 3professor and head, department of pathology, j. l. n. medical college and hospital, ajmer (rajasthan). drpriyankanbansod@rediffmail .com abstract: gastroduodenal tuberculosis is rare location of abdominal tuberculosis. it usually occurs secondary to pulmonary tuberculosis. in our case, the rare gastroduodenal location of abdominal tuberculosis occurred as primary tuberculosis, in the absence of other identifiable location. keywords: gastroduodenal tuberculosis, tuberculosis, gastric outlet obstruction. pjmsvolume 4 : number 2 : july dec. 2014 case report 3 13,200/mm with polymorphs 70%, lymphocytes 28%, monocytes 1% and eosinophils 1%. haemoglobin was st 12.5gm% and esr 25 mm/ 1 hour (westergren). peripheral blood film examination showed normocytic normochromic picture. urine examination, blood sugar, blood urea, serum creatinine, sodium, potassium and chlorine, liver function test were normal. australia antigen test was negative and hiv test was non reactive. chest x-ray was normal. ultrasonography abdomen shows grossly dilated gut loops with to and fro movements suggestive of subacute intestinal obstruction. on barium meal, stomach mucosal folds were nd coarse and thickened. there was area of narrowing in 2 part of duodenum due to unknown cause. endoscopy showed duodenal ulcer with deformed first part of duodenum and gastric outlet obstruction. histopathology of the biopsy shows epithelioid cell granuloma of tuberculosis (fig. 1-3). the patient was then diagnosed as having duodenal stricture secondary to primary gastroduodenal tuberculosis. the patient was started on anti-tubercular medication and had improved on discharge. figure 1: h&e stained section of gastroduodenal junction showing granuloma in 10x view introduction: tuberculosis is a major health problem worldwide. gastrointestinal tuberculosis is an important health problem in developing countries. ileocaecal and ileal are the usual forms seen in gastrointestinal tuberculosis. gastroduodenal tuberculosis is a rare location of abdominal tuberculosis. in areas where tuberculosis is endemic, diagnosis of gastrointestinal tuberculosis must be kept in mind, particularly in patients with upper gastrointestinal obstruction and in those with peptic ulcer like symptoms not re s p o n d i n g t o a n y k i n d o f m e d i c a l t re a t m e n t . gastroduodenal tuberculosis usually occur secondary to pulmonary tuberculosis. the presentation of duodenal tuberculosis is varied; the commonest being gastric outlet obstruction (1-3). gastroduodenal tuberculosis is a real diagnostic challenge. clinical evaluation, radiology and endoscopy (4) are important modalities for diagnosis but they do have limitations. the diagnosis of abdominal tuberculosis is difficult, especially so in health care facilities in developing countries where laparoscopy and colonoscopy are rarely available. also the difficulty in diagnosing abdominal tuberculosis is due to the lack of efficient and sensitive diagnostic tools as well as its variable anatomical location. case history: we report a case of gastric outlet obstruction due to gastroduodenal tuberculosis. a 20-year-old unmarried male student presented with epigastric pain, frequent vomiting, nausea and low grade fever off and on of eight months. the patient also reported a slight undocumented weight loss. he had no history of tuberculosis and no known exposure to the disease. the patient's family history was also unremarkable. on physical examination, there was pallor and tenderness in epigastric area. on admission, the patient was oriented in time, place and person. patient was afebrile. his pulse was 88/min, good volume and synchronous with other side. blood pressure was 130/80 mm of hg. respiratory, cardiovascular and central nervous systems were normal. laboratory analysis revealed white blood cell count of gastroduodenal tuberculosis presenting as gastric outlet obstruction 1 2 3 bansod priyanka , kasliwal neena , pachori geeta pjmsvolume 4 : number 2 : july dec. 2014 case report 60 figure 2: h&e stained section of gastroduodenal junction showing granuloma and giant cell in 20x view figure 3: afb staining of gastroduodenal junction showing acid fast bacilli in 100x view discussion: gastric outlet obstruction is commonly associated with malignancies and peptic ulcer disease. proximal duodenal obstruction due to tuberculosis can masquerade as duodenal ulcer. however, when no malignancy is seen and the patient is non-responsive to conventional peptic ulcer treatment, other etiologies need to be explored. the radiological features of gastroduodenal tuberculosis are also non-specific. so the diagnosis of this disease is difficult and is often made postoperatively. in our case, the rare gastroduodenal location of abdominal tuberculosis occurred as primary tuberculosis in the absence of other identifiable locations. the diagnosis of this disease is difficult and is often made post-operatively. majority of patient with duodenal tuberculosis have signs and symptoms of gastric or duodenal obstruction due to extrinsic compression by matted tuberculous lymph nodes but few patients may have intrinsic strictures. gastroduodenal tuberculosis can even present with acute perforation of duodenal ulcer. surgery is the primary line of management of the presenting complication followed by a full course of anti-tubercular therapy. pyloroplasty with vagotomy was performed in this case. references: 1. ghadouane m, alani fz, hrora a, raiss m, baroudi s, tousi a. post-bulbar stenosis disclosing duodenal tuberculosis. apropos of a case. ann chir 1997; 51:655-6. 2. thakur s, minhas ss, kanga a, sharma v. tuberculous duodenal obstructiona case report. indian j med sci 1997; 51: 192-5. 3. di placido, pietroletti r, leardi s, simi m. primary gastroduodenal tuberculosis infection presenting as pyloric outlet obstruction. am j gastroenterol 1996;91:807-8. 4. ray jd, sriram pv, kumar s, vaiphei k. primary duodenal tuberculosis diagnosed by endoscopic biopsy. trop gastroenterol 1997; 18:74-5. 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2021;11(3):544–546 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article clinical profile of babies admitted with septic arthritis in neonates t v ram kumar1, budhia majhi1, sadhana panda1,* 1dept. of pediatrics, mkcg medical college and hospital, brahmapur, odisha, india a r t i c l e i n f o article history: received 30-12-2020 accepted 09-01-2021 available online 24-11-2021 keywords: septic arthritis (sa) neonatal methicillin resistant staphylococcal aureus (mrsa). a b s t r a c t background: septic arthritis (sa) in the neonatal period is rare but important clinical condition that needs timely recognition, and treatment to save the joint and life of the baby. the objective of this study was to look at the clinical profile of babies presenting with septic arthritis in neonatal period. materials and methods: this was a prospective observational study from 2019 to 2020 undertaken in sncu. results: there were 13 babies who met the criteria of sa and data was collected after obtaining consent. all of them were born at term, mostly males (n=12). the mean age at presentation was day 17 (10-28days), after a mean duration of 3 days from the onset of symptoms. it was monoarticular in 11 babies. the most common joint that got involved was knee. methicillin resistant staphylococcal aureus (mrsa) was the most common isolate from blood and joints. all the babies received a minimum of 3 weeks parenteral antibiotics. conclusion: the diagnosis of sa is mostly done clinically. with the advent of mrsa, it is important to include vancomycin/linezolid for the recommended duration. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction septic arthritis is a suppurative infection of the joint. it is a deep seated infection and presents with or without other systemic features. it has been seen in 0.3 to 0.6 in 1000 live births. 1 this when left untreated or recognized late in the course of disease can prove disastrous. the occurrence is contributed by the immature immune system, rich vascular supply, and poorly developed synovial basement membrane. 2 2. materials and methods this prospective observational study was conducted after institutional ethical clearance in special newborn care unit (sncu), department of pediatrics of mkcg medical * corresponding author. e-mail address: sadhanapanda48@gmail.com (s. panda). college and hospital. we have enrolled in our study those neonates getting admitted to sncu between 1.3.2019 to 31.5.2020 with swelling of joints. after obtaining informed written consent from parents, the relevant history and clinical details of the baby were taken and recorded. the babies underwent standard diagnostic study of joints, and treated as per the institutional antibiotic policy after sending blood cultures. after obtaining culture reports, the antibiotics were further modified to complete the course. all the details of reports were tabulated in the performa for analysis. the analysis was done with spss software. 3. results thirteen babies were admitted during the study period with swelling of joint/(s). the clinical details of the babies are mentioned in table 1. the babies were mostly born outside our hospital (77%). eleven (85%) were a product https://doi.org/10.18231/j.pjms.2021.106 2249-8176/© 2021 innovative publication, all rights reserved. 544 kumar, majhi and panda / panacea journal of medical sciences 2021;11(3):544–546 545 of vaginal delivery. except one, rest of them were all males. ultrasonography revealed collection in only 35% cases. a single joint was involved in 11 cases and 2 of them had multiple joints involvement. one case has developed osteomyelitis in admission, recognized on x-ray. most of them (n=9) were on left side, and 3 cases were bilateral. table 1: baseline characteristics of babies with septic arthritis characteristic n=13 day of admission (range and mean) 10-28/17 gestational age at birth in weeks (range and mean) 37-40/39 onset of symptoms and admission (range and mean) in days 1-5/3 fever 10 (77%) joint swelling 13 (100%) redness overlying the swelling 11 (85%) tenderness 13 (100%) poor feeding 8 (62%) excessive cry 13 (100%) hemoglobin (range and mean) in g/dl 10.7 (9-13) tlc (range and mean) in wbc /mm3 21,417 (18,65031,210) polymorphs (range and mean) in % 94 (87-99) joints involved knee 10 (77%) hip 2 (15%) elbow 1 (7%) shoulder 1 (7%) (tlc=total leucocyte count, wbc=white blood cells) the blood cultures obtained from these babies grew methicillin sensitive staphylococcus aureus (mssa) in 3 cases, methicillin resistant staphylococcus aureus (mrsa) in 9 cases and klebsiella was isolated from one case. the mssa were sensitive to cloxacillin and amikacin. mrsa strains were sensitive to vancomycin and linezolid. klebsiella was sensitive to meropenem and resistant to cephalosporins and piperacillin-tazobactam. the diagnostic joint aspiration was done in 9 cases. all the samples were gross pus, and were sent for gram stain and culture. gram stain showed gram positive cocci in clusters in 6 samples. mrsa was isolated in 7 of the aspirates, and other two were sterile. the mean duration of stay was 23 days (18-36 days). all the babies received minimum 21 days of injectable antibiotics by peripheral veins in 11 cases, and the other 2 received 16 and 18 days respectively and were prematurely discharged on oral linezolid to complete the course due to family constraints. the parenteral antibiotics that were administered to these included cefotaxime (n=3), amikacin (n=4), meropenem (n=5), vancomycin (n=6), and linezolid (n=2). all the babies had decrease in fever by end of first week (3-10/ mean 6 days) and resolution of swelling by third week (12-18/mean17 days). there was weight gain in all babies, and none of them required intravenous fluids. 4. discussion septic arthritis in neonates need high index of suspicion in children presenting with excessive cry with or without fever. in the present study, most of them were males and had involvement of single joint. similar finding was seen in other studies in past with male preponderance. 1,3–8 all of them were born at term, and were pre-morbidly healthy. none of them had any history of intravenous injections prior to that. however, the studies in past have shown that the preterm babies with risk factors of central umbilical venous catheterization, with or without mechanical ventilation. 6,7,9 usg was showing collection in only 35% cases like in study undertaken by others. 1,4,7,10 however in a study conducted by devi et al had very high number of findings detected on usg, which may be explained by the delay between onset of illness and date of presentation. 3 the most commonly involved joint was knee as seen in few studies in the past. 5,7 many studies conducted in babies with premorbid features and central umbilical catheters had primary involvement of hips. 1,3,4,6,7 all of them were managed medically by parenteral antibiotics. none in our study had surgical exploration unlike in many studies, which involved very sick babies getting infected during hospital stay and a marked delay at presentation of babies from community. 7,10 timely intervention of antibiotics as per protocol might decrease the need of arthrotomy and other surgical explorations. in our study, the most common organism was staphylococcal aureus (mrsa > mssa) similar to kabak et al. 4 however, in studies with involvement of premature sick babies with central venous access have predominance to klebsiella, and few also had fungal (candida spp). 3,7,10–12 based on the available culture patterns, our children responded well to parenteral vancomycin for a period of 21 days. few studies like conducted by akash et al have used parenteral for 2 weeks followed by oral unlike our study. 6 and few others had given injections for 4 to 5 weeks, with involvement of klebsiella and more serious course of disease. 7,11 5. conclusion this study outlines the importance of high index of suspicion, early recognition, and earliest institution of antibiotics and modifying as per the obtained cultures. we have to keep ourselves open to the changing scenario of organisms and their susceptibility pattern. the diagnosis rests primarily on clinical grounds, with timely assistance by usg and joint aspiration studies. the major limitation of the study is that we do not have the data on follow up. 6. acknowledgement sncu staff nurses. 546 kumar, majhi and panda / panacea journal of medical sciences 2021;11(3):544–546 7. sources of funding no financial support was received for the work within this manuscript. 8. conflicts of interest no conflicts of interest. references 1. narang a, mukhopadhyay k, kumar p, bhakoo on. bone and joint infection in neonates. indian j pediatr. 1998;65:461–4. doi:10.1007/bf02761144. 2. embree je, alfattoh ni. infections in the newborn. in: macdonald m, seshia m, editors. avery’s neonatology: pathophysiology and management of the newborn. 7th edn. new delhi: woletrs-kluwer; 2016. p. 930–81. 3. devi ru, bharathi sm, anitha m. neonatal septic arthritis: clinical profile and predictors of out-come. indian j child health. 2017;4(1):10–4. 4. kabak s, halici m, akcakus m, cetin n, narin n. septic arthritis in patients followed-up in neonatal intensive care unit. pediatr int. 2002;44(6):652–7. doi:10.1046/j.1442-200x.2002.01649.x. 5. halder d, seng qb, malik as, choo ke. neonatal septic arthritis. southeast asian j trop med public health. 1996;27(3):600–5. 6. rai a, chakladar d, bhowmik s, mondal t, nandy a, maji b, et al. neonatal septic arthritis: indian perspective. eur j rheumatol. 2019;7(1):72–7. doi:10.5152/eurjrheum.2019. 7. pittard wb, thullen jd, fanaroff aa. neonatal septic arthritis. j pediatr. 1976;88(4 pt 1):621–4. doi:10.1016/s0022-3476(76)800224. 8. li y, zhou q, liu y, chen w, li j, yuan z, et al. delayed treatment of septic arthritis in the neonate: a review of 52 cases. medicine (baltimore). 2016;95(1):e5682. doi:10.1097/md.0000000000005682. 9. rauch f, schoenau e. skeletal development in premature infants: a review of bone physiology beyond nutritional aspects. arch dis child fetal neonatal ed. 2002;86(2):f82–5. doi:10.1136/fn.86.2.f82. 10. deshpande ss, taral n, modi n, singrakhia m. changing epidemiology of neonatal septic arthritis. j orthop surg. 2004;12(1):10–3. doi:10.1177/230949900401200103. 11. riccio v, riccio i, porpora g, riccardi d, riccardi g. septic arthritis in children. pediatr med chir. 2012;34(3):123–8. doi:10.4081/pmc.2012.77. 12. sucato dj, schwend rm, gillespie r. septic arthritis of the hip in children. j am acadorthop surg. 1997;5(5):249–60. doi:10.5435/00124635-199709000-00003. author biography t v ram kumar, assistant professor budhia majhi, associate professor sadhana panda, associate professor cite this article: kumar tvr, majhi b, panda s. clinical profile of babies admitted with septic arthritis in neonates. panacea j med sci 2021;11(3):544-546. http://dx.doi.org/10.1007/bf02761144 http://dx.doi.org/10.1046/j.1442-200x.2002.01649.x http://dx.doi.org/10.5152/eurjrheum.2019 http://dx.doi.org/10.1016/s0022-3476(76)80022-4 http://dx.doi.org/10.1016/s0022-3476(76)80022-4 http://dx.doi.org/10.1097/md.0000000000005682 http://dx.doi.org/10.1136/fn.86.2.f82 http://dx.doi.org/10.1177/230949900401200103 http://dx.doi.org/10.4081/pmc.2012.77 http://dx.doi.org/10.5435/00124635-199709000-00003 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2021;11(3):569–572 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article review of clinical presentation of children with celiac disease a retrospective study sunil pathak1, avinash bothra1, manish rasania1, dipika bhil1,*, nimya mary1, prerna dogra1 1dept. of pediatrics, smt. b.k. shah medical institute & research centre, vadodara, gujarat, india a r t i c l e i n f o article history: received 22-02-2021 accepted 14-04-2021 available online 24-11-2021 keywords: celiac disease ttgtissue transglutaminase anemia short stature a b s t r a c t introduction: celiac disease is a chronic immune mediated enteropathy, produced by the gluten ingestion in susceptible people, where gluten act as environmental trigger. celiac disease has global prevalence of 1%. its presentation ranges from simple anaemia, gastrointestinal manifestation, short stature to neurological manifestations. the high level of suspicion helps in prevention of chronic complications of the disease. objective: to identify diverse clinical manifestations of children with celiac disease. materials and methods: children with previously established or newly diagnosed celiac disease, during (2011-2019) were recruited. data was collected retrospectively from medical records and clinical notes, and subsequently analysed. result: the mean age was 7.90 years (3-15 years). 59.09% (13) patients were females. 90.90% (20) patients had gastrointestinal symptoms and anemia and 81.81% (18) had short stature. other symptoms include lower-limb edema (1), seizure (1), dental caries (1), anasarca (1), abdominal koch (1), rashes (1), lower limb weakness (1). biopsy was positive in 7/8 patient. conclusion: knowledge of diverse clinical presentations will help in increased clinician’s awareness and high level of suspicion. it will enable an early diagnosis and management. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction celiac disease (cd) is a chronic small intestine immunemediated disorder elicited by the ingestion of gluten in genetically predisposed individuals. the disease is associated with human leukocyte antigen(hla) dq2 and dq8 haplotypes. 1 in the continued presence of gluten, cd is self-perpetuating. given the proven role of gluten in causing inflammation and autoimmunity, cd represents a unique example of immune mediated disease for which early diagnosis and dietary treatment can prevent severe, sometimes life threatening complications. 2,3 the universal screening is not currently being advised. however, * corresponding author. e-mail address: dipika7299@gmail.com (d. bhil). awareness should be raised and there should be a low threshold for investigating both symptomatic children and those with associated conditions, as it is known that approximately 90% of cases remain undiagnosed. 1,4 the cd is commonly detected in patients with diarrhoea, but the clinical manifestations of cd are numerous and vary from none (asymptomatic) to a broad spectrum of gastrointestinal symptoms and extra-intestinal manifestations. 1 these different modes of presentation, lead experts to elaborate the oslo classification, 5 which subdivides cd into symptomatic cd, includes the “classical” and “nonclassical” presentations, versus the “asymptomatic” or “subclinical” cd. the classic cd presents with signs and symptoms of malabsorption and the non-classic cd is characterized by other gastrointestinal symptoms apart from https://doi.org/10.18231/j.pjms.2021.112 2249-8176/© 2021 innovative publication, all rights reserved. 569 570 pathak et al. / panacea journal of medical sciences 2021;11(3):569–572 diarrhoea and extra-intestinal symptoms. the subclinical cd is below the threshold of clinical detection. there is also the “potential cd” describing the patients at risk of developing the disease in the future. this study was conducted retrospectively to examine the clinical presentation of celiac disease in paediatric patients, admitted to a tertiary medical centre in the years 2011-2019. our main goal was to identify the symptoms and clinical phenotype of these patients at presentation. 2. materials and methods this retrospective observational study assessed all the paediatric patients diagnosed as celiac disease, presented to dhiraj hospital from 2011 to 2019. data from each selected patient was obtained retrospectively from medical records of paediatric gastroenterology clinic and were scanned for patients with celiac disease in the span of last 9 years. total 22 patients record were found. their demographic characteristics, symptoms, associated diseases, type of clinical presentation, family history, serology tests requested at presentation and their results, histopathology findings if done, diet pattern, the clinical and growth response after treatment were recorded and put in excel sheet for further analysis. all the patients whose diagnosis was recorded as celiac disease were included in the study (based on serology ttgiga alone or serology plus histopathology). histological findings in small intestine biopsies, taken from the bulb or the second duodenal portion, were classified according to the modified marsh classification by oberhuber. 6 2.1. statistical method categorical data were presented as percentages and quantitative data were presented using average and range value. 3. result total 22 patients with celiac disease were isolated from records of paediatric gastroenterology clinic in the span of last 9 years (2011-2019). the mean age of the group on presentation was 7.9 (3 to 15 yrs.) yrs. maximum patients presented between the age of 7-10 years. 13 (59.09%) patients were females while 9 (40.90%) were males. majority of the patients, 18 (81.91%) were from the state of mp, while rest 4 (18.19%) patients were from gujarat. figure 1 shows that majority, 20 (90.90%) of the patients presented with gi symptoms. even the gi symptoms were diverse. 9 (40.90%) patients presented with the complaint of generalized weakness. 7 (31.81%) patients presented with the complaints of failure to gain height and weight. other spectrum of presentation observed in the group were seizures, dental caries, generalized swelling, skin rash and fig. 1: symptoms and clinical profile of children with celiac disease lower limb weakness in 1(4.5%) each of patients. fig. 2: gastro-intestinal symptoms of children with celiac disease. among gastro intestinal complaints majority 14 (63.63%) patients had loose stools as presenting complaint. abdominal distension was seen in 10 (45.54%) patients. 6 (27.27%) had history of pain abdomen on presentation and 2 (9.09%) patients presented with abdominal pain, vomiting and decreased appetite each. 1 patient had constipation as presenting complaint (figure 2). table 1: general physical finding of children with celiac disease. s. no. clinical feature n(%) 1. pallor 18(81.81%) 2. short stature 18(81.81%) 3. anasarca 1(4.5%) 4. clubbing 1(4.5%) 5. lymphadenopathy 1(4.5%) on examination, pallor was seen in 18(81.81%) of the patients. 18(81.81%) had short stature. anasarca, clubbing pathak et al. / panacea journal of medical sciences 2021;11(3):569–572 571 and lymphadenopathy was found in one patient each. table 2: laboratory investigation of children with celiac disease. laboratory investigation patients (n=22) serum ttgiga (positive) 22 duodenal biopsy positive for celiac disease 7 upper gi endoscopy and duodenal biopsy was done in only 8/22 patients. it was positive for celiac disease in 7/8 patients while 1 was indeterminate. mean hemoglobin of the patients on presentation came out to be 8.75 gm/dl (range 2.9 to 12.5 gm/dl). 20 (90.90%) patients had hemoglobin level less than 11gm/dl. 1(4.5%) patient had severe anemia, 12 had moderate and 7 patients had mild anemia at presentation. out of 22 patients only 8patients were followed up for 3months, 6 patients till 6 months, 3patients till 9 month and 2 patients till 12 month post diagnosis. average weight gain at 3,6,9 and 12 months were 935gm, 3953 gm, 3980 gm and 4790 gm respectively. similarly, height gain at 6 months and 12 months were 3.75cm and 8.3cm respectively. we could not retrieve data longer than one year follow up in any of the patients. 4. discussion the children included in this retrospective study presented with a wide variety of clinical features. we found an increased prevalence of coeliac disease amongst male compared to females. in our study, we found that majority of patients were from the state of mp, this could be attributed to the fact that mp is primarily a wheat eating state. study by yacha et al reported that prevalence of celiac disease is eight times less in gujarat as compared to punjab. he attributed this to genetic difference in two population. 7 but it may also be due to dietary pattern of two population, as staple diet of people in punjab, haryana, rajasthan, madhya pradesh and western uttar pradesh is mainly wheat based while in gujarat it is mixed wheat and rice. considering that the variable clinical picture of coeliac disease is related to genetic and immunological base, the age of onset may influence the clinical presentation. in our study, mean age at diagnosis was 7.9 years (3-15 years). in a study by yacha et al., he reported mean age at diagnosis between 6.38.6 years (2.514 years). 8 we found that maximum number of patients presented between the ages of 7-10 years. similar to study by bharadiya et al. diarrhoea (63%), abdominal distension (45%) and abdominal pain (27%) were the most common gastrointestinal symptoms at presentation and short stature was the extra-intestinal finding. 8 study by gracinda et al, found abdominal pain and diarrhoea as major presenting symptoms. 1 while study by bhattacharya m et al, found abdominal pain and abdominal distension as main gastro-intestinal symptoms and short stature as extra-intestinal finding at presentation. 7 all the patients were investigated for complete blood count at the time on presentation and anaemia was found in 49% of total. prevalence of anemia among patients with celiac disease reportedly varied from 23% to 90% in different studies. 1,7,8 serological markers provide simple yet non-invasive initial screening test especially for the individual who presents with atypical clinical manifestation. in our study, the diagnosis was based mainly on clinical suspicion and confirmation by serum ttgiga. although, small bowel biopsy remains the gold standard for the diagnosis of coeliac disease. in our study, what-ever biopsy was done, it was done in other hospital due to non-availability of gastrophysician, that sometimes become too costly affair to our patients. biopsy was done in only 8 out of 22 patients. in 7 out of 8 patients biopsy findings were consistent with celiac disease, while in one patient finding was indeterminate. most of the patients in our study were from far distance (madhya pradesh). getting long term follow up is a difficult for poor parents. that is one of the reasons of lost to long term follow in current study. availability of at least good counselling centre nearby, where patients can take regular counselling can keep them motivated and aware for importance of gluten free diet. patients can be monitored there for growth and development, and adherence to gluten free diet. 5. conclusion this study outlines the diverse clinical presentations of paediatric celiac disease. a high level of suspicion and increased clinician’s awareness will enable an early diagnosis and treatment, with subsequent improvement in symptoms and nutritional status. 6. sources of funding no financial support was received for the work within this manuscript. 7. conflicts of interest no conflicts of interest. references 1. oliveira gn, mohan rf. review of celiac disease presentation in a pediatric tertiary centre. arq gastroenterol. 2018;55(1):86–93. 2. makharia gk, verma ak, amarchand r, bhatnagar s, das p, goswami a, et al. prevalance of coeliac disease in the northen part of india;a community based study. j gastroenterol hepatol. 2011;26(4):894–900. 3. sollid lm, mcadam sn, molberg o. genes and environment in celiac disease. acta odontol scand;59(3):183–6. 4. murch s, jenkins h, auth m, bremner r, butt a, france s, et al. joint bspghan and coeliac uk guidelines for the diagnosis and management of coeliac disease in children. arch dis child. 2013;98(10):806–11. 572 pathak et al. / panacea journal of medical sciences 2021;11(3):569–572 5. ludvigsson jf, leffler da, bai jc, biagi f, fasano a, green phr, et al. the oslo definitions for coeliac disease and related terms. gut. 2013;62(1):43–52. doi:10.1136/gutjnl-2011-301346. 6. oberhuber g. histopathology of celiac disease. biomed pharmacother. 2000;54(7):368–72. 7. bhattacharya m, kapoor s, dubey ap. & dubey a. celiac disease presentation in a tertiary refferal centre in india; current scenario. indian j gastroenterol. 2013;32(2):98–102. doi:10.1007/s12664-012-0240-y. 8. yacha sk, poddar u. celiac disease in india. indian j gastroenterol. 2007;26(5):230–7. author biography sunil pathak, associate professor avinash bothra, assistant professor manish rasania, professor dipika bhil, assistant professor nimya mary, resident prerna dogra, resident cite this article: pathak s, bothra a, rasania m, bhil d, mary n, dogra p. review of clinical presentation of children with celiac disease a retrospective study. panacea j med sci 2021;11(3):569-572. http://dx.doi.org/10.1136/gutjnl-2011-301346 http://dx.doi.org/10.1007/s12664-012-0240-y 43 1 2 junior resident, associate 3 professor, professor and head, department of community medicine, nkpsims&rc, hingna road, digdoh hills, nagpur 440019. ausvisamina@gmail.com abstract: neonatal health is the key to child survival. india is the first country to add neonatal component to integrated management of childhood illness (imci). after so many years of implementing the integrated management of neonatal and childhood illness(imnci) strategy through reproductive and child health(rch) ii/national rural health mission(nrhm), neonatal care practices should have changed. this study was done withaims and objectives to assess the practices of neonatal care in rural area, to assess the impact of nrhm in the field of neonatal care practices in rural area.the cross sectional study was carried out among 370 mothers who had a child completed neonatal period preceding the study by interview using pretested questionnaire & was analyzed using epi info statistical software. result of the study suggested that many harmful and un-indicated neonatal care practices were prevalent in the community. mothers had traditional care practices pertinent to breastfeeding, bathing, kajal in eyes, massage of anterior fontanels, pre-lacteal feed etc. bathing the baby immediately at birth was commonly practiced in 60 %. 37.02% mothers initiated breast feeding within half hour of birth. early initiation of breast feeding was more likely in neonates with mother with higher education and higher income and those belonging to joint families.27.56 % mothers had not given colostrum to their babies & in majority the reason was family customs or prohibited by elderly. turmeric or ghee was applied to cord in 75.94 %. after 7 years of implementation of imnci strategy through nrhm we got mixed pattern of results in neonatal care practices.unsafe and harmful traditional practices in neonatal care are more prevalent in the rural areas. still 13% deliveries are home deliveries emphasizing the need for further education in safe and healthy practices to the mothers and the community. keywords: neonatal care practices,impact of nrhm,exclusive breastfeeding, colostrum. pjmsvolume 4 : number 2 : july dec. 2014 original article india is the first country to add neonatal component to integrated management of childhood illness (imci). after so many years of implementing the integrated management of neonatal and childhood illness(imnci) strategy through reproductive and child health(rch) ii/national rural health mission(nrhm), neonatal care practices should have changed.the present study aims to study the practices in relation to newborn care like prevention of hypothermia, colostrum feeding, early initiation of breast feeding and prelacteal feeding so as to improve neonatal survival and decrease morbidity and mortality in rural area in india and to assess the impact of nrhm in the field of neonatal care practices in rural area. material and methods: this crosssectional study was carried out between november 2012 to january 2013 among the mothers residing in rural area of the central india,who had given birth to a live born within the last one year. sample size calculated on the basis of percent distribution of neonates who were breastfed within 1 hr of birth in maharashtra according to nfhs 200506 which was 52%. considering 10% allowable error calculated sample size was 369 which were rounded off to 370.permission of institutional ethical committee was taken before starting the study. it was a cross sectional study using a multistage random sampling.tertiary care hospital is situated introduction: new born or neonatal period include the time from birth to 28 day of life. this is the crucial period in laying the foundation of good health. at this time specific biological and psychological needs must be met to ensure the survival and healthy development of the child into a future adult (1). neonatal care refers to the care given by the mother to her newborn such as breastfeeding, personal hygiene, and prevention of hypothermia & infection and safety measures(2).mother has prime responsibility for caring her newborn which comprises the following aspects; they are thermal regulation, breast feeding, hygienic practice including skin care, eye care, cord care etc. and safe environment(3). newborn care practices which are harmful are major contributors for high mortality rates, especially in developing countries where 96% of the world's approximate 5 million annual neonatal deaths occur. each year in india over 1 million newborn die before they complete their first months of life, accounting for 30% of the world's neonatal deaths. india's current neonatal mortality is higher in rural areas at 49/1000 live births v/s 27/1000 in urban area. neonatal health is the key to child survival(4). many of the lifethreatening conditions could be prevented or treated with low cost technology, improved labor and delivery care attention to the physiological needs of the newborn (5). prevalent neonatal care practices in rural area of central india: the truth revealed 1 2 3 ausvi samina , joshi mohan , kasturwar nandkishor pjmsvolume 4 : number 2 : july dec. 2014 original article 44 in a taluka having total 56 gram panchayats. out of 56 gram panchayats, one gram panchayat was selected randomly. the selected gram panchayat is having two villages. one village was again selected randomly by random sampling method. the population of the area was 5,044 and 6 anganwadis were there in that village with 580 registered pnc mothers. out of which 4 anganwadis were selected randomly and list of mothers taken and visited to them. all participants were informed regarding the purpose of the study and their consent taken for the study. mothers were interviewed by the investigator using predesigned pretested questionnaire. mothers with post partum psychosis, mothers not consenting were excluded. data was analyzed by using epi info software 3.4.3 version. main outcome measures calculated in percentage were thermal care, breast feeding practices and some cultural practices. results: out of total 370 mothers, 48 (12.97%) deliveries were home deliveries while 322 (87.03%) were hospital deliveries. majority of mothers (80%) were of age less than 26 years.most of the mothers (93.5%) have education upto hssc and only 6.5% mothers were graduate and postgraduate and out of the total 24.32% mothers were employed. nearly more than half of the mothers (54.05%) belonged to nuclear family and remaining 11.35% mothers belonged to joint family and 34.59% mothers were from three generation family. 32.97% mothers were from class i and ii of socioeconomic status(ses) and 67.03% were from class ii, iv and v of ses according to modified prasad scale (table 1).out of total 34 deliveries conducted by dais, 26(76.47%) were untrained and 8(23.53%) were trained dais. majority of the total i.e.(79.45%) were normal deliveries, 6 (1.62%) were instrumental deliveries and 70 (18.91%) were cesarean sections. table 1: sociodemographic characteristics of the mothers (n=370) result of the study (table 2) revealed that many harmful and unindicted neonatal care practices were prevalent in the community. still 60% mothers had traditional care practices pertinent to breastfeeding and bathing at birth. table 2: prevalent neonatal care practices characteristics number percentage religion hindu 200 54.05 muslim 22 5.9 buddhist 140 37.83 others 8 2.1 education of mothers illiterate 0 0 upto high school 174 47.02 upto hsc 172 46.48 degree 20 5.40 post graduate 4 0.01 age of mothers 19-22 yrs 135 36.48 23-26 yrs 162 43.78 27-30 yrs 73 19.72 occupation of mothers employed 90 24.32 unemployed 280 75.68 type of family – nuclear 200 54.05 joint 42 11.35 three generation 128 34.59 socio-economic status i 10 2.7 ii 117 31.62 iii 214 57.83 iv 29 7.8 v 5 1.3 prevalent neonatal n = 370 care practices parameters number percent bathing at birth 222 60 skin to skin contact 44 11.89 colostrum discarded 102 27.56 breast feeding within 138 37.29 half hour on demand breast 244 65.94 feeding rooming in 319 86.21 prelacteal feed 122 32.97 breast feeding 42 11.35 counseling not received hand washing after 240 64.86 change of soiled nappy application of 281 75.94 substance on cord kajal application in eyes 282 76.21 putting oil in nose and ears 202 54.59 procedure to avoid evil eye 326 88.10 knowledge of danger 230 62.16 signs to mother pjmsvolume 4 : number 2 : july dec. 2014 original article 45 only 24% mothers were keeping cord dry and clean as indicated.75.94% motherswere applying substance on cord; most commonly applied substance was oil (fig. 1). figure 1:substance application on cord 76.21% mothers were applying kajal in eyes. prelacteal feedwas given by 32.97% mothers most commonly used prelacteal feed was honey (50%)(fig. 2). figure 2: types of prelacteal feed used bathing the baby immediately at birth was commonly practiced in 60 %. only 37.02% mothers initiated breast feeding within half hour of birth. early initiation of breast feeding was more likely in neonates with mother with higher education (p< 0.01) and higher income (p<0.05) and those belonging to joint families (<0.01)(table3). . table 3: association of various factors with early initiation of breastfeeding (n=370) 27.56 % mothers had not given colostrum to their babies & in majority the reason was family customs or prohibited by elderly (fig. 3). figure 3: reasons for discarding colostrum discussion: after 7 years of implementation of imnci strategy through nrhm we got mixed pattern of results in neonatal care practices in rural area.the present study showed that 60 % of newborn were given a bath immediately after birth. same results were observed there in study of gupta p et al which was 79.7 %(6).similarly, singh (7) in a study in rural area of ghaziabad u.p. also reported that bath was given in 71.2% of newborns.similarly kumar et al (8) in a study in haryana found that 65% were bathed within 24 hours of delivery. these findings show that there was very less awareness in community regarding prevention of hypothermia. factors early bf initiation total 'p' value chi or initiation of bf in square (95% >1/2 hr ci) joint & 88 112 200 3 gen family nuclear 50 120 170 0.003831 19.08 1.88 family total 138 232 370 edu> 92 104 196 hsc edu< 46 128 174 0.000046 16.57 2.46 hsc total 138 232 174 higher 58 69 127 income group lower 80 163 243 0.01607 5.79 1.71 income group total 138 232 370 pjmsvolume 4 : number 2 : july dec. 2014 original article 46 in the present study, it was found that 37.29 % mothers initiated breast feeding within half hour of birth. similarly gupta p (6) in her study revealed 36.6% mothers initiating breast feeding within half hour which is in close approximation to the present study. according to dlhs-4 nagpur (2011-2012)(9) 73.2% mothers initiated breast feeding within 1 hour which is in contrast for our study, while national average of percentage of initiation of breast feeding was 37% within 24 hours of birth. grover p in his study found breast feeding was initiated within one hour in only 12% of the newborn(10) which was very low as compared to present study. the present study revealed that more than half (72.44%) had given colostrum to their newborn. in contrast to our study, singh (2002) had shown in his study that about 47.8% had given colostrum to the neonate (7). dlhs-4 nagpur reported that only 60 % of mothers had given colostrum to their babies which less than in the present study. in contrast to present study, taja et al (2001) (11) in a district of mp found that 77.3% mothers discarded colostrum and only 22.7% of mothers had given it to their baby. in the present study the reasons found for discarding colostrum were prohibited by elderly (42.15%), family customs (34.31%), ignorance about advantages (15.68%) and baby was admitted in nicu (7.8%).in contrast to our study, singh et al (2002) showed in his study that about 36.8% mothers gave no milk secretion as the reason for not giving colostrum, 28.9% said that they did not know that it should be given while 18.4% said that giving colostrum was against the tradition of the family and community and another 15.7% said that elderly female prevented them from giving colostrum (7). present study findings were compared with nfhs-3 (12) data with regards to cord cutting in home deliveries, delivery by untrained persons, delivery by tba, bathing at birth, weighing the baby at birth, something given along with the breast feeding, breast feeding during neonatal period, neonatal checkup within 2 days of birth, bcg and opv immunization and it was observed that mixed results were there(fig. 4). figure 4: comparison of present study variables with nfhs-3 conclusion: unsafe and harmful traditional practices in neonatal care are more prevalent in the rural area though nrhm has positive impact in certain neonatal care practices there is need for further education in safe and healthy practices to the mothers and the community in rural area. recommendations: in majority of cases, correct practices regarding newborn care were poor among mothers and this should be promoted through improved coverage with existing health services.the government should take necessary steps in terms of increasing awareness of mothers through information education and communication activities about the safety measures for handling neonates. references: 1) subbiah nanthini. a study to assess the knowledge, attitude, practice and problems of postnatal mothers regarding breast feeding. nursing journal of india; 90(12):1232-7. 2) sreerama reddy ct, joshi hs, srekumaran g, chuni n. home delivery and newborn care practices among urban women in western nepal: bmc pregnancy child birth. 2006;6:27. th 3) gupte s. the short textbook of paediatrics. 10 ed. new delhi: jaypee brothers medical publishers (p) ltd., 2004. p. 617. 4) kumar d, verma a, sehgal vk. neonatal mortality in india: rural and remote health.7:833. 5) murray s. neonatal care in developing countries. modern midwife 1997; 7:26-30. 6) gupta p. newborn care practices in urban slums of lucknow city, u.p.indian journal of community medicine 2010;35(1):82-5. 7) singh d. a study of the knowledge,attitude and practices regarding care of the neonate in rural community. thesis submitted to the faculty of medical sciences, university of delhi, 2002. 8) kumar r, agarwal ak. body temperatures of home delivered newborns in north india. trop doct 1998; 28:134 6. 9) dlhs-4, district level household & family survey4, district factsheet, nagpur (2012-13) i.i.p.s. mumbai. 10) grover p,chhabrap. neonatal care practices in urban villages. indian medical gazette january 2012:32-38. 11) tajaverma p, gupta n. feeding practices and malnutrition in infants of bhil tribe in jhalva district of m.p. ind j nutrition and dietetics 2001;38:160. 12) nfhs-3 ms (2005-2006).international institute for population sciences, mumbai. panacea final 2014 28 effect of 12 weeks of pranayama training on basal physiological parameters in young, healthy volunteers 1 1 2 dinesh t , venkatesan r , venkidusamy s 1 2 assistant professor, professor and head department of physiology, dhanalakshmi srinivasan medical college and hospital, perambalur, tamilnadu, india621113. drdineshphysiologist10@yahoo .co.in abstract: pranayamas are breathing techniques that exert profound physiological effects on pulmonary, cardiovascular and mental functions. it deals with the knowledge, control and enrichment of this vital force. the study was conducted to study the effect of 12 weeks of pranayama training on basal physiological parameters in young subjectson 60 healthy volunteers. after obtaining informed, written consent, subjects were randomized into pranayama (n=30) and control groups (n=30). supervised training was given to the pranayama group by a certified yoga instructor and they practiced pranava, nadishodana and savitri pranayamas. basal physiological parameters such as heart rate (hr), systolic blood pressure (sbp), diastolic blood pressure (dbp) and respiratory rate (rr) were recorded at the beginning and after 12 weeks of study period. pranayama training resulted in marginal improvement (p>0.05) in the measured cardiovascular parameters while rr decreased significantly from 17.66 ± 1.2 to 16.86 ± 0.92 (p<0.01). in control group there was no significant change (p>0.05) in the tested cardiovascular parameters such as hr, sbp and dbp. 12 weeks of pranayama training showed improvement in the tested basal physiological parameters with significant decrease in rr. the rr depends on mental-emotional activity and this decrease in rr may be attributed to a calm and stable mind-emotion complex in our subjects. keywords : pranayama, basal physiological parameters, yoga. introduction: the spiritual-scientific discipline of yoga is the most precious gem of vedic philosophy and our cultural heritage. it incorporates a wide variety of practices whose ultimate goal is the development of mental and physical health, well being, inner harmony and ultimate union of the human individual with the universal and transcendent existence (1-2). as a deep breathing technique, pranayama reduces dead space ventilation and decreases work of breathing. it also refreshes air throughout the lungs, in contrast with shallow breathing that refreshes air only at the base of the lungs(3). pranayama has variable effect on cardio-respiratory system (4). regular practice of pranayama improves cardio-vascular and respiratory functions, improves autonomic tone towards parasympathetic system, decreases the effect of stress and strain on the body and improves physical and mental health(5-7). versions of pranayama vary from single nostril breathing to bellow breathing and it consists of three phases: purak (inhalation), kumbhak (retention) and rechak (exhalation) (8). few previous studies found out the combined effect of slow and fast pranayama training (9). also there is a paucity of data on the evaluation of the cumulative effect of commonly practiced pranayamas on basal physiological parameters (10). hence the present study was planned to find out the cumulative beneficial effects of commonly prescribed pranayama training on basal physiological parameters in young, healthy volunteers. materials and methods: the present study was conducted in the department of physiology, jipmer, puducherry on 60 healthy volunteers of both genders. inclusion criteria: healthy volunteers of both genders in the age group of 18-30 years. exclusion criteria: · history of chronic respiratory illness. · subjects receiving medication for any chronic ailment. · smokers and alcoholics. · athletes. · any history of previous yoga or bio feedback techniques training in the last one year. the purpose of the study, procedures and benefits were explained to them in detail. the willing participants were randomized into pranayama (n=30) and control groups (n=30) after getting informed written consent, by simple randomization method using random numbers generated through computer. average age of the volunteers was 18.58 ±2.27 (mean ± sd).among these 60 volunteers, 45 were females and 15 were males. the study did not involve invasive procedures at any stage. parameters: basal physiological parameters including resting hr, sbp and dbp were measured after 10 minutes of supine rest using digital bp monitor (citizench 432b, japan) and respiratory rate (rr) was recorded passively by observing the abdominal movements. the same procedure was followed while recording the values at the end of thestudy period. pjmsvolume 4 number 1: jan june 2014 original article 29 pranayama training: supervised pranayama training was given to the study group by a certified yoga instructor at advanced centre for yoga therapy education and research (acyter), jipmer, puducherry as per the guidelines of morarji desai national institute of yoga, new delhi and they practiced pranav pranayama,nadishodana and savitri pranayamas for 30 minutes/day, thrice/week for 12 weeks. rests of the days, subjects were motivated to practice at their home. each round (7 minutes) of session consisted of practicing 2 minutes of nadishodhana, pranava and savitri pranayama interspersed with 1 minute of rest between each pranayama and was done in comfortable posture (sukhasana). subjects were asked to perform nine or more rounds according to their capacity. ·nadishodhana pranayama is rhythmic and slow alternate nostril breathing. one round consisted of inhaling through one nostril, exhaling through other nostril and repeating the same procedure through other nostril. ·savitri pranayama is a slow, deep and rhythmic breathing, each cycle having a ratio of 2:1:2:1 between inspiration (purak), held-in breath (kumbhak), expiration (rechak), and held out breath (shunyak) phases of the respiratory cycle. ·pranava pranayama is slow, deep and rhythmic breathing where emphasis is placed on making the sound aaa, uuu and mmm while breathing out for duration of two to three times the duration of the inhaled breath. at the end of each session subjects were instructed to lie down in shavasana and relax for 10 minutes. control group were not involved in any of the pranayama training during this 12 weeks study period. ethics: the study was conducted after obtaining clearance from the institute ethics committee of jipmer and carries less than minimal risks. statistical analysis: data for all parameters were collected as per the study protocol and computerized in microsoft excel database. data was summarized by using descriptive statistics such as mean and sd. longitudinal changes in each group were compared by using student's paired t-test. all statistical analyses were done at 5% level of significance and p<0.05 was considered as statistical significant. results: mean age of the volunteers was (18.54 + 1.65). changes in pranayama group (n=30) and control group (n=30) before and after 12 weeks of study period on cardio-respiratory parametershas been given in table 1. it shows a significant decrease in rr from17.66 ± 1.2 to 16.86 ± 0.92 (p<0.01) and marginal decrease in other parameters (p>0.05) such as sbp, dbp and hr indicates there was statistically significant improvement in the pranayama group participants on respiratory parameters and marginal improvement on cardiovascular parameters. discussion: pranayama, the fourth step of ashtang yoga is an important component of yoga training. 'prana' is the vital life force that acts as a catalyst in all our activities and 'ayama' is its control and expansion. pranayama can be defined as the science of controlled, conscious expansion of prana in our energy body sheath (3). pranayama involves manipulation of breathing movements and the breath is a dynamic bridge between the body and mind. as a technique, pranayama can assume complex forms of breathing. but the essence of the practice is slow and deep breathing. resting hr is determined mainly by parasympathetic tone and decrease in hr and bp indicates either an increase in parasympathetic activity or a decrease in sympathetic activity (11-12). our results demonstrate that there was a significant reduction in rr in pranayama group. on the contrary, there was a significant increase in rr in the control group. there was a statistically insignificant but definite trend towards decrease in hr, sbp and dbp in pranayama group. according to the traditional wisdom of yoga, pranayama is the key for bringing about psychosomatic integration and harmony. by voluntarily controlling breathing pattern, it is possible to influence ans functions(13). a study conducted by kullok et al in 1990 explained changes in autonomic activity by breathing pjmsvolume 4 number 1: jan june 2014 original article table 1: comparison of tested basal physiological parameters before and after 12 weeks of study period (mean ± sd) parameters pranayama group (n=30) control group (n=30) before after before after hr (beats/min) 76.41 ± 5.48 75.15 ± 4.52 79.33 ± 3.65 80.47 ± 2.78 sbp (mmhg) 114.93 ± 10.11 113.03 ± 12.58 107.23 ± 13.55 111.4 ± 11.24 dbp (mmhg) 72.76 ± 7.29 71.586 ± 7.35 71.45 ± 6.791 73.73 ± 9.239 rr(beats/min) 17.66 ± 1.2 16.86 ± 0.92** 17.23 ± 1.22 18.33 ± 1.81*** values are expressed as mean ± sd analysis done by student's paired t-test. *p<0.05, **p<0.01, ***p<0.001 30 exercises on the basis of known anatomical asymmetries in the respiratory, cardiovascular and nervous system and that the coupling mechanisms between each of these systems: lung-heart, heart-brain and lungs-brain are also asymmetrical (14).we propose that these changes might have been caused by pranayama practice resulting in an improved autonomic tone towards parasympatho dominance which leads to hypo metabolic state, relaxed state of mind and improved cardiac vagal tone. when the mind is relaxed and resting, parasympathetic activity increases and rr decreases. increase in parasympathetic activity decreases resting hr and decrease in sympathetic tone in skeletal muscle, blood vessels, decreases peripheral vascular resistance and hence, decrease in dbp and improved tissue perfusion(13). further our study substantiates the claim that pranayama practice is beneficial on cardio-respiratory function in healthy volunteers. acknowledgement: we acknowledge programme director, coordinator, yoga instructors of acyter, jipmer. author would like to thank professors, assistant professors, phd scholars of department of physiology, jipmer who helped us to carry out this project. authors feel deep gratitude for all the subjects who volunteered for the present study. references: 1. madanmohan, rai uc, balavittal v, thombre dp, swami gitananda. cardio-respiratory changes during savitri pranayam and shavasan. the yoga review 1983; 3: 25–34. 2. khalsa s. yoga as a therapeutic intervention. indian j physiol pharmacol 2004; 48 (3): 269-85. 3. bijlani rl. the yogic practices: asanas, pranayams and kriyas. bijlani rl, editor, understanding medical physiology, third edition. new delhi, india: jaypee brothers medical publishers 2004; 883-9. 4. veerabhadrappa sg, baljoshi vs, khanapure s, herur a, patil s, ankad rb, et al. effect of yogic bellows on cardiovascular autonomic reactivity. cardiovascular dis res 2011; 2(4):223-7. 5. udupa k, madanmohan, ananda ab, vijayalakshmi p, krishnamoorthy n. effect of pranayama training on cardiac function in normal young volunteers. indian j physiolo pharmacol 2003; 47:27-33. 6. udupa kn, singh rh. the scientific basis of yoga. jama 1972; 220(10):136. 7. bhargava r, gogate mg, mascarenhas jf. autonomic responses to breath holding and its variations following pranayama. indian j physiolo pharmacol 1988; 32(4): 25764. 8. chodzinski j. the effect of rhythmic breathing on blood pressure in hypertensive adults. j undergrad res 2000; 1(6): 78-98. 9. jore sb, bhutada tb, patil us, patil sv, gaikwad pb. effect of combined slow &fast pranayamic breathing exercises on autonomic nervous system. inter j rec trend sci tech 2012; 3(1): 5-8. 10. sharmavivek kumar, rajajeyakumar m, velkumary s, subramanian senthil kumar, bhavanani ananda b. effect of fast and slow pranayama practice on cognitive functions in healthy volunteers. j clin diagn res 2014; 8 (1):10-13. 11. gopal ks, bhatnagar op, subramanian n, nishith sd. effect of yogasanas and pranayama on bp, pulse rate and some respiratory functions. indianj physiology pharmacology 1973; 17: 273–76. 12. upadhyay dk, malhotra v, sarkar d, prajapati r. effect of alternate nostril breathing exercise on cardio respiratory functions: nepal med coll j 2008; 10(1): 25-27. 13. jerath r, edry jw, branes va, jerath v. physiology of long pranayama breathing: neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. med hypotheses 2006; 67:56–71. 14. kullok s, maver c, backon j, kullok j. interactions between non-symmetric mechanical vector forces in the body and the autonomic nervous system. med hypotheses 1990; 32:173–80. pjmsvolume 4 number 1: jan june 2014 original article page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 429 too many requests you have sent too many requests in a given amount of time. panacea final 2014 62 association of non-clinical characteristics and lipid profile with gall bladder stone patients; a case control study 1 2 2 3 dwivedi shipra , singh shraddha , singh devendra , tewarisunita 1 2 ph.d student, professor, department of physiology, 3 professor& head department of general surgery, king george's medical university, lucknow, u.p., india. dr.shraddha22@rediffmail.com abstract : increased incidence of cholelithiasis has been reported among female with advancing of age. age, gender, race, obesity, diabetes, dietary factors and parity have all been identified as significant risk factors for the development of gallstones. cholelithiasis is frequently associated with carcinoma gallbladder up to 40%-100% patients and is the most common associated factor independent of age or sex. a case control study. was carried out in 160 subjects (case n=80, control n=80). a detail questioner has been filled for non-clinical characteristics. lipid profile has been done with the help of spectrophotometer by using the commercially available kit. in the present study we found the significant association of postmenopausal women, use of contraceptive pills and high parity with the gall bladder stone disease in comparison of control group.the level of total cholesterol (tc), triglyceride (tg), low density lipoprotein (ldl), very low density lipoprotein (vldl)were significantly (p<0.001)higher in study group in comparison of control group. high density lipoprotein (p<0.001) .our study revealed that gall bladder stone patients have increased level of total cholesterol, triglycerides, low density lipoprotein, and very low density lipoprotein. keywords : gall bladder stone, lipid profile, contraceptive, high parity. however, (hdl) cholesterol serum levels were found significantly lower in cases in comparison of controls introduction: these days the world is bearing an assortment of noncommunicable diseases. gallstone disease is a major health problem worldwide, particularly in adult population. its occurrence has been found to be at least 6% in the adult population of northern india (1). age, gender, race, obesity, diabetes, dietary factors and parity have all been identified as significant risk factors for the development of gallstones (3-4).the pathogenesis of cholesterol gallstones is known to be multifactorial with the key factors includingcholesterol supersaturated bile, nucleation and growth of cholesterol monohydrate crystals and altered biliary motility. in addition, epidemiologic evidence, particularly ethnic differences, suggests the importance of genetic factors that affect susceptibility to gallstone formation and gallbladder disease (5). cholesterol is water insoluble lipid, and it is digested in intestine after micelles formation. micelles are aggregates of phospholipids, bile salts, and cholesterol, and vesicles are closed spherical bilayers of phospholipids with associated cholesterol (6). cholelithiasis is frequently associated with carcinoma gallbladder in up to 40%-100% patients and is the most common associated factor independent of age or sex (7). the risk of carcinoma gall bladder in patients with gall stones may be increased 4 to 7 times (8) and patients with gallstones more than 3cm in diameter have a much higher risk (9). hypercholesterolemia is common finding in adults and pure cholesterol gallstones are more common as compared to other types of gallstones (10). gallstone disease (cholelithiasis) has been reported among female with advancing of age and a spurt in it has been noted recently (2). the risk factors for the development of cholelithiasis include repeated pregnancy, use of contraceptive pills, a family history of gall material and methods: statistical stones, serum lipids, dietary factors, chronic liver disease and possibly major abdominal surgery (11).this study was carried out with an objective to evaluate the association of contraceptive use, menstrual status, parity and lipid profile with gall bladder stone patients and control in north indian population. the present study was approved by the institutional ethics committee of king george's medical university, up, lucknow india. this present case control study was carried out in the department of physiology with the collaboration of general surgery, king george's medical university, up, lucknow, india. after obtaining the informed consent total n=160subjects were selected for the study in which n = 80(male=10, female=70) case group and n= 80(male=11, female=69) control group. subjects between the age group of 20 to 50 years were included in the study on the basis of well define inclusion and exclusion criteria. 3 ml blood sample was collected from each participant and the serum has been separated. a detail questioner has been filled for non-clinical characteristics such as contraceptive use, menstrual status and parity. lipid profile has been done with the help of spectrophotometer by using the commercially available kit.(microlab 300, merck) on the same day of sample collection. low density lipoprotein and very low density lipoprotein was calculated by the friedewald formula [ldl= tc-(hdl+ vldl) and vldl = tg/5] (12). all the analyses were carried out by using spss 16.0 pjmsvolume 4 number 1: jan june 2014 original article 63 version (chicago, inc. usa).we used chi-square test for analysis of categorical data and student t test for noncategorical data. we have found majority of the patients were females in comparison of male in both study and control group (p<0.8149). postmenopausal women had more significant (p<0.001) relation in gallstone patient in comparison of control subjects. level of total cholesterol, triglyceride, low density lipoprotein, very low density lipoproteinwere significantly (p<0.0001) higher in patients compared with controls. however, high-density lipoprotein was significantly (p<0.0001) higher among controls in comparison of gall bladder stonepatients . gallstones are a major cause of morbidity worldwide.the larger occurrence of gallstones in elderlyfemale is frequently result: in present study the significant association (p<0.001) were found in case with oral contraceptive user. the female subjects with high parity were also significantly (p<0.002) associated with gall bladder stone (table1). table 1: distribution of gender, menstrual status, contraceptive user and parity in case and control the comparison of lipid level between case and control shows the (table 2) table 2: comparison of lipid profile in study and control group discussion: reported in literature(13). this affinity was also reported in the present study,as most of the patients were women in comparison of men. in general, women are probably at increased risk because estrogen stimulates the liver to remove more cholesterol from blood and divert it into the bile. an increased risk of gallbladder stone was seen with postmenopausal status, because use of hormone replacement therapy (hrt) has more risk for gallstones. the finding was consistent with an earlier report, which suggests that the premenopausal status probably had a protective role in the development of gallbladder stone. the underlying mechanism for the familial tendency of gallstone disease may be related to genetic susceptibility or shared lifestyle or metabolic factors. although the present association appeared independent risk factors for gallstones, such as lifestyle factors, diet, and some time genetic factors. in the present data, the high parity was also significantly associated with gall bladder stone disease and the finding was consistent with our previous report as well as some others (14-16). it is proposed that the lithogenicity of bile increases in pregnancy due to the effect of estrogen and progesterone hormones, predisposing to gallstone formation and probably gallbladder carcinoma (17). the majority of studies have evaluated that the gall bladder stonehas positive associationwithincreased triglyceride, total cholesterol, low density lipoprotein and very low density lipoprotein concentration. in this study, the similar observation was found between lipid profile concentration and gall bladder stone subjects in comparison of controls. several epidemiologic studies have linked that the high serum triglyceride and low high density lipoproteinserum cholesterol due to(increased activity of 3-hydroxy-3-methyl glutaryl-coa reductase) associated with gallstone for mation (18-19).lower high density lipoprotein increases biliary cholesterol secretion there by raising the level of cholesterol precipitation and gallstone formation. women are more pjmsvolume 4 number 1: jan june 2014 original article gall bladder stone (n=80) (n=80) gender male 10 (12.5%) 11 (13.7%) female 70 (87.5%) 69 (86.3%) 0.8149 0.896 (0.357-2.246) menstrual status n=70 n=69 premenopausal 17 (24.3%) 42 (60.9%) postmenopausal 53 (75.7%) 27 (39.1%) 0.001* 0.206 (0.099-0.427) contraceptive user n=70 n=69 yes 52 (74.3%) 26 (37.7%) no 18 (25.7%) 43 (62.3%) 0.001* 4.778 (2.316-9.858) parity (childbirth) n=70 n=69 more than 3 children 42 (60%) 23 (33.3%) less than 3 children 28 (40%) 46 (66.7%) 0.002* 3.00 (1.501-5.996) 2 control ( ) p value or (ci 95%) p value<0.005* (statistically significant), orodd ratio, ciconfidence interval (95%) s.no. variable gall bladder stone (n=80) (n=80) 1. tc (mg/dl) 192.46±57.22 157.27±40.91 0.001* 2. tg (mg/dl) 177.50±91.81 125.35±74.67 0.001* 3. hdl (mg/dl) 26.84±8.82 32.97±11.05 0.001* 4. ldl (mg/dl) 130.11±53.25 99.22±37.60 0.001* 5. vldl(mg/dl) 35.50±18.36 25.07±14.93 0.001* control p value p value<0.005* (statistically significant) prone for gallbladder stone formation than men, because of oral contraceptive user, high parity and hormone replacement therapy. in general gallbladder stone formation is more common, those having altered lipid profile. therefore strategies can be made to improve nutrition and lifestyle which may have an influential consequence on a series of pathological conditions that signify a major source of morbidity and mortality in our society due to gallbladder stones and carcinoma. acknowledgement: we would like to acknowledge the indian council of medical research (icmr) new delhi for their financial support andthe faculty of department of general surgery, king george's medical university, uttar pradesh, lucknow, india for their valuable contribution in the work references: 1. mittal b, mittal rd. genetics of gall stone disease. journal of postgraduate medicine 2002; 48:149-152. 2. diehl kd, haffner sm, hazuda h, stern m.coronary risk factors and clinical gallbladder disease:an approach to the prevention of gallstone? am jpub health1987;77: 841-845. 3. paigen b, carey mc. gallstones. in: king, rotter, motulsky, eds. 2nd edition, 2001: 166-173. 4. everhart je, khare m, hill m, maurer kr. prevelance and ethinic differences in gall bladder diseases in the unites states.gastroenterology 1999; 117:632–639. 5. lammert f, carey mc,paigen b. chromosomal organization of candidate gene involved in cholesterol formation: a murine gallstone map.gastroenterology 2001; 120:221–238. 6. channa na. gallstone disease: a review. pak armedforces med j 2008; 58: 197-208. 7. hart k, modan b,shani m. cholelithiasis in the aetiologyof gallbladder neoplasms. lancet 1971; 1:1151-1153. 8. nervi f, duarte i, gómez g, rodríguez g, del pino g,ferrerio o, et al. frequency of gallbladder cancer in chile. intj cancer 1988; 41: 657-660. 9. diehl ak. gallstone size and the risk of gallbladder cancer. journal of the american medical asso 1983; 250:23232326. 10. channa na, soomro am,ghangro ab. cholecystectomyis becoming an increasinglycommon operation inhyderabad and adjoining areas. rawal medical journal 2007; 32:128130. 11. kosters a, jirsa m, groen ak. genetic background of cholesterol gallstone disease.bioch biophy acta2003; 137: 1-19. 12. friedewald wt, levy ri,fredrickson ds. estimation of the concentration of low-densitylipoprotein cholesterol in plasma without use of the preparative ultracentrifuge. clin chem1972; 18:499-502. 13. jorgensen t,jensen kh. who has gallstones? current epidemiological studies. nord med1992;107:122-125. 14. dwivedi s, madeshiya a, shingh d, shingh s, krishna a. gall bladder cancer and some epidemiological factors: a cross sectional study.biomed research2013; 24: 83-87. 15. hemminki k, li x. familial liver and gallbladder cancer: a nationwide epidemiological study from sweden. gut 2003; 52: 592-596. 16. kuroki t, tajima y, matsuo k, kanematsu t. genetic alterations in gallbladder carcinoma. surg today 2005; 35: 101-105. 17. nakagaki m, nakayama f. effect of female sex hormones on lithogenicity of bile. jpn j surg 1982;12:13-18. 18. dowling rh. review: pathogenesis of gallstones. alim pharmacol ther 2000;14: 39–47. 19. paumgartner g, sauerbruch t. gallstones: pathogenesis. lancet1991; 338: 1117–112. pjmsvolume 4 number 1: jan june 2014 original article 64 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 429 too many requests you have sent too many requests in a given amount of time. original article panacea journal of medical science, january – april 2015:5(1);29-32 29 awareness of adolescent girls regarding menstruation and practices during menstrual cycle tarhane s1, kasulkar a2 abstract: although adolescent period marks the beginning of women’s menstrual and reproductive life, adolescent girls constitute a vulnerable group. hygiene related practices of menstruation are of considerable importance as it has health impact in terms of increased vulnerability to reproductive tract infections (rti). therefore, increased knowledge about menstruation right from childhood may escalate practices and may mitigate the sufferings of women. with this in mind, the present study was carried out to gather information regarding menstruation, hygiene related practices of menstruation, and its related problems among adolescent girls. a crosssectional study was carried out in 100 adolescent girls of age group 12-18 years. they were interviewed through pretested questionnaire. we found that 89% girls thought menstruation to be a normal process, 79% girls used sanitary napkins while 21% girls used clothes as absorbent during menses. mother seemed to be the first source of information in 88% girls. te girls should be educated about the menstruation and hygienic practices which can be achieved by educational television programs, school/nurses health personnel, compulsory sex education in school curriculum and knowledgeable parents. keywords: hygiene, menstruation, adolescent girls, reproductive tract infection. 1mbbs student, 2assistant professor, department of forensic medicine, nkpsims & rc, digdoh hills, hingna road, nagpur 440019. artinarde@rediffmail.com introduction: childhood to adulthood transition takes place during adolescence period which is characterized by major biological changes like physical growth, sexual maturation, and psycho-social development. as per world health organization (who), adolescence is the age group of 10-19 years. adolescent girls constitute 1/5th of the total indian population. it is marked by enhanced food requirement, increased basal metabolic and biochemical activities, endogenous processes like hormonal secretions with their influence on the various organ systems of which menarche is the most important event in case of adolescent girls that requires specific and special attention (1). it marks the beginning of woman’s menstrual and reproductive life which occurs between 11 and 15 years with a mean of 13 years. it is qualitative event of major significance in woman’s life, denoting the achievement of major functional state. during this phase of growth, the girls first experience menstruation and related problems marked by feelings of anxiety and eagerness to know about this natural phenomenon (2). adolescent girls constitute a vulnerable group, particularly in india where female child is neglected one. they do not get the proper knowledge due to lack of appropriate health education program in schools. moreover, the traditional indian society considers talks on such topics as prohibited and discourages open discussion on these issues. this leads to intense mental stress and they seek health advice from quacks and persons who do not have adequate knowledge on the subject (2). menstruation is still regarded something unclean or dirty in indian society (3). the reaction to menstruation depends upon awareness and knowledge about the subject. the manner in which a girl learns about menstruation and its associated changes may have an impact on her response to the event of menarche. moreover, the routine health services do not have provisions for adequate care of adolescent health problems which in turn exaggerates the problems in multiple. understanding the health problems related to menstruation, the health seeking behavior of the adolescent girls, their awareness about pregnancy and reproductive health will help us in planning programs for this vulnerable group. hygiene related practices of menstruation are of considerable importance as it has health impact in tarhane s et al. awareness of adolescent girls regarding menstruation and practices during… panacea journal of medical science, january – april 2015:5(1);29-32 30 terms of increased vulnerability to reproductive tract infections (rti). the interplay of socio-economic status, menstrual hygiene practices, and rtis are noticeable. today, millions of women are sufferers of rti and its complications and often the infection is transmitted to offspring of the pregnant mother (3). women having better knowledge regarding menstrual hygiene and safe practices are less vulnerable to rti and its consequences. therefore, increased knowledge about menstruation right from childhood may escalate practices and may help in mitigating the suffering of millions of women. with this in mind, the present study was carried out to gather information regarding menstruation, hygiene related practices of menstruation, and its related problems among adolescent girls along with to review perceptions, belief and expectations regarding menstruation among adolescent girls. material and methods: a questionnaire based prospective cross-sectional study was carried out in n.k.p. salve institute of medical sciences and lata mangeshkar hospital, nagpur in 100 female adolescent girls (age group 1218 years) attending opd. the study was carried out for the duration of 2 months from june 2014 to august 2014. they were explained the purpose of study and prior written informed consent was obtained from them. a good rapport was established with them. they were informed about the confidentiality of the information collected so as to get more reliable answers from them. the study tool used was pre-designed, pre-tested, structured and self-administered questionnaire which was developed and translated into local language. the questionnaire was structured to obtain information relating to age at menarche, awareness about menstruation, source of information regarding menstruation, practices during menstrual cycles, menstrual history, regarding menstrual problems and treatment practices. the data thus obtained was tabulated and analyzed statistically for number and percentage using epi-info statistical version 7. results: in the present study, 100 adolescent girls of age group 12-18 years were included. we observed that maximum girls (44%) attended menarche at the age of 12 years with the mean age of menarche as 14 years (range 12-16 years) (table 1). regarding right age of menarche, only 40% girls were aware. we observed that in 46% girls, response to menarche was sad, in 28% girls it was normal, 17% girls were scared, and 6% girls were happy, but we could not get any response in 3% girls. sixty-eight girls (68%) knew about the source of menstrual blood and 67% girls knew about the right interval between the two menses. table 1: information about menarche (n=100) age of menarche in years number (%) 12 44 (44%) 13 20(20%) 14 18(18%) 15 08(08%) 16 07(07%) ninety-six (96%) girls thought menstruation to be good for health and 89% girls thought menstruation to be a normal process. as in table 2, the source of information about menstruation, we observed that mother seemed to be source of information in maximum (88%) girls followed by relatives and friends (7%). 92% girls thought menstruation to be dirty, 98% girls bathed during menses, 87% girls performed household activities during menses, 66% girls attended social activities during menses, 84% girls did not visit holy places during menses, 52% girls felt isolated during menses. table 2: source of information (n=100) source of information number (%) mother 88 (88%) relatives and friends 07 (07%) social programs 04 (04%) teachers 01(01%) out of 79 girls who used sanitary napkins, 1.3% girls changed it once a day, 35.4 % twice a day, 40.5% girls thrice a day, 18.9% girls changed it 4 times a day, and 3.8% girls > 4 times a day. only paper for wrapping the used napkins was used by 40.5% girls, 32.9% girls used paper and plastic, and 10.1% girls used only plastic. 82.2% girls threw the pads in house dustbin and 2.5% girls threw on roadside. out of 21 girls who used clothes as absorbent during menses, 66.6% girls used clothes of cotton variety while 33.4% used clothes of other variety. frequency of changing clothes was 2 times a day in 52.4% girls, 3 times a day in 38.1%, and 4 times a day in 9.5% girls. the used clothes were washed using soap and water by 80.9% girls, 9.5% used only water, and 9.5% used disinfectant. the clothes were dried in house corner by 80.9% girls and 19.1% girls dried the clothes in sunlight whereas 80.9% girls finally disposed off the used clothes after 2-3 months, 4.8% after 4-5 months, and 9.5% after 6-12 months by burning(19.1%), throwing in dustbin (14.3% ), and 4.8% threw on roadside. 41% girls washed the genitals with only water, 40% girls with soap and water, and 19% girls with water and disinfectant. tarhane s et al. awareness of adolescent girls regarding menstruation and practices during… panacea journal of medical science, january – april 2015:5(1);29-32 31 menstruation was regular in 84% girls and irregular in 13% girls. length of the menstrual cycle was normal in 70% girls. quantity of menstrual blood flow was normal in 79% girls, excess in 15% girls, and scanty in 5% girls. sixty-six (66%) girls knew that excess bleeding leads to anemia. only 14% girls knew about the reproductive tract infections. 59% girls suffered from premenstrual syndrome, out of which 30.5% had headache, 33.8% had irritability, 13.5% had breast pain, 6.7% had vomiting, 1.7% had edema, 1.7% had headache and breast pain, 1.7% had headache with edema, and 3.4% had irritability and headache. ninety-four (94%) girls experienced dysmenorrhea, frequency being every month in 42.5% girls, rare in 32.9% girls, and in 13.8% girls it was most of the times. intensity of pain was mild in 30.9% girls, moderate in 52.1% girls, severe in 14.8% girls. as remedial measures, 2.1% girls used analgesics and salt water (1.1%). during menses, 14% girls bunked the schools due to dysmenorrhea (28.6%) and excessive bleeding (42.9%). discussion: the present study was conducted in 100 adolescent girls of which majority girls (61%) were of age group 15-16 years. drakshayani dk et al (1) reported the age of menstruating girls as 14-17 years with maximum (76.3%) number of girls between 14-15 years of age which is in accordance with our findings. we observed that maximum number of girls (44%) attained menarche at 12 years, the mean age being 14 years which is in concordance with a study conducted (3-6). though it is desirable to have school teacher or health worker to be the first source of information ensuring that right knowledge has been imparted, it was seen that major source of information in the study was mother (88%) followed by relatives and friends (7%) which is also similar to other studies (1-2,4-8). it was observed that the mothers were the most common source of information which retells the fact that mothers of adolescents should be integral part of all programs on adolescent health and especially menstrual hygiene. it was seen that though almost all girls had heard about menstruation, the level of knowledge was poor which is similar to study by shanbhag d et al (3). it was observed that 89% girls thought menstruation to be a normal process which is in accordance with similar study conducted in west bengal by dasgupta et al (7) nearly 86.25% girls believed that menstruation was a natural process. it was sad to observe that only 40% of girls knew about the right age of menarche, only 68% girls knew about the source of menstrual blood and only 67% knew about the right interval between the two menses. in the present study though most of the girls knew about menstruation, majority of girls (46%) were sad followed by 17% girls who were scared at the time of menarche. in the study done in bangalore by shanbhag d etal (3), 44.1% girls felt fear, 26.1% were anxious at the time of menarche. the reason for this may not be due to lack of prior knowledge regarding menstruation, but may be due to inadequate or wrong knowledge and low levels of education especially among the mothers. it was seen in present study that 79% used pads and 21% used clothes whereas in similar study conducted it was found that 62% girls used clothes while 38% used sanitary pads. the use of pads was higher which was probably due to the fact that availability was high in these areas and also due to influence of television which has increased awareness regarding availability and use of sanitary napkins. it was observed that the usual practice was to wash cloth with soap and water after use and dry it at some secret place like house corner. to keep the clothes away from prying eyes, they are hidden in some unhygienic places (3, 6). privacy for washing, changing or cleaning purpose is something very important for proper menstrual hygiene. in the study, it was found that 40% girls washed the genitals with soap and water, 41% with only water and only 19% with water and disinfectant. this when compared to another study undertaken in rural west bengal which showed that 97.5% girls used soap and water (1). this shows that personal hygiene practices were unsatisfactory in the study population. regarding the method of disposal of the used material, most of the girls reused cloth pieces for 2-3 months and 19.4% properly disposed the used clothes (1,4,6,8). dysmenorrhea prevailed among 94% of the girls and premenstrual syndrome prevailed among 59% of the girls (5). most of the participants desired for more information regarding menstruation and hygienic practices. awareness regarding the need for information for information about healthy menstrual practices is on rise among young women. it is possible that mechanism be introduced to provide knowledge about menstrual health and self-maintenance among women (3). different restrictions like 84% girls were restricted from visiting holy places and 34% were restricted from doing social activities in the current study, possibly due to ignorance and false perceptions regarding menstruation. family life has been recognized as an important component of school health program. it emphasizes upon developing healthy attitude towards human reproduction and family life among older school students. health professionals should organize educative sessions for tarhane s et al. awareness of adolescent girls regarding menstruation and practices during… panacea journal of medical science, january – april 2015:5(1);29-32 32 parents so that they can be trained to give adequate knowledge on reproductive health problems to their children. conclusion: we concluded that the proper menstrual hygiene and correct perception can protect the women from suffering. before bringing any change in menstrual practices, the girls should be educated about the facts of menstruation, physiological implication, about the significance of menstruation and development of secondary sexual characters, and above all about proper hygienic practices and selection of disposable sanitary menstrual absorbent. this can be achieved through educational television programs, school/nurses health personnel, compulsory sex education in school curriculum and knowledgeable parents so that her received education should wipe away the age-old wrong ideas and make her feel free to discuss menstrual matters including cleaner practices without any hesitation. all mothers being the first source of information in maximum girls should be taught about the menstruation and hygienic practices and to break their inhibitions about discussing with their daughters about menstruation much before the age of menarche. thus the above findings reinforce the need to encourage safe and hygienic practices among adolescent girls and bring them out of traditional beliefs, misconceptions and restriction regarding menstruation. references: 1. drakshayani dk, venkata rp. a study on menstrual hygiene among rural adolescent girls. indian j of med sci 1994; 48 (6): 139-43. 2. singh mm, devi r, gupta ss. awareness and health seeking behavior of rural adolescent school girls on menstrual and reproductive health problems. indian j of med sci 1999; 53:439-43. 3. shanbhag d, shilpa r, d’souza n, josephine p, singh j, goud br. perceptions regarding menstruation and practices during menstrual cycles among high school going adolescent girls in resource limited settings around bangalore city, karnataka, india. international j of collaborative research on internal medicine and public health 2012; 4(7): 1353-62. 4. nayar p, grover vl, kannan at. awareness and practices of menstruation and pubertal changes amongst unmarried female adolescents in a rural area of east delhi department of community medicine, university college of medical sciences & gtb hospital, dilshad graden, delhi 110095, india, 2007; 32(2): 156-157. 5. nagar s, aimol kr. knowledge of adolescent girls regarding menstruation in tribal areas of meghalya. stud tribes tribals 2010; 8(1): 27-30. 6. singh ak, bandhani a, malik n. knowledge, attitude and practices about menstruation among adolescent females in uttarakhand. panacea journal of medical sciences july-december 2013; 3 (2): 19-22. 7. dasgupta a, sarkar m. menstrual hygiene: how hygienic is the adolescent girl? indian j community med april 2008; 33(2): 77–80. 8. .dube s, sharma k. knowledge, attitude and practices regarding reproductive health among urban and rural girls: a comparative study. ethno med 2012; 6(2): 8594. 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2022;12(1):39–44 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article comparison of surgical biliary bypass and biliary metallic stents for palliation of incurable malignant distal bile duct obstruction: a prospective observational study mukund p kulkarni1,*, nagaraj naik1 1dept. of surgical gastroenterology, karnataka institute of medical sciences, hubli, karnataka, india a r t i c l e i n f o article history: received 06-02-2021 accepted 15-05-2021 available online 30-04-2022 keywords: efficacy biliary metallic stents palliation malignancy obstruction a b s t r a c t background: management of obstructive jaundice from periampullary and pancreatic head malignancies is mostly palliative. with advancements in endoscopic and stent technology and instrumentation, endoscopic interventions are gaining popularity and acceptance over surgical relief of jaundice. objective: to study efficacy of surgical biliary bypass over biliary metallic stents for palliation of incurable malignant distal bile duct obstruction materials and methods: prospective observational study was carried out among 77 patients with incurable malignant distal bile duct obstruction. 45 of them chose to undergo surgical bypass while 32 agreed to undergo metallic stenting. parameters like improvement in jaundice, procedure related morbidities, need for re-hospitalization, need for re-intervention, quality of life and survival were compared in two groups. chi square test and t test were applied to compare two groups. results: there was prompt and good relief of jaundice in both groups. there was one procedure related mortality in each group. the morbidities were comparable. the stented patients were hospitalized for a cumulative mean period of 34.1 days compared to 14.2 days in the surgical bypass group (p= 0.0001). the global quality of life, pain, nausea, vomiting and appetite were significantly better in the surgical bypass group. there was significantly improved overall survival in the surgical bypass group (163.5 days vs. 150 days, p= 0.0001). conclusion: surgical bypass offers safe and superior palliation to obstructive jaundice from inoperable periampullary and pancreatic head cancer. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction malignant biliary obstruction from periampullary and pancreatic head lesions is common. majority of them especially pancreatic head cancer, present at an advanced stage with vascular invasion. the patients also have high levels of bilirubin, advanced age with multiple co morbidities like diabetes, advanced stages of atherosclerosis, pulmonary diseases, poor performance status and poor nutrition. 1 all these factors make palliation of jaundice as the only feasible treatment in a large subset * corresponding author. e-mail address: mukundaiims@gmail.com (m. p. kulkarni). of patients. before the mid 1980’s, palliation was provided primarily through surgical bypass2. cholecystojejunostomy and hepaticojejunostomy are established surgical biliary bypass procedures. cholecystojejunostomy is shorter of the two procedures and can be done with a small sub costal incision under epidural or short general anesthesia. if the cystic duct is blocked by tumor as with very low insertion into common bile duct (cbd) or by nodal mass, the bypass becomes ineffective. finding of white bile in gall bladder should raise suspicion for cystic duct block although occasionally a long standing high grade obstruction also can cause white bile. if on finding white bile a patent cystic duct cannot be demonstrated a choledochojejunostomy https://doi.org/10.18231/j.pjms.2022.008 2249-8176/© 2022 innovative publication, all rights reserved. 39 40 kulkarni and naik / panacea journal of medical sciences 2022;12(1):39–44 is indicated. the evolution of endoscopic retrograde cholangiography (ercp) with placement of larger plastic stents and later uncovered and covered metallic stents allowed this procedure to become a viable alternative to surgical palliation. 1 the main advantage of ercp is non operative technique and good patient acceptance. the disadvantage of plastic stents including stent block, stent migration have largely been addressed by the advent of self expanding metallic stents (sems). 2 self expanding metallic biliary stenting although popular has not been compared with palliative surgical bypass in any randomized study. 3 there is only one retrospective study comparing the efficacy of metallic stents with surgery. 4 hence with this background, present study was carried out to study efficacy of surgical biliary bypass over biliary metallic stents for palliation of incurable malignant distal bile duct obstruction 2. materials and methods this prospective observational study was conducted at a government medical college hospital ‘karnataka institute of medical sciences’ hubli, karnataka, india. the prospectively collected data of 110 patients with distal common bile duct malignant obstruction in our center, between september 2010 and september 2019 was analyzed. institution ethics committee permission was obtained and written informed consent was taken from all eligible and willing patients for the present study. all standard protocols and procedures were followed. 2.1. inclusion criteria all patients with obstructive jaundice from lower end common bile duct obstruction of malignant etiology undergoing palliative treatment the bilirubin should be more than 5 mg/dl 2.2. exclusion criteria patients undergoing curative surgery for periampullary carcinoma. patients not willing for either surgical bypass or stenting. out of these 110 patients treated at our institute for surgical obstructive jaundice from periampullary lesions during this period, 77 patients were included in the present study based on their informed consent and eligibility criteria. they were explained in detail about the two modes of therapy for surgical biliary bypass and biliary metallic stents for palliation of incurable malignant distal bile duct obstruction and given the choice to undergo the treatment. 45 of them agreed to undergo surgical bypass while 32 agreed to undergo metallic stenting. the diagnosis was established by a multiphase computed tomography scan in the presence of obstructive jaundice. additional tests like ca19.9, side viewing endoscopy and biopsy were done. those patients who were considered unsuitable for curative resection either because of locally advanced growth, metastasis or poor general condition and co morbidities precluding major resection were offered palliative biliary drainage if the bilirubin was high (>5 mg/dl). all treatment options, palliative metallic stenting, surgical cholecystojejunostomy or choledochojejunostomy and supportive care alone were extensively discussed with the patient and relatives including risks, complications and costs. patients selected for stenting underwent uncovered metallic biliary stent using side viewing endoscope under fluoroscopic guidance, a 10 mm wall stent (boston scientific corporation, natick, ma) either 6 or 8 cm was used according to stricture location and length. sphincterotomy was performed at the discretion of endoscopist. patients opting for palliative surgery underwent cholecystojejunostomy to a proximal loop of jejunum, using two layer anastomosis. the stoma was 2 cm wide, performed at or near the fundus of gall bladder. in patients where in white bile was found in the gall bladder, cholecystectomy with choledochojejunostomy was done. gastrojejunostomy was performed when duodenal obstruction was evident. patients who did not want any procedure were given supportive care only. the patients were followed up at regular intervals for three months. for those who did not come to hospital, a telephonic follow up was done. the relief of jaundice was monitored. the re hospitalization for different indications like pain, cholangitis, decreased oral intake were determined. the european organization for research and treatment of cancer quality of life 30 questionnaires (eortc qlq30) 5 was administered at three months after the procedure. the five function domains assessed were physical, role, emotional, cognitive and social function, the nine symptom domain were fatigue, nausea and vomiting, pain, dyspnea, anorexia, constipation, diarrhea and economic difficulty as well as one question on general health situation. 2.3. statistical analysis statistical analysis was performed using open epi software version 3.01. continuous variables were tested using independent student t test, categorical variables using chi square test, survival was compared using kaplan maier plots and log rank test. the quality of life parameters were compared using chi square test. p value less than 0.05 was considered as statistically significant. kulkarni and naik / panacea journal of medical sciences 2022;12(1):39–44 41 3. results 1. on initial recruitment = 110 patients 2. eligible and willing = 77 3. surgical bypass group = 45 and metallic stenting group = 32 (table 1) 4. one from each group had procedure related mortality (surgical bypass group=44 & metallic stenting group=31) [table 2] twenty-two patients underwent surgery with curative intention. two of them were found un-resectable due to locally advanced disease and underwent palliative roux en y choledochojejunostomy and gastrojejunostomy. thirty-eight patients were selected for ercp and biliary stenting. in six patients stenting could not be done for technical reasons, one for scope could not be passed due to deformed duodenum and in five due to failure of cannulation (13%). these six patients along with 37 patients underwent palliative surgical biliary drainage. thirteen patients received supportive therapy only. among patients undergoing surgical bypass seven (15.5%) underwent cholecystectomy with choledochojejunostomy and gastrojejunostomy. the other 38 (84.4%) had cholecystojejunostomy alone. all procedures were done under either epidural or general anesthesia. hows patient characteristics. the patients who underwent stenting (n=32) and those who had palliative surgical bypass (n=45) were comparable with regard to age, gender; mean bilirubin, type of tumor, co morbidities and american society of anesthesiology scores (asa). hows follow up parameters. one patient in the surgical arm died in the postoperative period due to respiratory infection and sepsis. one patient in the endoscopy and stent group developed severe acute pancreatitis with renal failure and could not be salvaged. the relief of jaundice was prompt in both groups. at 4 weeks following the procedure the average bilirubin was 3.5 and 4.3 in bypass and stent groups respectively. two patients in the stent group had acute cholecystitis with empyema of gallbladder necessitating cholecystectomy, which could be done laparoscopically in both cases. after excluding admissions for chemotherapy and its complications like vomiting and diarrhea, patients undergoing stenting needed frequent hospitalization (p=0.005) mainly to treat repeated cholangitis, pain and dehydration. in all five patients in surgical bypass group and four patients in stent group took chemotherapy. the cumulated total length of hospital stay per patient including postoperative stay was significantly less for surgical bypass patients. hows eortc qlq– c30 comparison at 3 months. two patients in the stent group developed persistent vomiting due to gastric outlet obstruction and were given supportive care only as they were too frail to receive additional therapy either duodenal stent or gastric bypass. patients on regular follow up received antacids, analgesics, multivitamins and anxiolytics. the quality of life eortc questionnaire was completed by 63 patients at 3 months follow. the patients in surgical bypass group experienced significantly better overall global health status, nausea, pain and appetite. the median overall survival was significantly better in the surgical bypass group compared to stented patients (163.5 days vs. 150 days) (figure 1) fig. 1: overall survival following surgical bypass and self expanding metallic stent (sems). [timein days] 4. discussion lower end common bile duct obstruction from periampullary carcinoma and pancreatic head cancers pose unique problem. the tumor is often un-resectable due to local spread or distant metastasis, or patient is medically unfit to undergo a major surgery. palliation is often the only option available. the main goals of palliation are relief of jaundice, treatment of duodenal obstruction when present and pain management. relieving the biliary obstruction can be done by surgical bypass or by endoscopic biliary stenting either plastic or metallic. duodenal obstruction can be palliated by either a surgical gastrojejunostomy or by endoscopic duodenal stenting. with improvement in endoscopic technique and instrumentation and wider access to these procedures, and better patient acceptance for endoscopic palliation, endoscopic palliation is pushed more zealously over surgical palliation. there is still disagreement as to whether endoscopic or surgical palliation is associated with better outcome. endoscopic techniques are being continuously refined in order to make up for its shortcomings, in the form 42 kulkarni and naik / panacea journal of medical sciences 2022;12(1):39–44 table 1: patient characteristics variables surgical bypass group (n=45) metallic stenting group (n=32) t/chi square value p value age (years) mean+sd 62+12.3 64+11.4 t = 0.734 0.4654 sex male 30 (66%) 22 (68%) x2 = 0.354 0.5516 female 15 (34%) 16 (32%) bilirubin (mg/dl) mean+sd 14+5.7 12+5.3 t = 1.581 0.1183 tumor cause pancreatic head 17 (37.7%) 12 (37.5%) x2 = 0.045 0.8307 periampullary 28 (62.3%) 20 (62.5%) reason for inoperability locally un-resectable 15 (33.3%) 9 (28.1%) x2 = 0.867 0.833poor clinical condition 24 (53.3%) 17 (53.1%) metastatic disease 3 (6.6%) 2 (6.2%) combination of above 3 (6.6%) 4 (12.5%) asa status asa-1 2 (4.4%) 4 (12.5%) x2 = 1.689 0.4297asa-2 20 (44.4%) 13 (40.6%) asa-3 23 (51.2%) 15 (46.9%) table 2: follow up parameters variables surgical bypass group (n=45) metallic stenting group (n=32) t/chi square value p value bilirubin (mg/dl) 4 weeks after procedure [mean+sd] 3.5+1.9 4.3+2.0 t = 1.7659 0.0821 morbidity yes 4 (9.1%) 5 (16.1%) x2 = 0.299 0.5845 no 41 (90.9%) 27 (83.9%) hospital stay mean days 14.2+3.2 34.1+8.1 t = 13.185 < 0.001 30 day mortality yes 1 (2.3%) 1 (3.2%) x2 = 0.2318 0.6302 no 44 (97.7%) 31 (96.8%) table 3: eortc qlq – c30 comparison at 3 months surgical bypass(35) mean (sd) metallic stent(28) (mean and sd) p global health status 69.20 (24.2) 56.43 (28.2) 0.05 physical functioning 70.7 ( 23.2) 66.4 ( 24.3) 0.47 role functioning 70.5 (32.8) 68.8 (30.2) 0.83 emotional functioning 65.7 (24.6) 60.9 (26.7) 0.46 cognitive functioning 85.1 (23.5) 86.2 (22.5) 0.85 social functioning 72.2 (27.6) 74.1 (28.2) 0.78 fatigue 34.1 (32.5) 45.4 (42.5) 0.23 nausea and vomiting 8.0 (16.8) 18.0 ( 22.5) 0.04 pain 27.0 (34.4) 45.4 ( 35.6) 0.04 dyspnea 22.7 ( 29.3) 21.8 ( 24.9) 0.89 insomnia 28.6 (30) 27.6 (34.5) 0.90 appetite loss 20.20 sd(30.10) 36.40 (32.50) 0.04 constipation 17.8 (24.5) 16.8 ( 23.3) 0.86 diarrhea 4.5 (23.7) 7.3 ( 32.1) 0.69 financial difficulty 52.4 (35.6) 57 (45.0) 0.65 sd: standard deviation kulkarni and naik / panacea journal of medical sciences 2022;12(1):39–44 43 of multiple plastic stents, to uncovered to covered metallic stents. the type of surgical palliation differs from studies. the very term palliation means as much less invasive procedure as possible. but in some studies compulsory hepaticojejunostomy 6 along with gastrojejunostomy is done in all patients 7 which is a far too big procedure compared to simple cholecystojejunostomy in these often asthenic, sick patients, inviting higher morbidity and mortality. life expectancy was considered an important factor in deciding whether to do surgical or endoscopic palliation. 6 endoscopic plastic stenting was recommended for those with poor prognosis and short life expectancy given the chance for stent block and stent migration in these patients. with metallic stenting this problem is reduced 8 hence the renewed interest for metallic stenting in patients with longer life expectancy. 3 cholecystojejunostomy is a simple procedure and can be done under epidural anesthesia especially in thin and frail patients with a small sub costal incision. the distended gall bladder is easily exposed and anastomosed to a proximal loop of jejunum. because of simplicity and short duration of the procedure morbidity and mortality are low. surgical bypass had good long term relief of jaundice and required no re intervention. the stent group had repeated hospitalizations (p=0.005) due to recurrent illnesses, low grade sepsis, pain and low oral intake and cholecystitis. the metallic stents were recommended over plastic stents due to larger size and less likelihood of blockage. the cholangitis in presence of patent metallic stents may be due to continuous reflux of bile through sphincter made incompetent by stent .the increase in pain in stent group may be due to stent induced cholangitis, and stretching of ampulla. cholecystitis also contributes to the morbidity, reduced global health status, nausea and reduced appetite. as a permanent palliation, surgical bypass may be superior to metallic stenting, especially if the patient is expected to live longer. in the absence of randomized study, bias in case selection and institutional expertise cannot be overlooked. a randomized study is not easily feasible and hence only cohort studies are possible with possible bias and lack of clinical significance. in the literature there is a lack of definition of palliation. 9 some define palliation based on improvement in bilirubin, 10 while some define it by survival, 11 and some by quality of life. 12 as much as palliation is the goal of therapy, quality of life assessment using appropriate valid instrument is essential. in our setup where health care expenditure is personal and family problem, palliation has to be individualized based on economic status and expectations of family. metallic stenting requires a high end setup and special expertise which is not easily available in small cities. a cost comparison will add to the value of the study. in a government hospital where care is highly subsidized and many things are free, cost comparison is difficult. the costs should include not only hospital costs and cost of consumables like stent, but also the cost of repeated hospitalization, lost working hours for the patient and attending relation. taylor mc et al 9 carried out a meta analysis and stated that they could find only three randomized controlled trials eligible for inclusion in their meta analysis. they observed that for comparison of failure of treatment in two procedures, the summary odds ratio could not be calculated as the three trials were heterogeneous. they also noted the odds of requiring more treatment sessions was 7.23 for stent group than the surgery group and found that the 30 day mortality was not significantly different in two groups which is comparable with the present study findings. they confessed that it is difficult to conclude as which treatment method is better as only few randomized controlled trials are existing and there is a need to carry out more randomized controlled trials. scott en et al 7 studied 56 patients (endoscopic stenting group = 33 and surgical bypass group = 33) retrospectively and found that complications and mortality were comparable in two groups and this finding is in accordance with the present study. but they found that 39.4% of the stented group patients were re-admitted compared to only 13% from the surgical group which was statistically significant. they noted that the survival was significantly greater in surgical group compared to stenting group and we also observed similar finding. nikfarjam m et al 13 studied 69 patients retrospectively of whom 28 underwent surgical bypass and 41 biliary stenting. they found that the complications were significantly more in stenting group compared to bypass group. but we observed that the rate of complications or morbidities in two groups was comparable. the authors reported that requirement of further procedures was significantly increased in stent group compared to bypass group. they observed that the survival was comparable in two groups while we found that the survival was more in bypass group compared to stent group. ueda j et al 14 compared two groups of patients undergoing either bypass or stent and found that two patients died in stent compared to zero in bypass group. they also noted a greater morbidity in stent group while we found that the morbidities were comparable in two groups. they noted that the survival was comparable in two group but we observed that the survival was more in bypass group compared to stent group. 5. conclusion surgical biliary bypass namely cholecystojejunostomy offers superior palliation of malignant lower end biliary obstruction, and it can be used to palliate all patients 44 kulkarni and naik / panacea journal of medical sciences 2022;12(1):39–44 including those who are unsuitable for endoscopic procedure due to poor fitness and technical difficulty. the patients undergoing surgical bypass experienced lesser re hospitalization and lesser re interventions and had better quality of life. it can be done with minimal morbidity and mortality even in patients with poor performance status and also those who were unsuitable for endoscopic stenting due to technical difficulty. the metallic stenting being a high end procedure is not widely available in small towns and cities, in addition to cost considerations. 6. source of funding none. 7. interest of conflicts none. references 1. cotton pb. non-surgical palliation of jaundice pancreatic cancer. surg clin north am. 1989;69(3):613–27. 2. moole h, jaeger a, cashman m, volmar fh, dhillon s, bechtold ml, et al. are self expandable metal stents superior to plastic stents in palliating malignant distal biliary strictures? a meta analysis and systematic review. med j armed forces india. 2017;73(1):42–8. 3. kozarek ra. metallic biliary stents for malignant obstructive jaundice: a review. world j gastroenterol. 2000;6(5):643–6. 4. maosheng d, ohtsuka t, ohuchida j. surgical bypass versus metallic stent for un-resectable pancreatic cancer. j hep bil pancr surg. 2001;8(4):367–73. doi:10.1007/s005340170010. 5. european organization for research and treatment of cancer (eortc). quality of life of cancer patients. qlq-c30. available from: https://qol.eortc.org/questionnaires/ accessed on: 3-1-2019. 6. distler m, kersting s, rückert f, dobrowolski f, miehlke s, grützmann r, et al. palliative treatment of obstructive jaundice in patients with carcinoma of the pancreatic head or distal biliary tree. endoscopic stent placement vs. hepaticojejunostomy. j pancreas. 2010;11(6):568–74. 7. scott en, garcea g, doucas h, steward wp, denninson ar, berry d, et al. surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma. hpb. 2009;11(2):118–24. doi:10.1111/j.14772574.2008.00015.x. 8. davids ph, groen ak, rauws ea, tytgat gn, huibregtse k. randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. lancet. 1992;340(88348835):1488–92. doi:10.1016/0140-6736(92)92752-2. 9. taylor mc, mcleod rs, langer b. biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a meta-analysis. liver transpl. 2000;6(3):302–8. 10. shepherd ha, royle g, ross ap, diba a, arthur m, colin-jones d, et al. endoscopic biliary endoprostesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial. br j surg. 1988;75(12):1166–8. 11. andersen jr, sørensen sm, kruse a, rokkjaer m, matzen p. randomized trial of endoscopic endoprostesis vs. operative bypass in malignant obstructive jaundice. gut. 1999;30(8):1132–5. 12. smith ac, dowsett jf, russell rc, hatfield ar, cotton pb. randomized trial of endoscopic stenting vs. surgical bypass in malignant low bile duct obstruction. lancet. 1994;17(8938):1655–60. 13. nikfarjam m, hadi ak, muralidharan v, tebbutt n, fink ma, jones rm, et al. biliary stenting versus surgical bypass for palliation of periampullary malignancy. indian j gastroenterol. 2013;32(2):82–9. 14. ueda j, kayashima t, mori y, ohtsuka t, takahata s, nakamura m, et al. hepaticocholecystojejunostomy as effective palliative biliary bypass for un-resectable pancreatic cancer. hepatogastroenterology. 2014;61(129):197–202. author biography mukund p kulkarni, associate professor nagaraj naik, junior resident cite this article: kulkarni mp, naik n. comparison of surgical biliary bypass and biliary metallic stents for palliation of incurable malignant distal bile duct obstruction: a prospective observational study. panacea j med sci 2022;12(1):39-44. http://dx.doi.org/10.1007/s005340170010 http://dx.doi.org/10.1111/j.1477-2574.2008.00015.x http://dx.doi.org/10.1111/j.1477-2574.2008.00015.x http://dx.doi.org/10.1016/0140-6736(92)92752-2 review article panacea journal of medical science, january – april 2015:5(1)2-6 2 prediction of preeclampsia by biomarkers: a review of literature gupta m1 abstract: preeclampsia is a leading cause of maternal and perinatal mortality and morbidity internationally. the aetiology of this disease is unknown, though widespread endothelial dysfunction is considered to be the major reason. early identification of this disease would be helpful in early identification of the high risk patients, diagnosis and better prenatal care. several biomarkers either individually or in combination have been identified which either increase or decrease in pe and may be of utility either as predictors or diagnostic tools. this review focuses on various available biomarkers and their utility from the already existing literature. keywords: preeclampsia, angiogenic factors, laboratory investigations. 1professor and head, dept. of biochemistry, nkp sims&rc, digdoh hills, hingna road, nagpur-440019. drmadhur20@rediffmail.com introduction: preeclampsia (pe) is a pregnancy-specific condition characterized by hypertension and proteinuria that remits after delivery. pe with a high prevalence in the first pregnancy is associated with the highest maternal and foetal morbidity and mortality, preterm birth, perinatal death, and intrauterine growth restriction and affects between 0.4% and 2.8% of all pregnancies in developed countries (1). the criteria for pe have not changed over the past decade (systolic blood pressure >140 mmhg or diastolic blood pressure ≥90 mmhg and 24-hour proteinuria ≥0.3 g). clinical features and laboratory abnormalities define and determine the severity of pe. unfortunately, the pathophysiology of this multisystem disorder, characterized by abnormal vascular response to placentation, is still unclear. considering the impact of pe in obstetrics, screening women at high risk, preventing recurrences and to offer specific preventive measures are key issues in the management of pe. accurate prediction of pe would enable early and optimal management of women at high risk. several predictive tests are being assessed currently. though numerous tests have been described either in alone or combination, the sensitivity and specificity of the tests needs to be evaluated. this article focuses on the biochemical markers which may be used in the prediction of pe. pathophysiology: classically, pe has been associated with inadequate trophoblast invasion of the spiral arteries and consequent failure of development of a low-resistance uteroplacental circulation that characterizes normal pregnancies. it is postulated that circulating factors are produced by the placenta as a result of oxidative stress resulting in excessive systemic inflammatory response (2) and generalized maternal endothelial dysfunction, contributing to the maternal clinical features of pe (3). shallow placentation is associated with abnormal invasion of cytotrophoblasts, leading to incomplete remodelling of maternal uterine spiral arterioles, which supply blood to the developing placenta (4). hypoxic stress in the placenta causes the release of endothelial damaging factors into the maternal circulation (5). the severity of hypertension in pe may be related to the degree of trophoblastic invasion. it may also said to be associated with immunological responses. prediction is basically based on clinical tests, such as blood pressure measurement during the second trimester or 24-hour ambulatory blood pressure monitoring, but these lack sensitivity and specificity (6). many biomarkers have been evaluated which could help in the accurate prediction of the pe in the first trimester itself. this review thus focuses on the available biomarkers and their utility. angiogenic factors: angiogenic factors are thought to be important in the regulation of placental vascular development. their receptors, fmslike tyrosine kinase or flt1 (also known as vascular endothelial growth factor receptor 1 (vefgr-1), vegfr-2, tie-1, and tie-2, are essential for normal placental vascular development. since the placenta is a rich source of these factors, during the first trimester in pregnancy, in humans, gupta m prediction of preeclampsia by biomarkers: a review of literature panacea journal of medical science, january – april 2015:5(1)2-6 3 vegf ligands and receptors are highly expressed by the placental tissue. invasive cytotrophoblasts express vegf, placental growth factor (plgf), and vegfr1; and these are altered in pe (7). evidence suggest higher expression of placental sflt-1 along with decreased vefgr and pigf signalling during the first trimester are associated with a significantly increased risk of pe (8). circulating sflt1 levels stay relatively low early in pregnancy (9), gene-expression studies from chorionic villous biopsies at 11 weeks of gestation in women who subsequently developed pe showed marked alterations in angiogenic factors, including upregulation of sflt1 message (10) and begin to rise in the third trimester. other studies have also demonstrated that compared to normotensive controls, in patients with severe pe, free plgf and vegf levels are significantly decreased (11), and sflt1 levels are significantly elevated (1213). vegf is a central requirement for endothelial stability, and its blockade is an important part of the pathophysiology of pe.vegf is necessary for glomerular capillary repair and may be particularly important in maintaining the health of the endothelium. vegf is highly expressed by glomerular podocytes, and vegf receptors are present on glomerular endothelial cells (14). as with sflt1, circulating seng levels are elevated weeks prior to pe onset (15). the levels of sflt-1 and pigf in some studies (16) have also been found to be altered in the second trimester in cases with subsequent iugr. hence this biomarker may not be specific for pe. inhibin a and activin a: these glycoproteins are produced by the fetoplacental unit. though the levels of these glycoproteins are increased (17) in the maternal blood in the first trimester of patients who subsequently developed pe, no association was found between the impaired trophoblast invasion and endothelial dysfunction. pregnancy associated plasma protein-a (papp-a): it is 1628 amino acid peptide linked by disulphide bonds mainly produced by the trophoblastic cells. it is said to have a role in regulating foetal growth due to its action of cleavage of insulin like growth factor binding proteins. studies have indicated a decrease in the plasma levels of papp-a in all the trimesters of pregnancy suggesting the requirement of larger trials to confirm its utility as a biomarker in pe (18). neutrophil gelatinase-associated lipocalin (ngal): ngal is a protein belonging to the lipocalin superfamily. it is encoded by the lcn2 gene. it is basically expressed in neutrophils. low levels are found in the kidney, prostate, and epithelia of the respiratory and alimentary tracts (19). ngal has been used as a biomarker of kidney injury (20). it is responsible for the decrease in gfr primarily through reduction in ultra-filtration as opposed to diminished plasma flow (21). the circulating increase of serum ngal may be a result of a leukocyte-derived inflammatory activity and endothelial activation (22) and the serum level of ngal are closely related to endothelial injury. it has been demonstrated that positive correlation between serum ngal level and covariate such as systolic and diastolic blood pressure and proteinuria might be a consequence of endothelial dysfunction on which hypertension and proteinuria probably depend (23). placental protein 13: galactoside-binding soluble lectin 13 or placental protein 13(pp13) is a protein encoded by the lgals13 gene in humans (24). females having pp13 levels low in the first trimester of pregnancy have a risk for developing pe later in pregnancy (25). although the in vivo functions of pp13 are still unknown, a metaanalysis study has shown that low serum levels of pp13 in the first trimester of pregnancy can predict the development of pe later in pregnancy. a recent pilot study conducted by huppertz (26) has shown that in gravid rats pp13 causes significant vasodilatation, reduced blood pressure and increased maternal uterine artery remodelling. however, according to akolekar r(17) measurement of serum pp13 at 11–13 weeks does not improve the performance of screening for early-pe achieved by a combination of maternal factors, uterine artery pi and serum papp-a. soluble endoglin (seng): endoglin is a type i membrane glycoprotein located on cell surfaces is an auxiliary receptor for the tgf-beta receptor complex (27). hence, it is involved in modulating a response to the binding of tgf-beta1, tgf-beta3, activin-a, bmp-2, and bmp-7. beside tgf-beta signalling endoglin may have other functions. in vitro, seng is a negative regulator of angiogenesis and hence to be elevated in pe. the levels of seng are also increased in pregnancies with iugr without maternal syndrome (28), gestational hypertension or chronic hypertension (29). preliminary results have suggested that the patterns of changes in the levels of seng alone are not specific. http://en.wikipedia.org/wiki/neutrophils http://en.wikipedia.org/wiki/kidney http://en.wikipedia.org/wiki/prostate http://en.wikipedia.org/wiki/respiratory http://en.wikipedia.org/wiki/alimentary_tract http://en.wikipedia.org/wiki/protein http://en.wikipedia.org/wiki/gene http://en.wikipedia.org/wiki/pre-eclampsia http://en.wikipedia.org/wiki/glycoprotein http://en.wikipedia.org/wiki/cell_(biology) http://en.wikipedia.org/wiki/tgf_beta_1 http://en.wikipedia.org/wiki/tgf_beta_3 http://en.wikipedia.org/wiki/activin http://en.wikipedia.org/wiki/bmp7 http://en.wikipedia.org/wiki/tgf_beta_signaling_pathway gupta m prediction of preeclampsia by biomarkers: a review of literature panacea journal of medical science, january – april 2015:5(1)2-6 4 large scale studies are required to clarify the role of seng in the prediction of pe. ptx3: pentraxin-related protein ptx3 (tnf-inducible gene 14 protein (tsg-14)) is a protein encoded by the ptx3 gene in humans (30). since an excessive maternal inflammatory response to pregnancy is one of the etiology of pe, elevated maternal plasma levels of ptx3 has been found in preeclamptic versus normal pregnancies (31). adam 12: the soluble form of the disintegrin metalloprotease adam 12 (a disintegrin and metalloproteinase 12; meltrin-alpha) represented the most upregulated transcript. adam 12 could serve as an early biomarker for pe that may be of predictive and/or functional significance (32). the maternal serum levels of adam12 are significantly lower during the first trimester in women who later develop pe during pregnancy when compared with levels in women with normal pregnancies (33) and are significantly decreased in correlation with c reactive protein (34). p selectin: p-selectin is a protein is encoded by the selp gene in humans (35). platelet activation in pe is reflected by elevated levels of platelets exposing p-selectin. in plasma, a non-cell bound (soluble) form of p-selectin is present. elevated levels of this soluble form have been reported in pe. plasma p-selectin may consist of two fractions: microparticle (mp)--associated pselectin and non-mp--associated p-selectin. mp associated p-selectin exclusively originates from platelets, this fraction indicates platelet activation. platelet activation is prominent in pe and this study proves that at least a part of the plasma p-selectin originates from platelets (36). in an inflammatory model for pe it is thought that endothelial cell activation may be secondary to a primary inflammatory response. thus plasma p-selectin has significant potential as a first trimester clinical marker of pe (37). adiponectin: the reports of the role of adiponectin in pe are conflicting. it is proposed that adiponectin might be part of a feedback mechanism improving insulin sensitivity and cardiovascular health in pre-eclamptic patients (38) and thus pe is characterized by alterations in adiponectin multimers (39). resistin: resistin, along with human placental lactogen, prolactin, steroid hormones and other hormones, decreases insulin sensitivity, whereas leptin increases insulin sensitivity (40). the increase in serum resistin in the third trimester of pregnancy is in accordance with insulin resistance in normal pregnancy (41-42). pe has been proposed to be an exaggeration of insulin resistance although differing opinions exist (43). also an increase in serum resistin was found in the third trimester of normal pregnancy, but this increase was not present in pe (44). other tests: laboratory tests for oxidative response i.e malondialdehyde along with antioxidants have been assessed, including assays for uric acid, urinary kallikrein, and fibronectin, cytokines but no evidence of their relevance has so far been found (45). thus in clinical practice, because no single marker effectively predicts the risk of pe, the current trend is to test a combination of markers. studies involving a larger population are the need of the hour to determine the specificity and sensitivity of the individual parameters or a combination before any molecule is labelled as a biomarker for the early prediction of pe. references: 1. villar k, say l, gülmezoglu am, merialdi m, lindheimer md, betran ap, piaggio g. eclampsia and pe: a health problem for 2000 years. in: critchley h, maclean ab, poston l, walker jj, eds. pe. london: rcog press; 2003; 189–207. 2. redman cw, sargent il. latest advances in understanding pe. science. 2005;308(5728):1592-4. 3. maynard se, min jy, merchan j, lim kh, li j, mondal s, et al. excess placental soluble fms-like tyrosine kinase 1 (sflt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in pe. j clin invest. 2003;111(5):649-58. 4. harris lk, keogh rj, wareing m, baker pn, cartwright je, aplin jd, et al. invasive trophoblasts stimulate vascular smooth muscle cell apoptosis by a fas ligand-dependent mechanism. am j pathol. 2006;169(5):1863-74. 5. burton gj, woods aw, jauniaux e, kingdom jc. rheological and physiological consequences of conversion of the maternal spiral arteries for uteroplacental blood flow during human pregnancy. placenta. 2009;30(6):473-82. 6. conde-agudelo a, villar j, lindheimer m. obstet gynecol. vol. 104. world health organization: systematic review of screening tests for pe 2004: 1367–1391. 7. zhou y, mcmaster m,woo k, janatpour m, perry j, et al. 2002. vascular endothelial growth factor ligands http://en.wikipedia.org/wiki/protein http://en.wikipedia.org/wiki/gene http://en.wikipedia.org/wiki/protein http://en.wikipedia.org/wiki/gene gupta m prediction of preeclampsia by biomarkers: a review of literature panacea journal of medical science, january – april 2015:5(1)2-6 5 and receptors that regulate human cytotrophoblast survival are dysregulated in severe pe and hemolysis, elevated liver enzymes, and low platelets syndrome. am j pathol 2002; 160:1405–23. 8. ahmed a. new insights into the etiology of pe: identification of key elusive factors for the vascular complications. thromb res. 2011;127(suppl 3):s72– 75. 9. levine rj, maynard se, qian c, lim kh, england lj, et al. circulating angiogenic factors and the risk of pe. n engl j med 2004; 350:672–83. 10. farina a, sekizawa a, de sanctis p, purwosunu y, okai t, et al.gene expression in chorionic villous samples at 11 weeks’ gestation from women destined to develop pe. prenat diagn 2008; 28:956–61. 11. wikstrom ak, larsson a, eriksson uj, nash p, norden-lindeberg s, olovsson m. placental growth factor and soluble fms-like tyrosine kinase-1 in earlyonset and late-onset pe. obstet.gynecol 2007;109:1368–74. 12. thadhani r, mutter wp, wolf m, levine rj, taylor rn, et al. first trimester placental growth factor and soluble fms-like tyrosine kinase 1 and risk for pe. j clin endocrinol metab 2004; 89:770–75. 13. shibata e, rajakumar a, powers rw, larkin rw, gilmour c et al.soluble fms-like tyrosine kinase 1 is increased in pe but not in normotensive pregnancies with small-for-gestational-age neonates: relationship to circulating placental growth factor. j clin endocrinol metab 2005; 90:4895–903. 14. maharaj as, saint-geniez m, maldonado ae, d’amore pa. vascular endothelial growth factor localization in the adult. am j pathol 2006; 168:639– 48. 15. levine rj, lam c, qian c, yu kf, maynard se, et al. soluble endoglin and other circulating antiangiogenic factors in pe. n engl j med 2006; 355:992–1005. 16. stepan h, unversucht a, wessel n,faber r. predictive value of maternal angiogenic facors in the secnd trimester pregnancies with abnormal uterine perfusion. hypertension 2007, 49:818-824. 17. akolekar r,minekawa r, veduta a, romero xc and nicolaides kh. maternal plasma inhibin a at 11-13 weeks of gestation in hypertensive disorders of pregnancy. prenatal diagnosis 2009; 29(8): 753-760. 18. spencer k,cowans nj, nicolaides kh. low levels of maternal serum papp-a in the first trimester and the risk of pe. prenatal diagnosis 2008;28(1):7-10. 19. cowland jb, borregaard n (october 1997). "molecular characterization and pattern of tissue expression of the gene for neutrophil gelatinaseassociated lipocalin from humans". genomics 45 (1): 17–23. 20. devarajan p. review: neutrophil gelatinase-associated lipocalin: a troponin-like biomarker for human acute kidney injury". nephrology 2010;15 (4): 419–28. 21. kjeldsen l et al. isolation and primary structure of ngal, a novel protein associated with human neutrophil gelatinase. j biol chem 1993; 268: 1042510432. 22. var a. yildirian y. onur e, et al. endothelial dysfunction in pe:increased homocysteine and decreased nitric acid levels. gynecol obstet. invest. 2003;56:221-24. 23. roberts jm, gammil hs. pe: recent insights. hypertension.2005;46:1263-9. 24. visegrády b, than ng, kilár f. homology modelling and molecular dynamics studies of human placental tissue protein 13 (galectin-13). protein eng 2002; 14 (11): 875–80. 25. burger o, pick e, zwickel j. placental protein 13 (pp13): effects on cultured trophoblasts, and its detection in human body fluids in normal and pathological pregnancies. placenta 2004;25 (7): 608–22. 26. huppertz b, meiri h, gizurarson s, osol g, sammar m. placental protein 13 (pp13): a new biological target shifting individualized risk assessment to personalized drug design combating pe. hum reprod update. 2013 jul-aug;19(4):391-405. 27. guerrero-esteo m, sanchez-elsner t, letamendia a, bernabeu c .extracellular and cytoplasmic domains of endoglin interact with the transforming growth factorbeta receptors i and ii. j. biol. chem. 2002; 277 (32): 29197–209. 28. wathen ka, tuutti e, stenman uh, alfthan h, halmesmaki e, finne p, yikorkala o, vuorela p. maternal serum-soluble vascular endothelial growth factor-1 in early pregnancy ending in pe or intrauterine growth retardation. j clin endocrinol metab 2006,91:180-184. 29. salahuddin s, leey, vadnais m, sachs bp, karumanchi sa, lim kh. diagnostic utility of soluble fms-like tyrosine kinase 1 and soluble endoglin in hypertensive disease of pregnancy. amj obstet gynecol 2007;197:28-6. 30. breviario f, d'aniello em, golay j, peri g, bottazzi b, bairoch a et al. interleukin-1-inducible genes in endothelial cells. cloning of a new gene related to creactive protein and serum amyloid p component. j biol chem 1992; 267 (31): 22190–7. 31. cetin i, cozzi v, papageorghiou at, maina v, montanelli a, garlanda c, thilaganathan b. first trimester ptx3 levels in women who subsequently develop pe and fetal growth restriction. acta obstet gynecol scand. 2009;88(7):846-9. 32. gack s, marmé a, marmé f, wrobel g, vonderstrass b, bastert g, lichter p, angel p, schorpp-kistner m. pe: increased expression of soluble adam 12. j mol med (berl). 2005 nov;83(11):887-96. 33. laigaard j, sørensen t, placing s, holck p, fröhlich c, wøjdemann kr, sundberg k, shalmi ac, tabor a, nørgaard-pedersen b, ottesen b,christiansen m, wewer um. reduction of the disintegrin and metalloprotease adam12 in pe. obstet gynecol. 2005 jul;106(1):144-9. 34. el-sherbiny w, nasr a, soliman a. metalloprotease (adam12-s) as a predictor of pe: correlation with severity, maternal complications, fetal outcome, and doppler parameters. hypertens pregnancy. 2012;31(4):442-50. 35. ryan us, worthington re. cell-cell contact mechanisms. curr opin immunol 1992 4 (1): 33–7. 36. lok ca, nieuwland r, sturk a, hau cm, boer k, vanbavel e, vanderpost ja. microparticleassociated p-selectin reflects platelet activation in pe.platelets. 2007 feb;18(1):68-72. 37. bosio pm, cannon s, mckenna pj, o'herlihy c, conroy r, brady h. plasma p-selectin is elevated in http://www.ncbi.nlm.nih.gov/pubmed/?term=huppertz%20b%5bauthor%5d&cauthor=true&cauthor_uid=23420029 http://www.ncbi.nlm.nih.gov/pubmed/?term=meiri%20h%5bauthor%5d&cauthor=true&cauthor_uid=23420029 http://www.ncbi.nlm.nih.gov/pubmed/?term=gizurarson%20s%5bauthor%5d&cauthor=true&cauthor_uid=23420029 http://www.ncbi.nlm.nih.gov/pubmed/?term=osol%20g%5bauthor%5d&cauthor=true&cauthor_uid=23420029 http://www.ncbi.nlm.nih.gov/pubmed/?term=sammar%20m%5bauthor%5d&cauthor=true&cauthor_uid=23420029 http://www.ncbi.nlm.nih.gov/pubmed/?term=sammar%20m%5bauthor%5d&cauthor=true&cauthor_uid=23420029 http://www.ncbi.nlm.nih.gov/pubmed/23420029 http://www.ncbi.nlm.nih.gov/pubmed/?term=cetin%20i%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=cozzi%20v%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=papageorghiou%20at%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=maina%20v%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=maina%20v%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=montanelli%20a%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=garlanda%20c%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=thilaganathan%20b%5bauthor%5d&cauthor=true&cauthor_uid=19544202 http://www.ncbi.nlm.nih.gov/pubmed/19544202 http://www.ncbi.nlm.nih.gov/pubmed/19544202 http://www.ncbi.nlm.nih.gov/pubmed/?term=gack%20s%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=marm%c3%a9%20a%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=marm%c3%a9%20f%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=wrobel%20g%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=vonderstrass%20b%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=vonderstrass%20b%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=bastert%20g%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=lichter%20p%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=angel%20p%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=schorpp-kistner%20m%5bauthor%5d&cauthor=true&cauthor_uid=16247621 http://www.ncbi.nlm.nih.gov/pubmed/16247621 http://www.ncbi.nlm.nih.gov/pubmed/16247621 http://www.ncbi.nlm.nih.gov/pubmed/?term=laigaard%20j%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=s%c3%b8rensen%20t%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=placing%20s%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=holck%20p%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=fr%c3%b6hlich%20c%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=fr%c3%b6hlich%20c%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=w%c3%b8jdemann%20kr%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=sundberg%20k%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=shalmi%20ac%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=tabor%20a%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=tabor%20a%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=n%c3%b8rgaard-pedersen%20b%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=ottesen%20b%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=christiansen%20m%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=christiansen%20m%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=wewer%20um%5bauthor%5d&cauthor=true&cauthor_uid=15994630 http://www.ncbi.nlm.nih.gov/pubmed/15994630 http://www.ncbi.nlm.nih.gov/pubmed/15994630 http://www.ncbi.nlm.nih.gov/pubmed/?term=el-sherbiny%20w%5bauthor%5d&cauthor=true&cauthor_uid=22676623 http://www.ncbi.nlm.nih.gov/pubmed/?term=nasr%20a%5bauthor%5d&cauthor=true&cauthor_uid=22676623 http://www.ncbi.nlm.nih.gov/pubmed/?term=soliman%20a%5bauthor%5d&cauthor=true&cauthor_uid=22676623 http://www.ncbi.nlm.nih.gov/pubmed/22676623 http://www.ncbi.nlm.nih.gov/pubmed/22676623 http://www.ncbi.nlm.nih.gov/pubmed/?term=lok%20ca%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=nieuwland%20r%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=sturk%20a%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=hau%20cm%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=boer%20k%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=boer%20k%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=vanbavel%20e%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=vanderpost%20ja%5bauthor%5d&cauthor=true&cauthor_uid=17365856 http://www.ncbi.nlm.nih.gov/pubmed/17365856 http://www.ncbi.nlm.nih.gov/pubmed/?term=bosio%20pm%5bauthor%5d&cauthor=true&cauthor_uid=11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=cannon%20s%5bauthor%5d&cauthor=true&cauthor_uid=11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=mckenna%20pj%5bauthor%5d&cauthor=true&cauthor_uid=11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=o%27herlihy%20c%5bauthor%5d&cauthor=true&cauthor_uid=11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=o%27herlihy%20c%5bauthor%5d&cauthor=true&cauthor_uid=11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=conroy%20r%5bauthor%5d&cauthor=true&cauthor_uid=11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=brady%20h%5bauthor%5d&cauthor=true&cauthor_uid=11467696 gupta m prediction of preeclampsia by biomarkers: a review of literature panacea journal of medical science, january – april 2015:5(1)2-6 6 the first trimester in women who subsequently develop pe. bjog. 2001 jul;108(7):709-15. 38. abd-alaleem di, attiaa ki, khalefa aa, ahmad ra. adiponectin levels in serum of women with pe. east mediterr health j. 2011 jul;17(7):575-81. 39. mazaki-tovi s, romero r, vaisbuch e, kusanovic jp, erez o, gotsch f, chaiworapongsa t, than ng, kim sk, nhan-chang cl,jodicke c, pacora p, yeo l, dong z, yoon bh, hassan ss, mittal p. maternal serum adiponectin multimers in pe. j perinat med. 2009;37(4):349-63. 40. seely ew and solomon c g insulin resistance and its potential role in pregnancy-induced hypertension. j clin endocrinol metab 2003; 88, 2393–2398. 41. sattar n and greer i. insulin sensitivity in pe. br j obstet gynaecol 1999; 106, 874–875. 42. solomon cg, carroll j s, okamura k, graves s w and seely ew. higher cholesterol and insulin levels in pregnancy are associated with increased risk for pregnancy-induced hypertension. am j hypertens 1999; 12: 276–282. 43. bartha j l, romero-carmona r, torrejon-cardoso r. and comino-delgado r. insulin, insulin-like growth factor-1, and insulin resistance in women with pregnancy-induced hypertension. am j obstet gynecol 2002; 187, 735–740. 44. chen d, dong m, fang q, he j, wang z, yang x. alterations of serum resistin in normal pregnancy and pe. clin sci (lond). 2005 jan;108(1):81-4. 45. conde-agudelo a, villar j, lindheimer m. world health organization: systematic review of screening tests for pe obstet gynecol. 2004;104:1367–1391. http://www.ncbi.nlm.nih.gov/pubmed/11467696 http://www.ncbi.nlm.nih.gov/pubmed/?term=abd-alaleem%20di%5bauthor%5d&cauthor=true&cauthor_uid=21972480 http://www.ncbi.nlm.nih.gov/pubmed/?term=attiaa%20ki%5bauthor%5d&cauthor=true&cauthor_uid=21972480 http://www.ncbi.nlm.nih.gov/pubmed/?term=khalefa%20aa%5bauthor%5d&cauthor=true&cauthor_uid=21972480 http://www.ncbi.nlm.nih.gov/pubmed/?term=ahmad%20ra%5bauthor%5d&cauthor=true&cauthor_uid=21972480 http://www.ncbi.nlm.nih.gov/pubmed/21972480 http://www.ncbi.nlm.nih.gov/pubmed/21972480 http://www.ncbi.nlm.nih.gov/pubmed/?term=mazaki-tovi%20s%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=romero%20r%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=vaisbuch%20e%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=kusanovic%20jp%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=kusanovic%20jp%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=erez%20o%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=gotsch%20f%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=chaiworapongsa%20t%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=than%20ng%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=than%20ng%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=kim%20sk%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=nhan-chang%20cl%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=jodicke%20c%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=pacora%20p%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=pacora%20p%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=yeo%20l%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=dong%20z%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=yoon%20bh%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=hassan%20ss%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=mittal%20p%5bauthor%5d&cauthor=true&cauthor_uid=19348608 http://www.ncbi.nlm.nih.gov/pubmed/19348608 http://www.ncbi.nlm.nih.gov/pubmed/19348608 http://www.ncbi.nlm.nih.gov/pubmed/?term=chen%20d%5bauthor%5d&cauthor=true&cauthor_uid=15377276 http://www.ncbi.nlm.nih.gov/pubmed/?term=fang%20q%5bauthor%5d&cauthor=true&cauthor_uid=15377276 http://www.ncbi.nlm.nih.gov/pubmed/?term=he%20j%5bauthor%5d&cauthor=true&cauthor_uid=15377276 http://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20z%5bauthor%5d&cauthor=true&cauthor_uid=15377276 http://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20x%5bauthor%5d&cauthor=true&cauthor_uid=15377276 http://www.ncbi.nlm.nih.gov/pubmed/15377276 61 1 2 associate professor, senior 3 resident, junior resident, department of surgery, nkpsims&rc, hingna road, digdoh hills, nagpur 440019. drsatishdeshmukh90@yahoo. co.in abstract: pneumoperitoneum represents the perforation of bowel loops in most cases. pneumoperitoneum resulting from a spontaneous rupture of pyogenic liver abscess is rare. herein, we reported a case of spontaneous rupture of pyogenic liver abscess in a 42-year-old female with diabetes, systemic hypertension and ischemic heart disease. on x-ray abdomen standing and ultrasonography of abdomen, we diagnosed a ruptured liver abscess with free fluid in abdomen and pelvis mimicking pneumoperitoneum without any hollow viscous perforation. from this case, we concluded that though pneumoperitoneum resulting from a ruptured liver abscess is rare, we must keep it in mind especially when all hollow viscous inside the abdomen are normal. keywords: pneumoperitoneum, pyogenic liver abscess, diabetes. pjmsvolume 4 : number 2 : july dec. 2014 case report tomography (cect) abdomen was done which was suggestive of ruptured liver abscess. therefore, an urgent exploratory laparotomy was done with written informed consent taken.for laparotomy, an upper midline incision was taken. evidence of, a ruptured right lobe liver abscess with 1500ml of free fluid with pus and pus flakes was noted with an abscess in left lobe of liver of around 500ml noted. about 1500 ml of turbid pus was noted in the peritoneal cavity with adhesion of omentum with liver. on separation of omentum from liver, we found a ruptured liver abscess with abscess cavity of size 10 cm x 10 cm x 8 cm and purulent material covering it. we drained abscess cavity and pus in peritoneal cavity. all the hollow viscera and biliary system were found normal. two abdominal drain kit (adk) drains were kept in situ with one in sub-hepatic gutter and other in pelvic cavity. thorough wash with warm normal salinewas given and laparotomy wound was closed. e coli were isolated from pus of liver abscess sensitive to piperacillin,tazobactam, and imipenem. patient later developed bradycardia and hypotension for which he was shifted to surgical intensive care unit (sicu) with ventilatory support given and positive inotropic agents started. the patient recovered completely and drains (sub-hepatic and th nd pelvic) were removed on postoperative day 11 and 22 respectively. th the patient was discharged on the 24 postoperative day after the removal of sutures. discussion: pneumoperitoneum usually results from the perforation of intraperitoneal hollow organs, which had been thought surgical emergency in 85% to 90% of cases(1-2). therefore, about 10% of pneumoperitoneum are caused by nonsurgical reasons, in which surgical intervention is usually not r e q u i r e d . t h e r e p o r t e d c a u s e s o f n o n s u r g i c a l pneumoperitoneum include thoracic causes (chronic obstructive pulmonary disease, pneumothorax), abdominal causes(connective tissue disease, subclinical or sealed introduction: pneumoperitoneum referred to the presence of free air within the peritoneal cavity but outside the viscera, representing the perforation of bowel loops in 85% to 90% of cases(1-2). it can also be due to other nonsurgical causes and very rarely and unusually by rupture of an abscess in any intra-abdominal solid organ like spleen, liver(3). herein, we report a rare case of pneumoperitoneum resulting from a ruptured liver abscess. case history: a 42-year-old female presented to the emergency department with progressive distention of abdomen and fever since 15 days.patient had complaints of breathlessness and edema over bilateral lower limb since 7 days. she had history of diabetes mellitus for 4 years and was on irregular treatment. she was a known case of systemic hypertension and ischemic heart disease. hence, was admitted to medicine department. next day, patient developed severe pain in abdomen and surgical reference was taken. on examination, 0 she was febrile with temperature of 101 f,blood pressure was 90/60 mm of hg,pulse rate was 96 per minute,respiratory rate was 20 per minute. patient presented with pallor and icterus was positive. abdominal examination revealed distended abdomen with generalized tenderness and guarding present with rigidity. liver was enlarged and bowel sounds were absent. blood examination revealed hemoglobin 7.8 g%, blood count 13000/mm3 with neutrophils 90% and blood glucose 240 mg%. serum bilirubin was 1.9 mg/dl, sgot22.7 iu/i, sgpt57.6 and alkaline phosphatase158 iu/i. x-ray abdomen standing showed free gas under diaphragm and ultrasonography revealed gross free fluid in abdomen and pelvis and internal echoes in peritoneal cavity with hypoechoic lesion in left lobe of liver measuring approximately 10.2cm x 10.4cm x 8.6cm with approximate volume of around 500cc. a contrast-enhanced computed spontaneous rupture of liver abscess mimicking perforation of bowel (pneumoperitoneum): a case report 1 2 2 3 deshmukh satish , sonarkar rajiv , saboo rahul , shah prateek pjmsvolume 4 : number 2 : july dec. 2014 case report 62 perforated viscus), gynecological causes (pelvic inflammatory disease, recent vaginal examination, gynecological manipulations) and iatrogenic causes (previous open abdominal surgery with retained postoperative air, peritoneal dialysis, endoscopic gastrointestinal procedure)(4). however it may also result from rupture of abscess in any intra-abdominal solid organ like spleen, liver(3). in our case pneumoperitoneum was resulted from rupture of pyogenic abscess in right lobe of liver which is very rare and unusual. incidence of pyogenic liver abscess is 22-24 per 1, 00,000 hospital admissions(5). common causes are diseases of biliary system, portal venous source arising from intestinal pathology, embolization of bacteria via hepatic surgery, trauma(6). however in 15% to 45% of cases it is cryptogenic where no cause is identifiable and most of them are single and insidious in onset(7-8)which is alike to our case. for a liver abscess common predisposing factors are diabetes, older age(6, 9) which is similar to our study. of the patients with ruptured abscess diabetes mellitus is found in around 60.9% population. common causative agents are e-coli and klebsiellapneumoniae (10)which is same as our study. these organisms produce gas which is responsible for the pneumoperitoneum in our case. chou ff (11) reported that gas forming pyogenic liver abscess accounted for 10% to 20% of pyogenic liver abscess. morioka et al(12) reviewed the literature and reported 27 cases of gas containing pyogenic liver abscess in japan and 21 out of 27 cases had diabetes mellitus. chung-hunk-nee et al(3) and ukikasa(13)also described similar case. matsuyama(14)reported a case of pneumoperitoneum resulting from a ruptured liver abscess with an unusual gas shadow in the right upper quadrant of the abdomen which was overlooked on admission. ultrasonography and ct scan are sensitive tools for the diagnosis of liver abscess. only 40% of cases of pyogenic rupture abscess have complications amongst which intraperitoneal rupture accounts for 7.115.1% (15)withmortality rate of 42.8%(11). for unruptured pyogenic abscess, antibiotics and percutanous aspiration is required but if rupture with peritonitis sets in, open drainage, peritoneal lavage and antibiotics are recommended(6-7, 910). in our study, patient recovered well with open drainage, peritoneal lavage and antibiotics. conclusion: fro m o u r s t u d y, i t i s c o n c l u d e d t h a t t h o u g h pneumoperitoneum resulting from a ruptured liver abscess is rare, we must keep it in mind especially when all other hollow organs are normal. references: 1. omori h, asahi h, inoue y, irinoda t, saito k. pneumoperitoneum without perforation of gastrointestinal tract. dig surg 2003; 20:334-8. 2. mularski ra, sippel jm, osborne ml. pneumoperitoneum: a review of nonsurgical causes. crit care med 2000; 28:2638-44. 3. nee ch, huang cw. pneumoperitoneum from ruptured pyogenic liver abscess. j emergcrit care med 2010; 21:167171. 4. mularski ra, ciccolo mi, rappaport wd. nonsurgical causes of pneumoperitoneum. west j med 1999; 170:41-6. 5. angelica md, fong y. the liver. in: townsend, beauchamp, th evers, mattox et al,-sabiston textbook of surgery, vol. 2, 17 edition philadelphia, usa; elsevier, 2004: 1513-1596. 6. barnessa, lillemoe kd. liver abscess and hydatidcyst disease. in: zinner mj, schwarts si, ellis h, ashley sw, mcfadden dwmaingot's abdominal operations.vol 2.10th edition. mcgraw-hill, 2001: 1513-1546. 7. strung rw-pyogenic liver abscess. in: blumgart lh, belghiti j, jarnagin wr, dematteo rp, chapman wc, buchler mw et alsurgery of the liver, biliary tract and pancreas. 4thedition.philadelphia, usa; elsevier, 2007: 927-934. 8. kibbler ccthe liver in infections. in: dooley js, lok asf, burroughts ak, heathcole ejsherlock's diseases of the th liver and biliary system 12 edition. wiley blackwell publication, uk, 2011:632-5. 9. geller da, goss ja, tsung a-liver. in: andersen dk, billar tr, dunn dl, hunter jg, matthews jb, pollock roschwarts's th principles of surgery, 9 edition. mcgraw-hill, 2010: 111540. 10. davidson br. the liver in: russell rcg, williams ns, th bulstrode cjk.baily & love's short practice of surgery. 24 edition.edward arnold (publishers0 ltd; 2004:1062-83. 11. chou ff, sheen-chen sm, chen ys, lee ty. the comparison of clinical course and results of treatment between gasforming and non-gasforming pyogenic liver abscess. arch surg 1995; 130:401-5. 12. morioka t, makino h, takazakura e. two cases of gascontaining liver abscess:review of the japanese literature. nihon shoukakibyougakkaizasshi (jpn j gastroenterol) 1991; 88:2691-6. 13. ukikasu m, inomoto t, kitai t. pneumoperitoneum following the spontaneous pneumoperitoneum secondary to the rupture of a gascontaining pyogenic liver abscess: report of a case. surg today 1994; 24:63-6. 14. matsuyama s, satoh h, yunotani s. an unusual presentation of spontaneous pneumoperitoneum secondary to the rupture of a gascontaining pyogenic liver abscess: report of a case. surg today, 1994; 24:63-6. 15. chou ff, sheen-chen sm, lee ty. rupture of pyogenic liver abscess.am j gastroenterol 1995 may; 90(5):767-70. panacea journal of medical sciences 2022;12(2):241–244 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article study of serum high sensitivity c reactive protein, adipokines, hba1c, and fasting blood glucose level in patients of diabetes mellitus type ii with periodontal disease purnima dey sarkar1, vandana verma1, ajay bhatt2, shiv narayan lahariya1,* 1dept. of biochemistry, mgm medical college, indore, madhya pradesh, india 2dept of physiology, mgm medical college, indore, madhya pradesh, india a r t i c l e i n f o article history: received 19-04-2021 accepted 27-10-2021 available online 17-08-2022 keywords: periodontitis diabetes mellitus hscrp adipokines a b s t r a c t background: diabetes is a systemic disease with several complications affecting both the length and quality of life. one of these complications is periodontal disease (periodontitis). the periodontal diseases are considered as the “sixth complication of diabetes mellitus”. the results of this study indicate the presence of a significant relationship between periodontitis and diabetes mellitus. materials and methods: a total of 155 periodontitis patients with diabetes mellitus and 137 periodontitis patients without diabetes mellitus were selected for the study. hs-crp (high sensitivity c – reactive protein), adipokines, hba1c, and fasting blood sugar levels were compared with 160 healthy nondiabetics; non-periodontitis (control) subjects. fbs (fasting blood sugar) & hba1c were done by semi auto-analyzer diagnostic kit and adipokines by elisa method (kit method) and hs-crp (high sensitivity c reactive protein) was estimated by immunoturbidimetric method. for this study newly diagnosed type 2 diabetic and periodontitis patients were selected. results: fbs and hba1c in both study groups were higher than that in control group. statistical analysis showed that periodontitis with at least one tooth that displayed a probing pocket depth of > or = 6mm was significantly associated with higher blood sugar (p=0.005) and positive correlations are found between mean periodontal disease and hba1c (p = 0.009). adipokines, hba1c, hs-crp (high sensitivity c reactive protein), and periodontal parameters have significant role in periodontitis with diabetes mellitus. conclusion: the link between periodontal disease and type 2 diabetes mellitus (t2dm) has been suggested through a number of clinical and epidemiological studies. many studies have shown that the prevalence and severity of periodontitis is increased in the presence of diabetes mellitus. thus, diabetes is considered to be a risk factor for gingivitis and periodontitis. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction diabetes is the most common systemic disease that leads to many major complications affecting longevity of life. 1 as per estimates of the international diabetes federation in year 2011 about 366 million people had diabetes and by year * corresponding author. e-mail address: shivnarayanlahariya@gmail.com (s. n. lahariya). 2030 it will rise to 552 million people worldwide. a major concern of diabetes is the various complications which arise due to the disease. 2 type-2 diabetes mellitus constitute 90% of the cases. prolonged uncontrolled hyperglycemia in diabetes leads to multiorgan damage that predominantly involves kidneys, heart, blood vessels, nerves and eyes. 3 diabetes which has become major health problem globally is associated with multiple organ involvement https://doi.org/10.18231/j.pjms.2022.046 2249-8176/© 2022 innovative publication, all rights reserved. 241 242 sarkar et al. / panacea journal of medical sciences 2022;12(2):241–244 and complications like nephropathy, microvascular disease, neuropathy and delayed wound healing. 4 of all the complications periodontal diseases is sixth common condition in diabetes mellitus. 5 periodontitis is an advanced stage of irreversible gum disease with bone loss. it can lead to damage to gum tissue and bone surrounding and supporting teeth making them loose and fall out. unattended gingivitis in later stage leads to periodontitis. diabetics have more frequent and severe form of periodontitis which is also a known risk factor for type ii diabetes mellitus. 6,7 2. materials and methods the study protocol was in keeping with the ethical guidelines of the 1975 declaration of helsinki and all the patients gave written informed consent to the study. patients are taken from outpatient department of periodontics. this study was conducted in the biochemistry department of mahatma gandhi memorial medical college, indore; m.p. bmi of all patients was calculated by using the formula weight in kg/m2. brief clinical history, blood pressure, dietary habit and information on physical activity were taken before recruiting study participants. 2.1. sample size 1. study group (a) adults having periodontitis but not type ii dm – 137. (b) adults having periodontitis & also type ii dm – 155. 2. control group (a) healthy adults non-diabetic, non periodontitis – 160. 2.2. methodology 1. estimation of hs-crp (high sensitivity c reactive protein) was done by immunoturbidimetric method. 2. estimation of glycosylated hb (hba1c) was done with the help of semi auto-analyzer diagnostic kit. 3. fasting blood sugar was estimated by glucose oxidase peroxidase method. 4. serum resistin &adiponectin (adipokines) were determined by elisa method. 3. observations & results in our study the periodontal parameters in control group when compared to both the study groups were found to be statistically significant (p <0.0001) the mean values of high sensitivity creactive protein in patients having periodontal disease and diabetes mellitus type ii (0.60±0.90 mg/dl) and without diabetes mellitus type ii (0.94±1.92 mg/dl) was found to be statistically significant (p<0.0001) when compared to control group (0.18±0.32 mg/dl). mean resistin levels showed strong positive association with periodontal disease in both diabetics (3.71 ± 1.42 ng/ml) and non-diabetics (4.59 ± 1.04 ng/ml) in comparison to the control group (1.54 ± 0.51 ng/ml) (p<0.0001). thus in present study resistin levels in both the study groups of adults having periodontitis with and without type ii diabetes mellitus was significantly higher compared to healthy volunteers. serum resistin showed a significant (p<0.0001) positive correlation with hba1c. mean levels of serum adiponectin was lower in adults having periodontitis and type ii diabetes mellitus (4.48 ±0.96 µg/ml) and in non-diabetic adults with periodontitis (4.83 ± 1.10µg/ml)as compared to healthy subjects (6.95 ± 1.21µg/ml). the levels of adiponectin were inversely proportional to periodontitis in diabetics & non diabetics. the obesity variable: body mass index was found to be significantly higher in adults having periodontitis and type ii diabetes mellitus when compared to adults having periodontitis but not type ii diabetes mellitus and also when compared to the control group (p<0.0001). 4. discussion & conclusion the relationship of type 2 diabetes mellitus with periodontitis has been studied since a few decades. diabetes has been shown to be a risk factor for development of periodontitis. 8 apart from the known common complications of type ii diabetes mellitus, periodontitis is an additional sixth complication of diabetes, 9 at the same time it is been hypothesized that periodontitis can worsen the metabolism of diabetes. 10 adipokines are being postulated to play major role in this process of bidirectional association between diabetes and periodontitis. 11 in present study adults having periodontitis with and without type ii diabetes mellitus had low levels of adiponectin when compared to the control group. resistin levels were significantly higher in periodontitis cases with and without diabetes in comparison to the control group. the observations in the present study suggest that the presence of periodontitis influences the levels of serum adipokines and the presence of type 2 diabetes mellitus further enhances this effect. study by xu jing ling et al 12 and t. saito et al 13 have shown significant difference in adipokines in adults having periodontitis in comparison to the control group. the anti-inflammatory properties of adiponectin and its insulin sensitizing properties may play role in this effect. 14 adiponectin suppresses the production of inflammatory markers like tnfα and il-6, while it causes an increased secretion of antiinflammatory cytokines like il10 by monocytes, macrophages and dendritic cells. 15 sarkar et al. / panacea journal of medical sciences 2022;12(2):241–244 243 table 1: parameter wise comparison among the three studygroups parameter(mean ±sd) study group (a) (137) study group (b) (155) control group (160) f -value p -value body mass index (kg/m2) 23.71 ± 3.78 24.30 ± 3.42 21.19 ± 3.13 17.780 <0.0001 hba1c (%) 5.53 ± 0.38 7.57 ± 1.85 4.97±0.23 125.227 <0.0001 probing depth (mm) 3.94 ± 0.63 3.48 ± 0.77 2.18 ± 0.61 141.203 <0.0001 attachment loss (mm) 3.34 ± 1.17 2.63 ± 1.81 3.68±0.23 15.548 <0.0001 bleeding index 2.91 ± 0.75 2.53 ±0.77 0.69 ±0.46 266.248 <0.0001 adiponectin (µg/ml) 4.83 ± 1.10 4.48 ±0.96 6.95 ± 1.21 105.220 <0.0001 resistin(ng/ml) 4.59 ± 1.04 3.71 ± 1.42 1.54 ± 0.51 314.068 <0.0001 hscrp(mg/dl) 0.94±1.92 0.60±0.90 0.18±0.32 14.182 <0.0001 fasting blood glucose (mg/dl) 102.72±2.36 142.3±5.26 92.4±3.17 137.252 <0.0001 resistin induced insulin resistance is studied by experiments in mice, 16 and the role of resistin in rats and humans and its relation with diabetes has shown varied results. few of the recent studies have shown high resistin levels in blood and macrophages which support the theory of resistin playing important role in inflammatory process. 17 widespread distribution of bacteria (gram negative) in deep pockets characterizes periodontitis. increased blood levels of resistin in our study may be the result of increase release from monocytes and macrophages present in large numbers in periodontal inflammation. development of insulin resistance and diabetes is considered to be result of chronic inflammation. it is hypothesized that increased levels of inflammatory cytokines like, il-1, il-6 and tnf cause impairment of insulin signaling pathway and reduce the mitochondrial functioning leading to insulin resistance. 18 c-reactive protein (crp) is synthesized and released by liver as acute phase reactant protein as result of action of inflammatory cytokines.crp acts as an important biomarker of inflammation and acts like a parameter to monitor the progression of systemic diseases like diabetes, coronary heart disease, cancer and others. crp has emerged as robust and reliable marker for inflammation. the hs-crp test is a highly sensitive quantification of crp that detects minimal quantity. in present study we have found that mean levels of adiponectin and resistin were significantly different among periodontitis with and without diabetes groups as compared with control group. diabetes mellitus and periodontal diseases show close association and many similarities in pathophysiology. it is hypothesized that periodontal disease is an independent risk factor for the causation of type 2 diabetes mellitus. world health organization has projected that nearly 4.4% of the world population will be suffering from diabetes by year 2030. periodontitis is an established complication associated with type 2 diabetes mellitus leading to teeth loss. in our study we found positive association between diabetes mellitus and periodontitis. similar positive association among the two has been reported by aruna et al 19 and lacopino am et al. 1 the relationship between periodontal disease and type 2 diabetes mellitus may be related to pre-existing conditions like obesity and insulin resistance. inflammation has a pivotal role in such association, and it is now getting revealed by various studies. it is proposed that presence of type 2 diabetes mellitus leads to an increased risk of periodontitis, and the various possible bio physiological processes are being studied extensively. it is yet not clear that what is the effect of periodontitis on glycemic control and what is its mechanism of action. it is possible that periodontitis may have a role in the initiation or propagation of insulin regulation further dysregulating glycemic control. further studies are required to verify and establish the relationship between type 2 diabetes mellitus and periodontal diseases. 5. source of funding no financial support was received for the work within this manuscript. 6. conflict of interest the authors declare they have no conflict of interest. references 1. lacopino am. periodontitis and diabetes interrelationships: role of inflammation. ann periodontol. 2001;6(1):125–37. doi:10.1902/annals.2001.6.1.125. 2. international diabetes federation. in: idf diabetes atlas. 5th edn. brussels: idf; 2011. 3. nayak bs, roberts l. relationship between inflammatory markers, metabolic and anthropometric variables in the caribbean type-2 diabetic patients with and without microvascular complications. j inflamm (lond). 2006;3:17. doi:10.1186/1476-9255-3-17. 4. soell m, hassan m, miliauskaite a, haïkel y, selimovic d. the oral cavity of elderly patients in diabetes. diabetes metab. 2007;33(1):10– 8. 5. loe h. periodontal disease the sixth complication of diabetes mellitus. diabetes care. 1993;16(1):329–34. 6. mealey bl, oates tw. diabetes mellitus and periodontal diseases. j periodontol. 2006;77(8):1289–303. doi:10.1902/jop.2006.050459. 7. janket sj, wightman a, baird ae, van dyke t, jones ja. does a periodontal treatment improve glycemic control in diabetic patients? a meta-analysis of intervention studies. j dent res. 2005;84(12):1154– 9. doi:10.1177/154405910508401212. http://dx.doi.org/10.1902/annals.2001.6.1.125 http://dx.doi.org/10.1186/1476-9255-3-17 http://dx.doi.org/10.1902/jop.2006.050459 http://dx.doi.org/10.1177/154405910508401212 244 sarkar et al. / panacea journal of medical sciences 2022;12(2):241–244 8. costa fo, cota lm, lages ep, oliveira a, oliveira pd, cyrino rm, et al. progression of periodontitis and tooth loss associated withglycemic control individuals under periodontal maintenancetherapy: a 5-year follow-up study. j periodontol. 2013;84(5):595–605. doi:10.1902/jop.2012.120255. 9. loe h. periodontal disease: the sixth complication of diabetes mellitus. diabetes care. 1993;16(1):329–34. 10. lim lp, tay fbk, sum cf, thai ac. relationshipbetween markers of metabolic control and inflammation onseverity ofperiodontal disease in patients with diabetesmellitus. j clin periodontol. 2007;34(2):118– 23. 11. grossi sg, genco rj. periodontal disease and diabetesmellitus: a twoway relationship. ann periodontol. 1998;3(1):51–61. 12. ling xj, xin mh, lu h, xian’e w, lin z. serum ratio of leptin to adiponectin in patients with chronic periodontitis and type 2 diabetes mellitus: hindawipublishing corporation isrn. biomarkers. 2014;doi:10.1155/2014/952636. 13. saito t, yamaguchi n, shimazaki y, hayashida h, yonemoto k, doi y, et al. serum levels of resistin and adiponectin in women with periodontitis: the hisayama study. j dent res. 2008;87(4):319–22. doi:10.1177/154405910808700416. 14. arner p. insulin resistance in type 2 diabetes: role of theadipokines. current molecular med. 2005;5(3):333–9. doi:10.2174/1566524053766022. 15. tilg h, moschen r. adipocytokines: mediators linkingadipose tissue, inflammation and immunity. nat rev immunol. 2006;6(10):772–83. 16. steppan cm, lazar ma. resistin and obesity-associated insulinresistance. trends endocrinol metab. 2002;13(1):18–23. doi:10.1016/s1043-2760(01)00522-7. 17. patel l, buckels ac, kinghorn ij, murdock pr, holbrook jd, plumpton c, et al. resistin is expressed in human macrophagesand directly regulated by ppar gamma activators. biochem biophys res commun. 2003;300(2):472–6. doi:10.1016/s0006-291x(02)02841-3. 18. hirabara sm, gorjão r, vinolo ma, rodrigues ac, nachbar rt, curi r, et al. molecular targetsrelated to inflammation and insulin resistance and potential interventions. j biomed biotechnol. 2012;doi:10.1155/2012/379024. 19. balasundaram a, ponnaiyan d, parthasarathy h. diabetes mellitus -a periodontal perspective. srm univ j dent sci. 2010;1(1):79–85. author biography purnima dey sarkar, professor vandana verma, associate professor ajay bhatt, associate professor shiv narayan lahariya, associate professor cite this article: sarkar pd, verma v, bhatt a, lahariya sn. study of serum high sensitivity c reactive protein, adipokines, hba1c, and fasting blood glucose level in patients of diabetes mellitus type ii with periodontal disease. panacea j med sci 2022;12(2):241-244. http://dx.doi.org/10.1902/jop.2012.120255 http://dx.doi.org/10.1155/2014/952636 http://dx.doi.org/10.1177/154405910808700416 http://dx.doi.org/10.2174/1566524053766022 http://dx.doi.org/10.1016/s1043-2760(01)00522-7 http://dx.doi.org/10.1016/s0006-291x(02)02841-3 http://dx.doi.org/10.1155/2012/379024 panacea journal of medical sciences 2022;12(1):164–171 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article correlation of platelet indices with the spectrum of acute coronary syndrome and extent of coronary artery disease chhabi satpathy1, nirmal kumar mohanty1,*, satyanarayan routray1, bijay dash1 1dept. of cardiology, s.c.b. medical college and hospital, cuttack, odisha, india a r t i c l e i n f o article history: received 04-05-2021 accepted 09-06-2021 available online 30-04-2022 keywords: acute coronary syndrome platelet distribution width mean platelet volume platelet large cell ratio total platelet count plateletcrit a b s t r a c t introduction: platelets have a major role in acute coronary syndrome and their activation is a hallmark of this. troponin i, troponin t and creatine kinase enzymes are not enough sensitive at an early stage of acute coronary syndrome. platelet indices can be detected earlier, inexpensive, widely available and easily recordable in most clinical laboratories, thus could be a better marker in these patients. the primary objective of this study is to determine the correlation between platelet indices and spectrums of acute coronary syndrome or the number of vessels involved. material and methods: this is a prospective observation study conducted in a tertiary care teaching hospital of eastern india over a period of six months where 125 patients were non-randomly selected with a diagnosis of acute coronary syndrome who underwent coronary angiogram and reports correlated with platelet parameters. results: a total of 100 patients were finally evaluated. only platelet large cell ratio and platelet-crit were significantly higher in st elevated myocardial infarction group compared to the unstable angina group. across all the spectrums of acute coronary syndrome or extent of coronary artery disease there was a strong positive correlation within platelet distribution width, mean platelet volume and platelet large cell ratio, which was also very significant. similarly total platelet count had a strong positive and very significant correlation with platelet-crit in the above groups. conclusion: increase platelet large cell ratio and platelet-crit seems to be independent risk factors for development of st elevated myocardial infarct than unstable angina. thus they could serve as simple but important early biomarkers for predicting development of st elevated myocardial infarction compared to unstable angina in acute coronary syndrome patients. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction platelets have a major role in acute coronary syndrome (acs) and their activation is a hallmark of this. 1 platelets have also been implicated in the pathogenesis of cardio-vascular disorders including atherosclerosis and its complications, such as acute myocardial infarction (ami), unstable angina (ua) and sudden cardiac death. 2 they play a crucial role in thrombus formation after rupture of the * corresponding author. e-mail address: diptinirmal.pattnaik@gmail.com (n. k. mohanty). atherosclerotic plaque. there will be increased release of larger platelets with denser granules that are highly active. 3 though trop i, trop t and creatine kinase enzymes are more sensitive and specific biomarkers of myocardial damage, they still are not enough sensitive at an early stage of acs, remaining undetectable in about 40 – 60% of patients. 4 platelet indices can be detected earlier, relatively in expensive, widely available and also easily recordable in most clinical laboratories. hence platelet parameters can be better used as markers for possible benefitting in timely intervention in the emergency department by improving risk https://doi.org/10.18231/j.pjms.2022.031 2249-8176/© 2022 innovative publication, all rights reserved. 164 satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 165 stratification. 5 the primary objective of this prospective observational study is to determine the correlation between platelet indices and the spectrum of acs and to analyze if there exists a statistically significant difference between these indices and the numbers of vessels involved in patients admitted to the cardiology ward and undergoing coronary angiogram. 6,7 2. materials and methods this is a prospective observational study conducted on a tertiary care teaching hospital of eastern india over a period of six months from jan 2018 to july 2018. 125 patients selected non-randomly with a diagnosis of acs admitted to the cardiology department who fulfilled the inclusion and exclusion criteria were enrolled for this study. 25 no of patients were excluded thereafter due to insufficient and unreliable data or withdrawal from voluntary consent. 2.1. inclusion criteria patients > 18 years of age presenting with pain chest consistent with acs with any of the following feature were added into the study population. 1. electrocardiographic (ecg changes (a) st elevation (b) st depression (c) t inversion. 2. trop t/trop i /creatine kinase mb isoform (ckmb elevation 2.2. exclusion criteria 1. patients already on antiplatelet/anticoagulant therapy 2. patients with bleeding or clotting disorders. 3. patients with blood/platelet product transfusion within last 3 months. 4. primary platelet disorders, aplastic anemia. 5. pregnancy, sepsis 6. cancer, chronic kidney disease (ckd) with creatine clearance < 60 ml/min/m2body surface area (bsa). 7. advanced liver diseases. 8. patient on drugs that decreases cell counthydroxyurea, anti-neoplastic drugs. 9. severe left ventricular (lv) systolic dysfunction with ejection fraction (ef) <30%. all the study participants after giving there informed consent were subjected to focus history taking and clinical examination to obtain information related to demographic profile, risk factor, presenting symptoms, vital recordings and baseline 12 lead ecg. information documented in a predesigned data sheet. for measuring platelet indices blood samples were taken at the time of admission before starting any specific treatment. 2 ml of blood taken on the ethylene diamine tetra acetic acid (edta) vacutainers obtained via antecubital venous access, examined within 30 minutes (6) by a fully automatic bidirectional hematology analyzer (sysmex xn 100) on flow cytometry principle for complete blood count. platelet parameters like total platelet count (tpc), mean platelet volume(mpv), platelet distribution width( pdw), platelet large cell ratio( p-lcr) and platelet-crit (pct) were noted. other regular blood investigations were also performed. selective coronary angiogram was performed by femoral or radial approach by expert cardiologist. angiogram results were interpreted by two different cardiologists according to quantitative coronary angiogram (qca) method. diameter stenosis > 50% in epicardial coronary arteries was accepted as significant. left main stenosis of more than 30% was included in triple vessel disease (tvd). in patients with typical pain chest of > 20 minutes duration st elevated myocardial infarct (stemi) was defined as > 2 mm st segment elevation at the ‘j’ point in at least 2 consecutive ecg leads from v1 to v3 or > 1 mm elevation in other leads. non st elevated myocardial infarct (nstemi) was defined as any ecg changes other than stemi and/or typical pain chest with positive cardiac biomarkers more than two fold of upper limit of normal values. unstable angina defined as typical pain chest and/or any of the ecg changes with non-diagnostic cardiac biomarkers. 2.3. statistical analysis statistical analysis was done using r version 3.6.3 for calculating mean and standard deviation (sd) of the continuous variables. comparison of the data distribution between groups was done using mann whitney wilcoxon test. p value of less than or equal to 0.05 was considered significant. pearson’s correlation between the platelet indices was obtained using the cor.test. correlation coefficient of more than 0.7 was considered strong and less than 0.5 was considered weak relation. 3. results a total of 100 acs patients were evaluated comprising of 78 stemi patients, 18 nstemi patients and 04 ua patients. the age range of the patients was 27-75 years. the male patients compromised 87.4% of the study population. the base line characteristics of the study patients are summarized in table 1. following coronary angiography the extent of coronary artery disease as per the number of vessels involved significantly by qca method was as follows in table 2. all the platelet parameters were found to be the highest in stemi, followed by nstemi and the lowest 166 satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 table 1: the base line characteristics of the study group parameters values age range 27-75 years male population 87.4% female population 12.6% hypertension 36% diabetes mellitus 40.8% smoking 28.8% body mass index 24 +3.4 (mean + sd) ejection fraction 55.34 + 11.3%(mean + sd) ldl(low density lipoprotein) 100 to 8 + 34.2 mg%(mean + sd) hdl(high density lipoprotein) 40.9 + 8.9mg%(mean + sd) tg(triglyceride) 160.2 + 92.3mg%(mean + sd) stemi 78% nstemi 18% ua 4% in ua patients, but the values of p-lcr and pct were significantly increased in stemi only when compared to ua patients (p=0.05, p=0.03) table 3. table 2: extent of coronary artery disease (cad) number of vessels involved n (%) single vessel disease (svd) 52 (52) double vessel disease (dvd) 28 (28) triple vessel disease (tvd) 20 (20) linear regression analysis performed to determine the pearson’s correlation between one platelet parameter with others. statistically very significant and strong positive correlation was observed amongst pdw, plcr and mpv (r=0.9) (tables 4, 5 and 6). similarly tpc and pct are very significantly related to each other with a strong positive correlation (r=0.9) (tables 7 and 8). these relations are seen across the entire spectrum of acs. there was no significant difference of the platelet indices according to the number of vessels significantly involved by qca method (table 9). pdw, plcr and mpv are very significantly related to each other with a strong positive association (r= 0.8 to 0.9) (tables 10, 11 and 12). similarly tpc and pct are also very significantly related to each other with a strong positive association(r=0.9) (tables 13 and 14). both the relations are found irrespective of the extent of cad (whether svd, dvd or tvd). 4. discussion platelet activation favours thrombus formation and coronary artery occlusion thus playing a key pathogenic role in ami. platelets are also heterogeneous in terms of size, density and activity. larger hyperactive platelets may play an important role in thrombus formation, resulting in acute thrombotic events. 8 release of larger platelets from bone marrow could follow decrease of tpc due to their consumption at the site of thrombosis. 9 thus these markers could maintain their strength and predictive value in acs patients. automated cell counters in hospital laboratories have made platelet indices available routinely and effortlessly as a byproduct, which can be added as a cost effective tool in diagnosis and prognosis of acs spectrum and cad extent. in the present study we measured the platelet parameters in patients suffering from acs with age range of 27-75 years comprising of 87.4% male and 12.6% females. in our study apart from p-lcr & pct other platelet indices did not show a significant difference amongst various spectrum of acs. this is comparable to the study, conducted by gargi g et al. 10 the value of p-lcr was significantly increased in stemi patients compared to ua patients. this is also comparable to the results of the study by ranjith mp et al. 11 wherein plcr was significantly higher in patients of acs, compared to control population. this could be because p-lcr is another index of platelet volume. the study conducted by sermin et al showed that mpv value of stemi patients was slightly higher than nstemi patients but without reaching statistical significance. 12 our study similarly showed mpv to be more in stemi than nstemi and least in ua without any statistically significant difference. our study also showed that tpc is highest in stemi, followed by nstemi and least in ua, without intergroup statistical significance. similar result was also observed by dehghani et al, 13 where platelet count was 2.8% more in mi compared to ua but p was 0.16. so also in that study mi patients had significantly higher plcr than ua, as seen in the present study. we found statistically significant weak negative correlation within tpc and platelet volume indices, which was also seen by bhawani ya et al. 4 pearson correlation analysis done to determine the relation of the tpc with other platelet indices showed that it is having a negative but significant correlation with mpv and pdw in stemi patients in the study by reddy sk et al. 14 similar to that our study shows that tpc is having significant negative correlation with all platelet volume indices in stemi patients. but in tvd group this is restricted to pdw and plcr but not mpv. increased mpv and pdw are known to be associated with increased morbidity, mortality and recurrent mi. 15,16 thus they could be simple and reliable biomarkers to predict significant and severe coronary events. in the study by dehghani et al pearson correlation analysis done had shown that significant negative correlation exist between tpc and mpv or plcr but not pdw (0.07) in mi patients. but here this relation is applicable to all volume indices in stemi patients. mpv value of more than 9.0 fl is usually defined as high. though in patients of acs, mpv is found to be high across satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 167 table 3: comparison of platelet indices between different spectrums of acs platelet indices stemi (i)n(78)mean + sd nstemi (ii)n(18)mean + sd ua (iii)n(4)mean + sd p value(d) a b c mpv(fl) 11.74+1.76 11.29+2.70 10.5+4.44 0.76 0.78 1.0 pdw(fl) 15.02+3.58 14.56+4.38 14.24+5.92 0.74 0.93 0.93 tpc (x103/µl) 264.69+92.59 231+78.87 192.96+82.83 0.23 0.07 0.32 plcr(%) 38.82+10.17 37.92+12.78 28.45+12.03 0.98 0.05d 0.08 pct(%) 0.31+0.10 0.26+0.08 0.21+0.09 0.06 0.03d 0.27 a p value within group i and ii bp value within group i and iii cp value within group ii and iii dp value <0.05 was considered statistically significant. table 4: pearson correlation (r) between pdw and other platelet indices in various spectrums of acs pdw vs. stemi nstemi ua tpc r value -0.45f -0.24 0.09 p value 3.48e-05d 0.31 0.87 mpv r value 0.91e 0.91e 0.96e p value 2.20e-16d 3.25e-08d 0.003d plcr r value 0.91e 0.97e 0.94e p value 2.20e-16d 1.03e-12d 0.004d pct r value -0.32f 0.06 0.25 p value 4.42e-03d 8.11e-01 0.63 d – p value of < 0.05 was considered statistically significant. e – pearson correlation co-efficient of >0.7 indicates strong relation. fpearson correlation co-efficient of <0.5 indicates weak relation. table 5: pearson correlation (r) between plcr and other platelet indices in various spectrums of acs plcr vs. stemi nstemi ua tpc r value -0.39f -0.35 0.39 p value 3.07e-04d 0.13 0.44 mpv r value 0.86e 0.87e 0.99e p value 2.20e-16d 7.62e-07d 0.000d pdw r value 0.91e 0.97e 0.94e p value 2.20e-16d 1.03e-12d 0.005d pct r value -0.24f -0.04 0.55 p value 3.18e-02d 8.68e-01 0.26 d – p value of < 0.05 was considered statistically significant. e – pearson correlation co-efficient of >0.7 indicates strong relation. fpearson correlation co-efficient of < 0.5 indicates weak relation. table 6: pearson correlation (r) between mpv and other platelet indices in various spectrums of acs mpv vs. stemi nstemi ua tpc r value -0.27f 0.06 0.38 p value 0.02d 0.80 0.46 pdw r value 0.91e 0.91e 0.96e p value 2.20e-16d 3.25e-08d 0.003d plcr r value 0.86e 0.87e 0.99e p value 2.20e-16d 7.62e-07d 0.000d pct r value -0.14 0.33 0.52 p value 2.08e-01 1.50e-01 0.29 d – p value of < 0.05 was considered statistically significant e – pearson correlation co-efficient of >0.7 indicate strong relation fpearson correlation co-efficient of <0.5 indicates weak relation 168 satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 table 7: pearson correlation (r) between tpc and other platelet indices in various spectrums of acs tpc vs. stemi nstemi ua mpv r value -0.27f -0.06 0.38 p value 0.02d 0.80 0.46 pdw r value -0.45f -0.24 0.09 p value 3.48e-05d 0.31 0.87 plcr r value -0.39f -0.35 0.39 p value 0.000d 0.13 0.44 pct r value -0.92e 0.94e 0.98e p value 2.20e-16d 4.84e-10d 0.000d d – p value of < 0.05 was considered statistically significant e – pearson correlation co-efficient of >0.7 indicates strong relation fpearson correlation co-efficient of <0.5 indicates weak relation table 8: pearson correlation (r) between pct and other platelet indices across various spectrums of acs pct vs. stemi nstemi ua tpc r value 0.87e 0.97e 0.91e p value 1.74e-07d 2.20e-16d 2.20e-16d mpv r value 0.21 0.05 -0.04 p value 3.52e-01 8.00e-01 0.78 pdw r value -0.04 -0.18 -0.23 p value 8.46e-01 3.46e-01 0.09 plcr r value -0.000 -0.16 -0.14 p value 9.99e-01 3.87e-01 0.31 d – p value of < 0.05 was considered statistically significant e – pearson correlation co-efficient of >0.7 indicates strong relation table 9: comparison of platelet indices with different extent of cad platelet indices svd (i)n(52)mean+ sd dvd (ii)n(28)mean + sd tvd (iii)n(20)mean + sd p value(d) a b c mpv(fl) 11.13+2.5 11.89+2.44 11.59+1.93 0.10 0.37 0.25 pdw(fl) 14.17+4.02 15.63+4.31 14.78+3.58 0.17 0.46 0.39 tpc (x103/µl) 238.90+81.06 243.31+93.94 260.59+87.30 0.96 0.27 0.31 plcr(%) 35.36+10.13 41.06+12.08 37.60+10.52 0.06 0.40 0.15 pct(%) 0.27+0.09 0.29+0.10 0.30+0.10 0.95 0.33 0.42 a p value within group i and ii b-p value within group i and iii c-p value within group ii and iii dp value <0.05 was considered statistically significant. table 10: pearson correlation (r) between pdw and other platelet indices across various extent of cadd – p value of <0.05 was considered statistically significant pdw vs. svd dvd tvd tpc r value -0.15 -0.35 -0.43f p value 0.51 0.06 0.001d mpv r value 0.89e 0.91e 0.92e p value 4.48e-08d 1.78e-12d 2.20e-16d plcr r value 0.92e 0.94e 0.90e p value 1.67e-09d 6.77e-15d 2.20e-16d pct r value -0.04 -0.18 -0.23 p value 8.46e-01 3.46e-01 8.74e-02 e – pearson correlation co-efficient of >0.7 indicates strong relation fpearson correlation co-efficient of <0.5 indicates weak relation satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 169 table 11: pearson correlation (r) between plcr and other platelet indices across various extent of cad plcr vs. svd dvd tvd tpc r value -0.13 0.35 -0.38f p value 0.57 0.06 0.004d mpv r value 0.84e 0.87e 0.85e p value 1.17e-06d 7.21e-10d 4.93e-16d pdw r value 0.92e 0.94e 0.90e p value 1.67e-09d 6.77e-15d 2.20e-16d pct r value -0.0003 -0.16 -0.14 p value 9.99e-01 3.87e-01 3.11e-01 d – p value of < 0.05 was considered statistically significant. e – pearson correlation co-efficient of >0.7 indicates strong relation. fpearson correlation co-efficient of <0.5 indicates weak relation. table 12: pearson correlation(r) between mpv and other platelet indices across various extent of cad mpv vs. svd dvd tvd tpc r value 0.16 -0.11 -0.21 p value 0.49 0.57 0.12 pdw r value 0.89e 0.91e 0.92e p value 4.48e-08d 1.78e-12d 2.20e-16d plcr r value 0.84e 0.87e 0.85e p value 1.17e-06d 7.21e-10d 4.93e-16d pct r value 0.21 0.05 -0.04 p value 3.52e-01 8.00e-01 7.81e-01 d – p value of < 0.05 was considered statistically significant e – pearson correlation co-efficient of >0.7 indicates strong relation table 13: pearson correlation (r) between pct and other platelet indices across various extent of cad pct vs. svd dvd tvd tpc r value 0.87e 0.97e 0.91e p value 1.74e-07d 2.20e-16d 2.20e-16d mpv r value 0.21 0.05 -0.04 p value 3.52e-01 8.00e-01 7.81e-01 pdw r value -0.04 -0.18 -0.23 p value 8.46e-01 3.46e-01 8.74e-02 plcr r value -0.0003 -0.16 -0.14 p value 9.99e-01 3.87e-01 3.11e-01 d – p value of < 0.05 was considered statistically significant. e – pearson correlation co-efficient of >0.7 indicates strong relation. table 14: pearson correlation (r) between tpc and other platelet indices across various extent of cad tpc vs. svd dvd tvd mpv r value 0.16 -0.11 -0.21 p value 0.49 0.57 0.12 pdw r value -0.15 -0.35 -0.43f p value 5.13e-01 0.06 0.001d plcr r value -0.13 -0.35 -0.38f p value 0.57 0.06 0.004d pct r value 0.87e 0.97e 0.91e p value 1.74e-07d 2.20e-16d 2.20e-16d d – p value of < 0.05 was considered statistically significant. e – pearson correlation co-efficient of >0.7 indicates strong relation. fpearson correlation co-efficient of <0.5 indicates weak relation. 170 satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 the spectrums, there is no significant relation of severity of cad with their mpv values. this was also seen by reddy sk et al. 14 in another large scale study by de luca g et al 17 there was no correlation between mpv or pdw and the extent of cad, according to coronary angiogram either in acs or elective cases. similarly in our study none of the volume indices is related to extent of cad in angiography of acs patients. in the earlier largest study so far pwd was inversely related to tpc in a significant manner (p<0.001). our study also showed significant negative correlation between pdw and tpc (p=0.001) but only in patients of tvd. but in stemi patients this negative correlation was found for both tpc (p=3.48 e-05) and pct (p=4.42 e-03). 5. conclusion irrespective of the spectrum of acs or extent of cad, platelet volume indices are very significantly associated with each other in a strong positive way. similarly tpc and pct are having such aforementioned relation with each other. however though the study showed that pdw and mpv may not be related to the spectrum of acs or to the cad extent, increased value of plcr and pct seems to be independent risk factors for development of stemi than ua. in addition in acs patients tpc is having a mild negative but significant correlation with all platelet volume indices only in stemi patients, but it has similar relation with only pdw and plcr in tvd patients. there simple, reliable, easy to perform, noninvasive and economic method may predict the risk of stemi in acs presentation, thus could serve as important tools for risk stratification in them. but conflicting results of various platelet indices in difference studies emphasizes that further large scale trials should be conducted in future to include those simple platelet parameters in triaging of acs patient management. 6. limitations this study had a smaller sample size and long term follow up was not done for prognostic evaluation of those parameters. risk factors ht, dm, smoking and drugs like atorvastasin, 18 insulin, 19 nonsteroidal anti-inflammatory drugs (nsaids) and caffeine, 20 could act as confounding factors. furthermore ivus could have provided more accurate information on the severity of cad and plaque burden which could not be done in this study. conventional cardiac biomarkers could also have been compared with platelet indices for better understanding of the process. 7. acknowledgement we are indebted to all the senior residents, nurses, technician and other paramedical staffs of our department and catheterization laboratory for their immense contribution and dedication for our patient treatment and clinical care. 8. source of funding no financial support was received for the work from any external source. self-funding only done for the hematological study. 9. conflict of interest none. references 1. kilicli cn, demirtune r, konuralp c, eskiser a, basaran y. could mpv be a predictive marker for ami? med sci monit. 2005;11(8):cr387–92. 2. endler g, klimesch a, sunder ph, schilliger m, exner m, mannhalter c, et al. mpv is an independent risk factor for mi but not cad. br j haemotol. 2002;117(2):399–404. doi:10.1046/j.13652141.2002.03441.x. 3. pal r, bagarhatta r, gulati s, rathore m, sharma n. mpv in patients with acs. a supportive diagnostic predictor. j clin diagn res. 2014;8(8):1–4. doi:10.7860/jcdr/2014/8394.4650. 4. lippi g, montagnana m, salvagno gl, guidi gc. potential value for new diagnostic markers in the early recognition of acs. cjem. 2006;8(1):27–31. doi:10.1017/s148180350001335x. 5. manchanda j, potekar rm, badiger s, tiwari a. the study of platelet indices in acs. ann pathol lab med. 2015;2(1):30–5. 6. lance md, van oerle r, henskens ym, marcus ma. do we need time adjusted mpv measurements? lab hematol. 2010;16(3):28–31. 7. thygesen k, alpert js, white hd. joint esc/accf/aha/whf task force for the redefinition of myocardial infarction; universal definition of myocardial infarction. eu heartj. 2007;28(20):2525–38. doi:10.1093/eurheartj/ehm355. 8. mathur a, rokinson ms, cotton j, martin jf, erusalimsky jd. platelet reactivity in acs. evidence for differences in platelet behavior between ua and mi. thromb haemost. 2001;85(6):989–94. 9. yetkin e. mpv not so far from being a routing diagnostic and prognostic measurement. thromb haemostat. 2008;100(1):3–4. doi:10.1160/th08-05-0336. 10. gargi g, saini a, sharma a, jaret p. mean platelet volume in acute coronary syndrome: diagnostic implications. heart india. 2018;6(4):123–6. doi:10.4103/heartindia.heartindia_17_18. 11. ranjith m, divya r, mehta v, krishnan m, kamalraj r, kavishwar a, et al. significance of platelet volume indices and platelet count in ihd. j clin pathol. 2009;62(9):830–3. doi:10.1136/jcp.2009.066787. 12. yekeler s, akay k, borlu f. comparison of mpv and plt values in patients with and without diagnosis of acs. jam coll cardiol. 2013;62(18-s2):116. 13. dehghani mr, sani lt, rezai y, rostami r. diagnostic importance of admission platelet volume indices in patients with acute chest pain suggesting acs. indian heart j. 2014;66(6):622– 8. doi:10.1016/j.ihj.2014.10.415. 14. reddy sk, shetty r, marupuru s, yedavalli n, shetty k. significance of platelet volume indices in stemi patients. a case control study. j clin diagn res. 2017;11(4):5–7. 15. chu sg, becker rc, becker rc, berger pb, bhatt dl, eikelboon jm, et al. mpv as predictor of cardiovascular risk. a systemic review and metaanalysis. j thromb haemostat. 2010;8(1):148–56. doi:10.1111/j.1538-7836.2009.03584.x. 16. alvitigala by, azra maf, kottahachchi du, jayasekera m, wijesinghe r. a study of association between platelet volume indices and st elevation mi. ijc heart and vasculature; 2018. 17. de luca g, venegoni l, lorio s, secco gg, cassetti e, verdoia m, et al. pdw and extent of cad: results from a large prospective study. http://dx.doi.org/10.1046/j.1365-2141.2002.03441.x http://dx.doi.org/10.1046/j.1365-2141.2002.03441.x http://dx.doi.org/10.7860/jcdr/2014/8394.4650 http://dx.doi.org/10.1017/s148180350001335x http://dx.doi.org/10.1093/eurheartj/ehm355 http://dx.doi.org/10.1160/th08-05-0336 http://dx.doi.org/10.4103/heartindia.heartindia_17_18 http://dx.doi.org/10.1136/jcp.2009.066787 http://dx.doi.org/10.1016/j.ihj.2014.10.415 http://dx.doi.org/10.1111/j.1538-7836.2009.03584.x satpathy et al. / panacea journal of medical sciences 2022;12(1):164–171 171 platelets. 2010;21(7):508–14. 18. akin f, ayca b, kose n, sahin i, akin mn, canbek td, et al. effect of atorvastatin on hematologic parameters in patients with hypercholesterolemia. angiology. 2013;64(8):621–5. 19. papanas n, symenoids g, maltezos e, mavridis g, karavageli e, vosnakidis t, et al. mpv in patients with type2 diabetes mellitus. platelets. 2004;15(8):475–8. 20. harrison p, mackie i, mumford a, briggs c, liesner r, winter m, et al. guidelines for the laboratory investigation of heritable disorders of platelet function. br j haematol. 2011;155(1):30–44. author biography chhabi satpathy, associate professor nirmal kumar mohanty, associate professor satyanarayan routray, professor bijay dash, assistant professor cite this article: satpathy c, mohanty nk, routray s, dash b. correlation of platelet indices with the spectrum of acute coronary syndrome and extent of coronary artery disease. panacea j med sci 2022;12(1):164-171. panacea journal of medical sciences 2021;11(3):547–552 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article an analysis of demographic and etiological factors of children and adolescents with short stature in the rural tertiary centeran observational study dixa shah1, sunil pathak2, ashutosh singh rathore2, prashant modi3,*, dhrumika sheth2, mayur shah2 1dept. of pediatrics, divine plus child hospital, tagore road, rajkot, gujarat, india 2dept. of pediatrics, smt. b.k.shah medical institute & research center, sumandeep vidyapeeth, vadodara, gujarat, india 3dept. of pediatrics, parul institute of medical sciences & research, parul university, vadodara, gujarat, india a r t i c l e i n f o article history: received 30-12-2020 accepted 09-01-2021 available online 24-11-2021 keywords: pathological short stature normal variants etiology malnutrition idiopathic short stature standard deviation score a b s t r a c t objectives: (i) to determine pattern of and proportion of various etiology of short stature. (ii) to determine relationship of the standard deviation score (sds) with etiology. materials and methods: this non-analytic observational study, assessed demographic parameters, anthropometry and etiology associate with short stature adolescents and children (6 months to 18 years). short stature was defined as length/ height for age < 3r d centile or < -2 sd as per age & gender specific growth charts. results: out of 105 subjects, 22 were 6 months to < 5 years age, 33 were 5 to 10 years age and 50 were 10 to < 18 years age with m: f ratio of 1.28:1. average value of chronological age, height age, and height sds were 8.86 years, 5.62 years, and – 3.44 sd, respectively. 45.71% subjects were malnourished. idiopathic short stature (24.7%), chronic renal diseases (12.3%) and endocrine disorders (12.3%) were found as etiology common in all three age groups. chronic neurological diseases (9.5%) were more common in 6 months to < 5-year age group; while endocrine disorders (16%), respiratory diseases (12%), gastrointestinal diseases (8%), and renal diseases (8%) were common in adolescents. the maximum average height sds (-2.3 ± 0.2) was observed with normal variants; while the lowest average sds (-4.8 ± 2.0) was observed with syndromic short stature children. conclusion: malnutrition was significant co-existing factor in pathological short stature. the common etiology of pathological short stature varied with different age groups. the sds is important in deciding evaluation plan for particular short stature case. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction growth monitoring is not only an essential part of preventive child health programs but is also pivotal for judging the children’s well-being. the short stature is not a disease per se. it reflects growth faltering in an otherwise normal-child due to a variety of underlying diseases. the first step in approaching a child with short stature is to differentiate * corresponding author. e-mail address: dpmm408@gmail.com (p. modi). normal variants from pathological short stature as it needs a separate set of investigations. 1 the comparison of individual stunted child’s height sds (standard deviation score) with his/her mid-parental-height (mph) sds is an essential clinical step in identifying pathological short stature. 2 the aetiologies causing pathological short stature include chronic systemic diseases, endocrine disorders, genetic diseases, malnutrition, skeletal dysplasia, rickets, etc. the short stature can be subcategorized into proportionate and dis-proportionate short stature based on https://doi.org/10.18231/j.pjms.2021.107 2249-8176/© 2021 innovative publication, all rights reserved. 547 548 shah et al. / panacea journal of medical sciences 2021;11(3):547–552 the us: ls ratio. generally, long-bones and vertebral deformity e.g. rickets and skeletal dysplasia results in disproportionate short stature; 3 while rest aetiologies cause proportionate short stature. the individual self-esteem may be influenced by his/her physical height to some extent. 4 the short stature children experience impairments in the form of adverse impact on their academic performance and social life. 5,6 national family health survey (nfhs)-4 data revealed 38.4% of under five-year children were stunted. 7 the overall prevalence of short stature was 13.8% in pankaj garg et al study. 8 in a study of child growth, conducted at bai jerbai wadia hospital for children in bombay, india, 5.6% (140/2500) children were short stature. 9 however, studies reporting the burden and etiological profile of short stature in older children are very less from india. hence, the early identification of pathological short stature and appropriate intervention before epiphyseal fusion is key for a good outcome. in this perspective, the present study was conducted to contribute demographic as well as etiological data to existing data and to demonstrate utility of height sds in approach to short stature children. the objectives of the study were to determine the pattern and the proportion of various etiology of short stature as well as to demonstrate the relationship of sds with various etiology. 2. material and methods this is a prospective observational study; in which 105 children and adolescents between ages of completed 6 months 18 years with short stature (length/ height for chronological age less than 3 percentile or minus 2 sd as per standard growth chart). 10 admitted in the pediatric ward of dhiraj hospital during december 2017 to july 2019, were included after approval from the institutional ethics committee. all children were enrolled after taking written informed consent from parents or guardians and also separate consent was taken from adolescent subjects. while children age less than 6 months and those whose parents or guardians did not give consent to participate were excluded. the sample size of 105 was obtained by using formula: n = z (1−α/2)2 pq d2 . where, n=minimum sample size required, z = statistic for a level of confidence, p = expected proportion (if the prevalence is 20%, p is 0.2), q= 1-p, and d = precision (if the precision is 5%, then d is 0.05). data was collected as per predesigned proforma. tools used in the study are 1. an infantometer for length measurement in children < 2 years age 2. a wall mount stadiometer for height measurement in children > 2 years age. 3. the gender-specific standard growth charts i.e., who length for age (for < 5-year age) and iap height for age (for > 5-year age). length, height, and mid-parental height (mph) were calculated as per standard method and formula. 8 furthermore sds (standard deviation score) for length/ height as well as for mph was derived by using the following formula. height sds= (observed heightmean height) / 1sd and mph sds= (observed thmean th) / 1sd, where 1 sd was calculated from length/ height for age growth charts. 11 the difference between height sds and mph sds of more 8.5 cm was considered significant to raise suspicion of pathological short stature. the physical findings like pallor, clubbing, lymphadenopathy, dysmorphism, typical features of particular chronic systemic disorder, skeletal deformity, sexual-maturating rating were recorded. the findings of investigations, ordered as per standard protocol, were noted. bone age was assessed by doing an age-appropriate skeletal x-ray and using greulich and pyle’s standards. serum tsh and free-t4 were done by using the chemiluminescent immunoassay (clia) method. epi info ver-7 software was used to analyse data statistically. quantitative data are presented as frequency, proportion, ratio, and percentage. 3. results in the present study 105 children and adolescents with short stature were enrolled during the study period. 59 (56.2%) were boys and 46 (43.8%) girls. 22 (21%), 33 (31%), and 50 (48%) children were belonging to 6 months to < 5 years, 5 to < 10 years, and 10 to 18 years age group, respectively. amongst 22 children of < 5 years, 8 (36%) were wasted; of which 5 (62.5%) were girls and 3 (37.5%) were boys. the study incidence of thinness among children between 5 to 18 years of age was 48.2% (40/83); the same was more prevalent amongst boys (57.5%) than girls (42.5%). average height sds of girls, boys with overall were -3.62, -3.29, and -3.44, respectively. in present study, distribution according to etiology in descending order was 26 (24.7%) idiopathic short stature, 14 (13.3%) chronic renal disorders, 13 (12.4%) endocrine disorders, 9 (8.6%) chronic neurological disorders, 7 (6.8%) chronic respiratory diseases, 7 (6.8%) chronic hematologic disorders, 6 (5.7%) chronic gastrointestinal diseases, 6 (5.7%) constitutional short stature, 5 (4.7%) familial short stature, 4 (3.8%) metabolic diseases, 3 (2.8%) syndromic short stature, 2 (2%) systemic inflammatory diseases, and 2 (2%) skeletal deformity. poor nutrition (wasting+ thinness) was found in 45.71% (48/ 105) children. amongst noticed diseases, the commonest were hypothyroidism 11 (10.48%), chronic kidney disease 7 (6.67%) and rickets 4 (3.80%). the age group-wise distribution of various aetiologies shows idiopathic short stature (8), chronic neurologic (5), and chronic kidney disorders (3) were common in 6 months to < 5 years aged children. among 5 to < 10 years aged children, idiopathic short stature (8), chronic renal (6), chronic hematologic (4), and endocrine (4) disorders shah et al. / panacea journal of medical sciences 2021;11(3):547–552 549 were common. in the group of 50 adolescent children, idiopathic short stature (10), endocrine disorder (8), chronic respiratory diseases (6), gastrointestinal disease (6), and chronic renal disease (4) were common. the relationship of sds with different etiology shows that the mean sds of more than 3 was observed with pathological short stature. the lowest mean sds (about -2.3 with sd 0.2) was observed with constitutional and familial short stature while the highest mean sds below 4.00 was observed with syndromic and metabolic disorder. the observed mean sds among idiopathic short stature was 3.5. 4. discussion in the present study, more than half of the subjects were boys with m: f ratio was 1.28:1. similarly, in s.k. bhadada et al study 12 and gutch m et al 13 study the m: f was 1.25:1 and 1.64 respectively. age distribution revealed predominantly affected age-group was adolescents followed by school-age and toddler-preschool-age. the study prevalence of wasting amongst toddler-preschool-age children was 36%, whereas the prevalence of same in india as well as in gujarat is 7.3% and 25.1%, respectively. 14,15 the prevalence of thinness among children (5-10 years aged) and adolescents was 48.2%. while, the prevalence of thinness in india amongst adolescent was 26.1% in 2016. 16 the overall study prevalence of poor nutrition of was 48 (45.7%). in the present study, the mean chronologic-age and height were 8.86 (0.5-17) years and 109.87 (59-154) cms respectively; while gutch m et al 13 mentioned the mean chronologicalage: 11.6 + 3.2 years, and mean height: 119.3+12.6 cm. the average bmi of children more than 5 years of age was 14.83 kgs/m2, which was similar to 15.9 kgs/m2 average bmi found in em lee et al study. 17 the proportion of normal variant short stature in this study was very low (11, 10.5%) and the same for pathological short stature was very high (94, 89.5%). in phirke ds et al study 26.5% and 73.5% were the normal variant short stature and pathological short stature, respectively. 18 in the present study, common aetiologies in descending orders were idiopathic short stature, chronic renal disorders, endocrine disorders, chronic neurological disorders, chronic respiratory diseases, chronic hematologic disorders, chronic gastrointestinal diseases, etc. in pankaj garg et al study, the commonest cause of short stature was protein energy malnutrition (pem) & chronic diseases occurring in 46 (53.5%) cases followed by normal variant short stature (24.4%), endocrine problems (4.7%) and miscellaneous (5.8%). 8 in contrast, s.k. bhadada et al study 12 mentioned normal variant (36.1%) was most common etiology followed by endocrine (30.09%), iugr and birth anoxia (8.52%), chronic systemic diseases (7.38%), metabolic bone diseases (5.68%) and malnutrition (5.1%). the reason behind this difference was the target population i.e., enrolment of hospitalized children with short stature. in a community-based study conducted by k velayutham et al familial short stature was reported as the commonest etiology (66.6%). 19 on exploring distribution of etiology among different age groups revealed that the proportion of idiopathic short stature was highest in all age-groups. among toddlerpreschool-age group other predominant aetiologies were chronic neurologic diseases and chronic kidney disorders; while among school-age children chronic renal diseases, chronic hematologic diseases, and endocrine disorders were common. in the adolescent-group endocrine disorder, chronic respiratory diseases, chronic renal disease, and systemic inflammatory disease were commonly observed aetiologies apart from normal variant and idiopathic short stature. in present study, the commonest diseases were hypothyroidism (10.48%), chronic kidney disease (6.67%) and rickets (3.80%). in velayutham k et study, hypothyroidism (13.79%), growth hormone deficiency (9.20%), and malnutrition (6.9%) were commonest diseases causing pathological short stature. 19 the current study showed that the average height sds was -3.36 (± 1.0). the lowest mean sds (about -2.3 ± 0.2) was observed with normal variant short stature while highest mean sds was observed with syndromic disorders (-4.8 ± 2.0), metabolic disorder (-4.17 ± 1.3) and endocrine disorders (-3.8 ± 1.2). the observed mean sds among idiopathic short stature was -3.5. average height sds in a study conducted by s. mohmmadian et al 20 was -4.16 ± 1.32. maximum height sds was observed in genetic disorder (-4.85 ± 1.26) followed by gh deficiency (-4.67 ± 1.35) constitutional short stature (-3.82 ± 1.22) and hypothyroidism (-3.63 ± 1.58). the limitations of this study were: (i) present study is hospital based only (ii) karyotyping was not done in all idiopathic short stature girls. (iii) some of the idiopathic short stature children did not evaluate after firstline investigations due to financial constraints and some of them left against medical advice. 5. conclusion pathological short stature was more common among hospitalized children. undernutrition was a predominant association found with short stature. hypothyroidism was commonest endocrine disease-causing short stature. a good community-based survey is mandatory to know an exact aetiological profile as the majority of normal variant short stature children do not seek health-care. a list of commonest etiology varies with different age groups. a group of children having idiopathic short stature with height sds significantly low on comparing with target height sds needs separate attention and evaluation strategy as it may be sequelae of severe malnutrition that had occurred in early age or maybe result of an underlying undiagnosed condition. 550 shah et al. / panacea journal of medical sciences 2021;11(3):547–552 table 1: various demographic factors analysis demographic factors female (n=46) male (n=59) total (n=105) average chronologic age (range) years 8.7 (1.1 17) 8.98 (0.517) 8.86 (0.5-17) average weight (range) kgs 18.03 (5.7 50.58) 18.98 (4.252.88) 18.57 (4.2-52.88) average height age (range) years 5.43 (0.712) 5.77 (0.1713) 5.62 (0.1713) wfl∗ kgs (for < 5 years) 9.6 11.2 10.4 wasted (wfl < -2sd) 5 (62.5%) 3 (37.5%) 8/22 (36%) bmiď kgs/m2 (for 5 or more years) 15.18 14.57 14.83 thinness (bmi < 5th %le) 17 (42.5%) 23 (57.5%) 40/83 (48.2%) height sds -3.62 -3.29 -3.44 ∗wfl: weight for length, ďbmi: body mass index table 2: etiology wise distribution etiology diseases – number (percentage) idiopathic (26) idiopathic short stature 26 (24.7%) normal variants (11) familial short stature 5 (4.76%), constitutional delay 6 (5.71%) hematological diseases (7) b thalassemia major 1 (0.95%), sickle cell disease 4 (3.81%), combined sicklebeta thalassemia 2 (1.90%) neurological diseases (9) cerebral palsy 4 (3.81%), hydrocephalus 2 (1.90%), intellectual disability 2 (1.90%), epilepsy1 (0.95%) endocrine disorders (13) hypothyroidism 11 (10.48%), cushing syndrome with obesity 1 (0.95%), insulin dependent diabetes mellitus 1 (0.95%) gastrointestinal diseases (6) ulcerative colitis 2 (1.90%), coeliac disease 1 (0.95%), functional abdominal pain 1 (0.95%), hirschprung’s disease 1 (0.95%), juvenile polyposis syndrome 1 (0.95%) metabolic disorders (4) calciopenic rickets 2 (1.90%), phosphopenic rickets 1 (0.95%), wilsons disease with rickets 1 (0.95%) renal disorders (14) chronic kidney disease 7 (6.67%), distal renal tubular acidosis 2 (1.90%), frequent relapse nephrotic syndrome 4 (3.81%), infrequent relapse nephrotic syndrome 1 (0.95%) respiratory diseases (7) asthma 3 (2.86%), tuberculosis 4 (3.81%) skeletal deformity (2) spinal deformity with dorso-lumbar severe kyphosis 1 (0.95%), atlanto-axial subluxation with severe spinal cord stenosis 1 (0.95%) genetic disorders (4) down syndrome 1 (0.95%), seckel syndrome -2 (1.90%) systemic inflammatory diseases (2) takayasu arteritis 1 (0.95%), rheumatoid arthritis 1 (0.95%) table 3: age group wise etiology distribution etiology < 5 years (n=22) 5 to 10 years (n=33) 10 to 18 years (n=50) hematological disease 0 4 (12.1%) 3 (6%) constitutional short stature 0 4 (12.1%) 2 (4%) neurological disease 5 (22.7%) 2 (6.1%) 3 (6%) endocrine disorder 1 (4.5%) 4 (12.1%) 8 (16%) familial short stature 0 2 (6.1%) 3 (6%) gastrointestinal disease 2 (9.1%) 0 4 (8%) idiopathic short stature 8 (36.5%) 8 (24.3%) 10 (20%) metabolic disorder 2 (9.1%) 1 (3%) 1 (2%) kidney disease 3 (13.6%) 6 (18.1%) 4 (8%) respiratory disease 1 (4.5%) 0 6 (12%) skeletal malformation 0 0 2 (4%) syndromic disease 0 2 (6.1%) 1 (2%) systemic inflammatory diseases 0 0 2 (4%) shah et al. / panacea journal of medical sciences 2021;11(3):547–552 551 table 4: average height sds in different etiology etology mean height sds sd chronic hematologic disease -2.57 0.65 constitutional short stature -2.26 0.13 chronic neurologic disease -3.73 0.74 endocrine disorder -3.82 1.23 familial short stature -2.33 0.31 chronic gastrointestinal disease -3.79 1.07 idiopathic short stature -3.59 1.21 metabolic disorder -4.17 1.30 chronic kidney disease -3.56 1.29 chronic respiratory disease -3.44 1.31 skeletal malformation -2.56 0.21 syndromic disease -4.87 2.00 systemic inflammatory diseases -3.058 1.58 the calculation of height sds is more useful than just labelling below -2sd, as more low height sds the chances of having pathological short stature are high. 6. acknowledgement we acknowledge the support provided by dr. manish rasania, dr. prasad muley and fellow colleagues. we thank our patients and their parents for their participation in the study. 7. sources of funding no financial support was received for the work within this manuscript. 8. conflicts of interest no conflicts of interest. references 1. menon p, menon rk, gupta a. normal variant short stature. ind j ped. 1983;50(5):533–5. 2. cole tj. a simple chart to identify non-familial short stature. arch dis childhood. 2000;82(2):173–6. 3. srinath ks. lethal forms of short limb dwarfsm. ind paed. 1995;32(9):1011–15. 4. lechelt ec. occupational affiliation and ratings of physical height and personal esteem. psychol rep. 1975;36(3):943–6. 5. gordon m, crouthamel c, post em, richman ra. psychosocial aspects of constitutional short stature: social competence, behavior problems, self-esteem, and family functioning. j pediatr. 1982;101(3):477–80. 6. stabler b, clopper rr, siegel pt, stoppani c, compton pg. academic achievement and psychological adjustment in short children. the national cooperative growth study. j dev behav pediatr. 1994;15(1):1–6. 7. national family health survey-4 (2015-16). ;available from: http:// rchiips.org/nfhs/nfhs-4reports/india.pdf. 8. garg p. short stature in indian children: experience from a community level hospital. sri lanka j child health. 2004;34(3):84–8. doi:10.4038/sljch.v34i3.399. 9. colaco p, desai cs, choksi. short stature in indian children: the extent of the problem. indian j pediatr. 1991;58(1):57–8. doi:10.1007/bf02750984. 10. gupta p. clinical methods in paediatrics. in: anthropometry: assessment of growth, 4th edn. new delhi: cbs publishers & distributors; 2009. p. 55–105. 11. who the z-score or standard deviation classification system;available from: https://www.who.int/nutgrowthdb/about/ introduction/en/index4.html. 12. bhadada sk, agrawal nk, singh sk, agrawal jk. etiological profile of short stature. indian j paediatr. 2003;70(7):545–7. 13. gutch m, sukriti k, keshav gk, syed mr, abhinav g, annesh b, et al. etiology of short stature in northern india. j asean fed endocr soc. 2016;31(1):23. 14. who guideline development group meeting scoping meeting for the who guideline on the prevention and treatment of wasting in infants and children. available from: https://www.who.int/news-room/events/ detail/2020/12/08/default-calendar/who-guideline-developmentgroup-meeting-scoping-meeting-for-the-who-guideline-on-theprevention-and-treatment-of-wasting-in-infants-and-children. 15. national family health survey-5 (2019-20). 1920;available from: http://rchiips.org/nfhs/nfhs-5_fcts/factsheet_gj.pdf. 16. who: prevalence of thinness among adolescents aged 10-19 years. available from: https://www.who.int/data/maternal-newbornchild-adolescent-ageing/indicator-explorer-new/mca/prevalence-ofthinness-among-adolescents-aged-10-19-years-(bmi--2-standarddeviations-below-the-median-(crude-estimate)). 17. lee em, park mj, ahn hs, lee sm. differences in dietary intakes between normal and short stature korean children visiting a growth clinic. clin nutr res. 2012;1(1):23–9. 18. phirke ds, phirke so, khot s. an aetiological evaluation of short stature. int j res med sci. 2017;5(9):3887–90. 19. velayutham k, selvan ss, jeyabalaji rv, balaji s. prevalence and etiological profile of short stature among school children in a south indian population. indian j endocrinol metab. 2017;21(6):820–2. 20. mohammadian s, khoddam h. an etiologic evaluation of children with short stature in gorgan. j med sci. 2005;7(7):1206–9. author biography dixa shah, consultant pediatrician sunil pathak, associate professor ashutosh singh rathore, associate professor prashant modi, associate professor http://rchiips.org/nfhs/nfhs-4reports/india.pdf http://rchiips.org/nfhs/nfhs-4reports/india.pdf http://dx.doi.org/10.4038/sljch.v34i3.399 http://dx.doi.org/10.1007/bf02750984 https://www.who.int/nutgrowthdb/about/introduction/en/index4.html https://www.who.int/nutgrowthdb/about/introduction/en/index4.html https://www.who.int/news-room/events/detail/2020/12/08/default-calendar/who-guideline-development-group-meeting-scoping-meeting-for-the-who-guideline-on-the-prevention-and-treatment-of-wasting-in-infants-and-children https://www.who.int/news-room/events/detail/2020/12/08/default-calendar/who-guideline-development-group-meeting-scoping-meeting-for-the-who-guideline-on-the-prevention-and-treatment-of-wasting-in-infants-and-children https://www.who.int/news-room/events/detail/2020/12/08/default-calendar/who-guideline-development-group-meeting-scoping-meeting-for-the-who-guideline-on-the-prevention-and-treatment-of-wasting-in-infants-and-children https://www.who.int/news-room/events/detail/2020/12/08/default-calendar/who-guideline-development-group-meeting-scoping-meeting-for-the-who-guideline-on-the-prevention-and-treatment-of-wasting-in-infants-and-children http://rchiips.org/nfhs/nfhs-5_fcts/factsheet_gj.pdf https://www.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/prevalence-of-thinness-among-adolescents-aged-10-19-years-(bmi--2-standard-deviations-below-the-median-(crude-estimate)) https://www.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/prevalence-of-thinness-among-adolescents-aged-10-19-years-(bmi--2-standard-deviations-below-the-median-(crude-estimate)) https://www.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/prevalence-of-thinness-among-adolescents-aged-10-19-years-(bmi--2-standard-deviations-below-the-median-(crude-estimate)) https://www.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/prevalence-of-thinness-among-adolescents-aged-10-19-years-(bmi--2-standard-deviations-below-the-median-(crude-estimate)) 552 shah et al. / panacea journal of medical sciences 2021;11(3):547–552 dhrumika sheth, resident mayur shah, resident cite this article: shah d, pathak s, rathore as, modi p, sheth d, shah m. an analysis of demographic and etiological factors of children and adolescents with short stature in the rural tertiary centeran observational study. panacea j med sci 2021;11(3):547-552. 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2021;11(3):527–532 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article role of spectral doppler in evaluation of palpable breast masses in co-relation with ultrasound guided fnac jeevika mu1, mahesh bg1,*, harikiran reddy1, yashas ullas l2, mounisha kethineni1 1dept. of radiodiagnostics, jjm medical college, davangere, karnataka, india 2dept. of radiodiagnostics, sri devaraj urs medical college, kolar, karnataka, india a r t i c l e i n f o article history: received 05-02-2021 accepted 21-04-2021 available online 24-11-2021 keywords: breast ultrasound resistive index pulsatality index spectral doppler and ultrasound guided fnac. a b s t r a c t background: breast disease is one of the most common complaints of females belonging to any age group. the breast masses range from benign to malignant. breast carcinoma is the second most common cause of mortality in females. therefore, early diagnosis is important for better management. the aim of this study is to assess the value of flow velocity and ri, in evaluating solid breast masses, to compare it with pathology results, and to determine specific gray scale characteristics with doppler parameters of lesion with fnac correlation in differentiating benign from malignant lesions. materials and methods : this prospective study was conducted at department of radio-diagnosis, bapuji hospital & chigatere general hospital, davangere attached to jaya jagadhguru murugarajendra medical college, davangere. total number of subjects selected for the study was 50 patients of age ranging between 17-56 years. initially sonography was performed and data was obtained. then tissue diagnosis was obtained in all 50 cases and and final diagnosis was obtained. patients who are referred to ultrasound with palpable breast masses were included in this study. the detailed physical and clinical examination was done for all the study subjects, in addition to sonography and histopathological examination. in this study all us examinations were performed with a 6-13 mhz high frequency linear-array transducer of volusen e6 model. fnac/surgical biopsy of these ultrasonographically detected breast lesions were done. fnac of breast lesions were done under ultrasound guidance. fnac was avoided in those patients with prolonged bt, ct, pt and decreased platelets counts. after correction of these abnormalities, patients were subjected to fnac. results: in the present study, spectral doppler shows sensitivity of 92% and specificity of 96% in diagnosing breast lesions when compared with fnac. in the present study, benign tumor was seen in 26 cases and malignant tumor was observed in 24 cases. compared with benign, malignant tumor showed significantly increased ri, pi and vmax. usg diangosis of palpable breast masses showed that, carcinoma was seen in 23 (46%), fibroadenoma 14 (28%), abscess and phyllodes tumour in 5 (10%) cases each and galactocoele in 1 (2%) case. in the current study, fnac diagnosis of palpable breast masses showed that, fibroadenoma in 16 (32%) cases, idc in 13 (26%) cases, idc with metastatic lymphadenopathy and carcinoma in 5 (10%) cases each, abscess in 3 (6%), galactocoele and lipoma in 2 (4%) cases each, benign papillary neoplasm and infiltrating ductal carcinoma g-ii in 1 (2%) case each. clinical diagnosis of palpable breast masses showed that, carcinoma was observed in 27 (54%) cases, fibroadenoma 20 (40%) cases, galactocoele in 2 (4%) cases and metastalgia in 1 (2%) cases. conclusion: ultrasound with colour doppler is safe, relatively inexpensive, widely available, free of radiation hazards, non-invasive essential modality for evaluation of breast lesions and should be one of the first investigations for evaluating a breast lesion before proceeding to aggressive invasive procedures. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com https://doi.org/10.18231/j.pjms.2021.103 2249-8176/© 2021 innovative publication, all rights reserved. 527 528 jeevika mu et al. / panacea journal of medical sciences 2021;11(3):527–532 1. introduction breast cancer is the leading cause of deaths (15%) among females in developed and developing countries worldwide, with over 1 million new cases in the world each year. though breast cancer is thought to be a disease of developed countries, the 50% of cases and 58% of deaths occur in developing countries. detection of cancer in the early stage can improve the survival of patients and cancer control can be achieved. 1 according to who in india about 1 lakh new patients with breast cancer are diagnosed annually and an estimated 70,218 indian women die due to breast cancer every year. early diagnosis of breast cancer remains to be pivotal in reducing the number of deaths due to breast cancer. fnac of breast masses was first introduced by martin and ellis long back in 1930 and this can be used for diagnosis of breast lesions. 2 age standardised cancer mortality trends was found highest for breast cancer when compared to all other cancers in india. breast cancers usually presents as a lump or mass in the breast. it is a major concern to the patient and it need to be evaluated as early as possible. 3 “lump” in breast, is therefore, a cause of great anxiety both to the patient and family members. the main motive behind the evaluation of such a newly detected palpable lump is basically to rule out malignancy. evaluation of breast lumps involves the rational use of a detailed history, clinical breast examination, imaging modalities and tissue diagnosis. 4 though the final diagnosis is made by histopathological examination of the excised tissue, routine excision of all breast lumps would not be rationale, because as much as 80% of lumps are benign. thus the need is the utilisation of less invasive and cost effective method(s) of diagnosis without resorting to a more painful and invasive surgical biopsy. the modality should also be acceptable to the patient, accurate, easy to apply, reproducible and must not need too much preparations. 5 given the common occurrence of breast cancer and the importance of accurately diagnosing a clinically palpable breast lump, with non-invasive techniques without routinely resorting to formal biopsy which is much invasive, the study is proposed to evaluate the accuracy of ultrasonography (usg) and fine needle aspiration cytology (fnac) in the diagnosis of newly detected clinically palpable breast lumps in comparison to the final histopathological (hpe) report of the biopsied specimens. although the accuracies of fnac and ultrasonography in the diagnosis of breast lumps have been tested individually in other studies, study comparing fnac and ultrasonography using upon the same population is not reported in literature. our study is designed to compare the results of fnac and ultrasonography in the diagnosis of newly detected clinically palpable breast lumps * corresponding author. e-mail address: maheshgurappa18@gmail.com (mahesh bg). in the same population. 6 there is a need to correlate the radiological and cytological findings of breast lesions with histopathological diagnosis to evaluate the diagnostic accuracy of sonomammography andbreast fnac. study aimed to correlate radiological and cytological findings of breast lesions with histopathological diagnosis. 2. materials and methods this prospective study was conducted at department of radio-diagnosis, bapuji hospital & chigatere general hospital, davangere attached to jaya jagadhguru murugarajendra medical college, davangere. the duration of study was december 2018 to september 2020. the study has been approved by the institutional ethics committee of jjm medical college. total number of subjects selected for the study was 50 patients of age ranging between 17-56 years. initially sonography was performed and data was obtained. then tissue diagnosis was obtained in all 50 cases and final diagnosis was obtained. patients who are referred to ultrasound with palpable breast masses were included in this study. already diagnosed cases and patients not willing to give consent were excluded from the study. the detailed physical and clinical examination was done for all the study subjects, in addition to sonography and histopathological examination. in this study all us examinations were performed with a 6-13 mhz high frequency linear-array transducer of volusen e6 model. fnac/surgical biopsy of these ultrasonographically detected breast lesions were done. fnac of breast lesions were done under ultrasound guidance. fnac was avoided in those patients with prolonged bt, ct, pt and decreased platelets counts. after correction of these abnormalities, patients were subjected to fnac. 2.1. statistical analysis categorical data was represented in the form of frequency and percentage. chi square test was used to know the association between variables and fisher’s exact test for all 2 x 2 tables where p value of chi square test was not valid due to small counts.quantitative data was represented as mean±sd. analysis of quantitative data was done using unpaired t-test. histopathological findings were correlated with adc values for diagnoses. sensitivity, specificity, positive predictive validity, negative predictive validity accuracy of the test findings will be calculated. roc curve will be applied to know the area covered for the accuracy. p-value of <0.05 was considered statistically significant. analysis was done by using ibm spss software version 22. jeevika mu et al. / panacea journal of medical sciences 2021;11(3):527–532 529 3. results in the present study, receiver operating curve (roc) for usg suggest the excellent sensitivity with 92% and with specificity with 96% in diagnosing breast lesions is shown when compared with fnac which is considered as gold standard (table 1). in the present study, it was found that mean score of malignant cases found significantly higher than benign cases. in the present study, benign tumor was seen in 26 cases and malignant tumor was observed in 24 cases. compared with benign, malignant tumor showed significantly increased ri, pi and vmax (table 2). in the present study, usg diangosis of palpable breast masses showed that, carcinoma was seen in 23 (46%), fibroadenoma 14 (28%), abscess and phyllodes tumour in 5 (10%) cases each and galactocoele in 1 (2%) case (table 3) in the current study, fnac diagnosis of palpable breast masses showed that, fibroadenoma in 16 (32%) cases, idc in 13 (26%) cases, idc with metastatic lymphadenopathy and carcinoma in 5 (10%) cases each, abscess in 3 (6%), galactocoele and lipoma in 2 (4%) cases each, benign papillary neoplasm and infiltrating ductal carcinoma g-ii in 1 (2%) case each (table 4). in the present study, clinical diagnosis of palpable breast masses showed that, carcinoma was observed in 27 (54%) cases, fibroadenoma 20 (40%) cases, galactocoele in 2 (4%) cases and metastalgia in 1 (2%) cases (table 5). 4. discussion patients with palpable breast masses commonly present for imaging evaluation. 7 breast cancer is the most common cancers in the world among women.1 fine needle aspiration cytology (fnac) for the diagnosis of breast masses. fnac of breast lump is now a well-established modality for accurately determining the nature of breast lumps. ultrasound is also useful in evaluation of breast lesions. breast ultrasound is now a well-established method and several studies have suggested that sonomammography can be useful in differentiating between benign and malignant lesions presenting as breast masses. 8 the purpose of this study was to compare the result of breast fnac and breast ultrasound with histological diagnosis to assess its diagnostic accuracy. early screening and diagnosis of breast lesions and categorization into different groups of breast pathology can be helpful in accurate management of the breast lesions. in a study done by wasan et al breast ultrasound had a sensitivity of 100%, specificity of 91.6 which is comparable to our study in which the sensitivity was 90.6% and specificity was 97.8%. benign lesions of the breast were more readily diagnosed by ultrasound than malignant lesions. 9 according to nandan kumar et al the sensitivity and specificity of breast ultrasound in categorising breast lesions as benign and malignant was 85.4% and 89.31%, which is slightly lesser compared to our study. 10 studies done by puja b. jarwani et al 11 and ambedkar raj, kulandai velu et al, 12 showed that breast fnac had a sensitivity ranging from 82% to 97.5% and specificity of more than 99%, which is comparable to our study. study done by shanmugasamy k et al showed that the sensitivity, specificity and diagnostic accuracy of breast fnac in diagnosis of malignancy was 93.5%, 100% and 98.3% respectively. mammography and sonography have been used in attempt to reduce the biopsy rate. however, mammography has not yet become widely available, is time consuming, costly and presents with radiation hazards. hence, now a days the technique of breast ultrasonography is evolving as a new modality in diagnosis and management of breast diseases. in the present study fibroadenoma accounted for maximum number of cases i.e. 16 (32%). starvas at et al studied 750 breast lesions and fibroadenoma accounted for 338 (48%) of all lesions. 13 fibroadenoma represents the most common benign tumour of young age group. freely mobile mass (mouse in breast) is its classical presentation. in the present study, 18 cases were below 30 years of age. fornage et al. studied sonographic patterns of 100 fibroadenomas, 71% of the lesions were homogenous, whereas 295 showed a variable degree of texture inhomogeneity, 90% were hypoechoic, 4% hyperechoic, 2% had mixed pattern, 1% anechoic and 1% isoechoic. 14 in the present study, out of 16 fibroadenoma, 12 (75%) were hypoechoic and 4(25%) were of mixed echogenicity. in the same study, 57% of the lesions had regular margins, 16% had lobulated margins, whereas 25% had irregular margins. in the present study, out of 16 fibroadenomas, 12 (75%) had regular margins and 4(25%) had lobulated margins. in 1983, beuglet c et al. studied 2000 sonomamograms, 73% of the lesions showed acoustic enhancement. 15 the present study, out of 3 cases of breast abscess, 2 were lactating mothers and 1 was post-traumatic. all 3 cases were hypoechoic, with irregular and ill-defined margins, internal echoes and showed posterior acoustic enhancement. ultrasound guided aspiration was done in all 3 cases. in 1 case, abscess was drained surgically and findings were confirmed. phyllodes tumour tends to occur at around 30 years of age. in the present study, 2 cases of phyllodes tumour were encountered. the present study, two cases of lipoma were studied. it was diffuse homogeneous mass lesion with echogenicity higher than normal breast. soskia et al. performed 500 breast examination, out of which 18% were non-palpable and 8% were palpable masses. in their study they found that lipoma had medium level, homogeneous echoes with thin peripheral capsules. 16 530 jeevika mu et al. / panacea journal of medical sciences 2021;11(3):527–532 table 1: area under the curve forusg area std. error asymptotic (p-value) asymptotic 95% confidence interval lower bound upper bound .940 .039 .000 .863 1.000 table 2: means score comparison of age, ri, pi andvmax among benign and malignant group n mean std. deviation mean difference age (years) benign 26 34.5 15.1 -18.96 malignant 24 53.5 8.9 p-value=.000* ri benign 26 .60 .07 -.16 malignant 24 .77 .08 p-value=.000* pi benign 26 .83 .21 -.65 malignant 24 1.4 .21 p-value=.000* v max (ms-1) benign 26 .09 .05 -.20 malignant 24 .29 .08 p-value=.000* *statistically significant table 3: usg diagnosis of palpable breast masses usg diagnosis frequency percent abscess 5 10.0 carcinoma 23 46.0 fibroadenoma 14 28.0 galactocoele 1 2.0 lipoma 2 4.0 phyllodes tumour 5 10.0 total 50 100.0 table 4: fnac diagnosis of palpable breast masses fnac diagnosis frequency percent abscess 3 6.0 benign papillary neoplasm 1 2.0 fibroadenoma 16 32.0 galactocoele 2 4.0 lipoma 2 4.0 phyllodes tumor 2 4.0 idc 13 26.0 idc with metastatic lymphadenopathy 5 10.0 infiltrating ductal carcinoma g-ii 1 2.0 carcinoma 5 10.0 total 50 100.0 table 5: clinical diagnosis of palpable breast masses clinical diagnosis frequency percent carcinoma 27 54.0 fibroadenoma 20 40.0 galactocoele 2 4.0 metastalgia 1 2.0 total 50 100.0 jeevika mu et al. / panacea journal of medical sciences 2021;11(3):527–532 531 infiltrating ductal carcinoma is the most common and lethal form of breast cancer accounting for 65-85% of invasive cancer. in the present study we came across 24 (44%) malignant lesions, out of which 13 are idc, 5 are idc with metastatic lymphadenopathy, 1 is idc with grade ii and 5 are other carcinomas. power doppler sonography was performed with color box adjusted to include the lesion and a small margin of normal breast tissue. the color sensitivity was adjusted so that only the background color was suppressed and small vessels could be detected. during the exploration, care was taken to apply as little pressure as possible with the probe to prevent vessels from collapsing. the exploration with power doppler sonography was considered positive if atleast one vessel was depicted within the lesion and it showed an arterial flow pattern when pulsed doppler imaging was used. if intralesional vascularization was detected then pulse wave doppler sonography was performed to obtain spectral waveforms. the resistive index (ri) and pulsatility index (pi) were calculated for all these waveforms. the ri value is calculated as (peak systolic velocity (psv) end diastolic velocity (edv) / psv. the pi values was calculated as (peak systolic velocity – minimum diastolic velocity)/ (mean velocity). the calculations were done automatically using the equipment’s inbuilt software. in our study, ri values equal to or greater than 0.67 and pi values greater than 0.85 were considered significant. 5. conclusion ultrasound is a safe and effective method for evaluation of breast lesion. in maximum number of cases the synchronized evaluation and characterization of breast lesion by ultrasound will help in overall assessment of breast lesions. taking into consideration the physical findings and the woman breast cancer risk profile (age, personal history, family history of breast cancer) along with sonographic features of breast lesion will help in reaching a probable diagnosis of the lesion and play a vital role in management of the patient. non-invasive procedure like ultrasound is essential before proceeding to invasive procedures. the identification of common lesion like breast cyst by ultrasound which has a diagnostic accuracy of 100% obviates the need for any further intervention. among remaining lesions, even slightly doubtful features on ultrasound should be subjected to histological diagnosis as ultrasound cannot accurately differentiate all benign lesions from malignant lesions. management of a solid breast lesion depends on its ultrasonographic features whether to go for fnac/biopsy or follow-up sonomammography. in colour doppler study of solid lesions, a greater number of malignant lesions showed vascularity as compared to benign lesions. but even presence of vascularity cannot be used as a definite criterion to diagnose a lesion as malignant as some benign lesions do show vascularity. ultrasound and colour doppler though not 100% accurate in differentiating benign from malignant lesion, when grey scale findings are used along with colour doppler, will definitely help the clinician to decide the further management of the lesion. thus, ultrasound with colour doppler is safe, relatively inexpensive, widely available, free of radiation hazards, non-invasive essential modality for evaluation of breast lesions and should be one of the first investigations for evaluating a breast lesion before proceeding to aggressive invasive procedures. 6. sources of funding no financial support was received for the work within this manuscript. 7. conflicts of interest no conflicts of interest. references 1. gupta k, chandra t, kumaresan mh, venkatesan b, patil ab. role of colour doppler for assessment of malignancy in solid breast masses: a prospective study. int j anat radiol surg. 2017;6(1):59– 65. 2. anto j, richie, mellonie p. radiological and cytological correlation of breast lesions with histopathological findings in a tertiary care hospital in costal karnataka. int j contemp med res. 2019;6(2):1–4. 3. krithika s, ilangovan g, balganesan h, pavithra a. ultrasound evaluation of palpable breast masses in correlation with fine needle aspiration cytology. int j contemp med surg radiol. 2020;5(2):27– 33. 4. pruthi s. detection and evaluation of a palpable breast mass. mayo clin proc. 2001;76(6):641–7. doi:10.4065/76.6.641. 5. tiwari m. role of fine needle aspiration cytology in diagnosis of breast lumps. kathmandu univ med j. 2007;5(2):215–7. 6. takhellambam ys, lourembam ss, sapam os, kshetrimayum rs, ningthoujam bs, khan t, et al. comparison of ultrasonography and fine needle aspiration cytology in the diagnosis of malignant breast lesions. j clin diagn res. 2013;7(12):2847–50. 7. tiwari p, ghosh s, agrawal vk. evaluation of breast lesions by digital mammography and ultrasound along with fine-needle aspiration cytology correlation. j can res ther. 2018;14(5):1071–4. 8. heinig j, witteler r, schmitz r, kiesel l, steinhard j. accuracy of classification of breast ultrasound findings based on criteria used for bi-rads. ultrasound obstet gynecol. 2008;32(4):573–8. doi:10.1002/uog.5191. 9. al-saadi wi, ahmed bs, mahdi qa, qader i, idrees y. non palpable breast mass. mustansiriya med j. 2011;15(1):20–4. 10. kumar n, shilpa n. mammographic and sonomammographic evaluation of breast masses with pathological correlation. innovative journal of medical and health science. 2016;6:132–135. 11. jarwani pb, patel dc, patel sm, dayal a, dayal a. fine needle aspiration cytology in a palpable breast. gcsmc j med sci. 2013;2(2):1–5. 12. shanmugasamy k, vaithy ka, bhavani k, kotasthane ds. cytological evaluation of benign breast lesions with histopathological correlation. indian j pathol oncol. 2016;3(2):328–35. 13. stavros at, thickman d, rapp cl, dennis ma, parker sh, sisney ga, et al. solid breast nodules: use of sonography to distinguish between benign and malignant lesions. radiology. 1995;196(1):123– 34. doi:10.1148/radiology.196.1.7784555. http://dx.doi.org/10.4065/76.6.641 http://dx.doi.org/10.1002/uog.5191 http://dx.doi.org/10.1148/radiology.196.1.7784555 532 jeevika mu et al. / panacea journal of medical sciences 2021;11(3):527–532 14. fornage bd, toubas o, morel m. clinical, mammographic, and sonographic determination of preoperative breast cancer size. cancer. 1987;60(4):765–71. doi:10.1002/10970142(19870815)60:4<765::aid-cncr2820600410>3.0.co;2-5. 15. beuglet c, soriano rz, kurtz ab, goldberg bb. fibroadenoma of the breast: sonomammography correlated with pathology in 122 patients. radiology. 1983;140:369. 16. hilton s, leopoid g, olson lk, wilson sa. real time breast sonography: application in 300 consecutive patients. ajr. 1986;147:479–86. doi:10.2214/ajr.147.3.479. author biography jeevika mu, professor and hod mahesh bg, post graduate student harikiran reddy, associate professor yashas ullas l, post graduate student mounisha kethineni, post graduate student cite this article: jeevika mu, mahesh bg, reddy h, ullas l y, kethineni m. role of spectral doppler in evaluation of palpable breast masses in co-relation with ultrasound guided fnac. panacea j med sci 2021;11(3):527-532. http://dx.doi.org/10.1002/1097-0142(19870815)60:4<765::aid-cncr2820600410>3.0.co;2-5 http://dx.doi.org/10.1002/1097-0142(19870815)60:4<765::aid-cncr2820600410>3.0.co;2-5 http://dx.doi.org/10.2214/ajr.147.3.479 panacea journal of medical sciences 2021;11(3):573–578 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article clinical profile of patients with interstitial lung disease in connective tissue disorders – an original study abhishek nuchin1, girija nair1, balaji tuppekar1, shahid patel1,*, abhay uppe1 1dept. of pulmonary medicine, d. y. patil medical college, navi mumbai, maharashtra, india a r t i c l e i n f o article history: received 17-03-2021 accepted 13-04-2021 available online 24-11-2021 keywords: interstitial lung diseases (ild’s). declaration of helsinki (doh) a b s t r a c t background and objectives: interstitial lung diseases (ild’s) are a heterogeneous collection of more than one distinct lung disorder which is grouped together owing to their clinical, radiographic, and pathologic features they share in common. connective tissue disease may be an underlying cause of interstitial lung disease, and often patients may not present with a pre-existing diagnosis. the aim of this study is to study the clinical profile of these patients including physiologic testing and have a better understanding of ctd-ild in the indian scenario. material and methods: this was a prospective, observational study conducted at d.y.patil hospital and medical research center, navi mumbai, india, between a two year period from december 2017december 2019. a total of 50 patients of age 18 and above with clinical diagnosis of connective tissue disease and interstitial lung disease were included in the study. clinical profile of the study participants was studied based on presenting symptomatology and history, chest x-ray and hrct findings, microbiological aspirates in sputum, pulmonary function testing, 6mwt and 2d-echo findings. the convenient sampling method was used for data collection and distribution of responses was examined using frequencies and percentages. further analysis was done using appropriate statistical tests (chi-square test, t-test) were used to compare responses between various subgroups. results: majority of the study subjects were females (56%) as compared to males (44%). mean age of the study participants was 58.08 ± 11.92 years, ranging from 27 years to 81 yrs. majority were of the age group 61-70 years(21%), followed by 51-60 years(16%) respectively. all the participants (100%) presented with dyspnea, more than half of them 28(56%) had cough and over a quarter of them had joint pain 15(30%).17(34%) symptomatic patients of ctd were also diagnosed as ild. 33(66%) of patients with ild had underlying ctd. 66% patients of ild had underlying connective tissue disease. uip pattern was the predominant in 88% of ra-ild and nsip pattern was predominant in other ctd-ild. restrictive abnormality on pft with reduced dlco was observed in all patients with raised pulmonary artery pressure in 70% patients. during the 6-minute walk test, 64% of patients walked <350 meters and significantly reduced spo2 levels were observed after exercise p<0.05. conclusion: our study showed a high frequency of lung involvement in the form of respiratory symptoms, radiological patterns, echocardiography, and changes in pulmonary function and exercise testing in patients with ild diagnosed to have underlying ctd. since lung involvement in ctd is associated with significant morbidity and mortality, a high index of suspicion in ild patients with underlying connective tissue disease will help in early diagnosis and treatment of ctd-ild which is associated with a better prognosis compared to other ild’s. further studies with a larger sample size and regular patient follow up are required for a better understanding of ctd-ild in the indian scenario. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com https://doi.org/10.18231/j.pjms.2021.113 2249-8176/© 2021 innovative publication, all rights reserved. 573 574 nuchin et al. / panacea journal of medical sciences 2021;11(3):573–578 1. introduction ild refers to a heterogeneous collection of lung disorders that tend to be grouped together since they share clinical, radiographic, and pathologic features. these disorders are sometimes called diffuse parenchymal lung disease (dpld). treatments may vary considerably depending on the diagnosis hence a structured approach. patients usually present with symptoms cough and dyspnoea on exertion. a detailed history regarding presence of respiratory symptoms with another underlying disease is important. eg. vasculitides, sarcoidosis, amyloidosis, glycogen storage disorders, gerd may all present with persistent cough. history of smoking, environmental exposure and familial disease must be documented. a careful physical examination usually reveals velcro crepitation’s or crackles. systemic features of underlying disease may also be present. a review of laboratory data, physiologic studies, radiography, bronchoalveolar lavage and in some cases pathologic tissue obtained from lung biopsy is essential. multidisciplinary approach is an important part of this process and can have a significant impact on diagnostic and management decisions. 1 distinguishing those patients who have a known cause for their ild (e.g., connective tissue disease, occupational or environmental exposure, or drug toxicity) from those who do not (e.g., ipf, sarcoidosis) is an important step. connective tissue disease may be an underlying cause of interstitial lung disease, and patients may sometime present with a pre-existing diagnosis. however, most will not and it is important to bring to clinical attention any associated or underlying autoimmune disease as soon as the onset of ild is diagnosed by the pulmonologist. in some cases, nonspecific symptoms such as night sweats, fever, fatigue, or weight loss may suggest an underlying inflammatory condition. in others, a detailed history and clinical examination of systems aid in the diagnosis of an underlying connective tissue disorder. for example, careful questioning regarding skin related symptoms may lead to the diagnosis of dermatomyositis as demonstrated by gottron’s papules, a heliotrope rash or “mechanic’s hands,” all of which may go unnoticed. patients with underlying systemic sclerosis (scleroderma) may give a history of skin tightness and telangiectasias, raynaud’s phenomenon, or digital pitting and skin thickening. papular eruptions, lupus pernio, and erythema nodosum may be seen in sarcoidosis. 2 patients with systemic lupus erythematosus (sle) may present with malar rash, photosensitivity skin reactions, or hair loss. a detailed review of systems may uncover sequelae of longstanding ild. in patients with advanced fibrotic lung disease and hypoxemia symptoms like increasing oedema, syncopal events or exertional chest discomfort may indicate * corresponding author. e-mail address: patel_shahid@hotmail.com (s. patel). core pulmonale and pulmonary hypertension. the lung is a frequent target of autoimmune-mediated injury in patients with connective tissue disorders due to abundance of connective tissue and blood supply. all compartments of the lung can be potentially affected including airways, lung parenchyma, vasculature and pleura. they can be affected in various combinations and degrees based on the underlying connective tissue disorder and are a significant cause of morbidity and mortality. 3 there are very few indian studies assessing the clinical profile of patients with connective tissue disorders in ild based on physiologic testing. this study aims to assess the clinical profile of patients with connective tissue disorder related ild based on spirometry, lung volumes, 6mwt, sputum culture and diffusing capacity and help understand the disease better in the indian scenario. 2. materials and methods this study documents were reviewed and approved by the institutional ethics committee (iec) of d.y.patil hospital (navi mumbai, maharashtra, india), and was conducted in adherence to good clinical practice (gcp) guidelines and declaration of helsinki (doh). this was a prospective, observational study conducted between a two-year period from december 2017december 2019. a total of 50 patients of age 18 and above with clinical diagnosis of connective tissue disease and interstitial lung disease were included in the study from the in-patient as well as outpatient setting. patients below the age of 18years with only connective tissue disease or only interstitial lung disease were excluded from the study. after taking written informed consent from each patient, they were provided with a patient information sheet which included personal data, presenting symptoms and past history, hrct thorax, pft, sputum culture and 2-d echo findings and performance on 6-minute walk test. the convenient sampling method was used for data collection and distribution of responses was examined using frequencies and percentages. further analysis was done using appropriate statistical tests (chi-square test, t-test) were used to compare responses between various subgroups. 3. results majority of the study subjects were females (56%) as compared to males (44%). mean age of the study participants was 58.08 ± 11.92 years, ranging from 27 years to 81 yrs. all the participants (100%) presented with breathlessness, more than half of them 28 (56%) had cough and over a quarter of them had joint pain 15 (30%), only 17 (34%) patients had initial involvement of others systems that is 15 (30%) patients had joint pain and 2 patients (4%) presented with skin tightness. (table 1) nuchin et al. / panacea journal of medical sciences 2021;11(3):573–578 575 majority were of the age group 61-70 years, followed by 51-60 years respectively. nearly half of the study participants 21 (42%) had history of hypertension, 13 (26%) had diabetes mellitus. 44 (88%) participants did not have smoking history. 6 (50%) participants who were smokers had 1 pack per year history of smoking. majority of the study participants were house wives 22(44%), followed by teachers 8(16%), clerks 7(14%). number of patients with ctd presenting with symptoms and diagnosed as ild were 17(34%) and number of patients of ild diagnosed as ctd (connective tissue disease) were 33(66%) (table 2). in case of chest x-ray findings, reticular opacities which are predominantly observed seen in lower zones in 47/50 cases (94%). more than twothirds of the participants showed bilateral lower zone reticular opacities 43(86%) (table 3). among the participants, 17 had ra. among those patients 15 had uip pattern and 2 had nsip pattern on hrct. out of 9 patients of systemic sclerosis 4 had uip pattern and 5 had nsip pattern. nsip was predominant in the remainder of ct-ild participants (tables 4 and 5). among the study participants; only 3(6%) patients reported a sputum culture growth. pseudomonas was cultured in the sputum of patients with polymyositis ild and two patients with scleroderma ild had sputum culture positive for staphylococcus. all the participants showed the restriction pattern on fvc and reduced dlco. among the study participants 27 (54%) had mild restriction, 18 (36%) had moderate restriction and 5 patients had severe restriction. all study subjects (100%) had reduced dlco with a mean of 54.22ml/min/mmhg. the lowest value was 18 ml/min/mmhg in a patient with systemic sclerosis with ild and highest value of 78ml/min/mmhg in a patient with raild. 23 (46%) patients had moderately reduced dlco, 20(40%) patients had mildly reduced dlco and severely reduced in 7(14%) of patients. however, nearly 43(86%) of the participants showed normal fev1/fvc ratio. (tables 6, 7 and 8). 35 (70%) participants showed increased pulmonary artery pressure. mean pressure of 33.76 with a maximum pasp of 65 and minimum pasp of 18. among the participants who had pulmonary hypertension (70%), 50% had mild, 14% had moderate and 6% had severe pulmonary hypertension (table 9 ). only 4 (8%) of the participants had mild dilation of the ra/ rv and rest did not show any such findings. nearly 49 (98%) of the participants had a normal lv ejection fraction (lvef) on 2d echo. the ra/ rv dilation was observed more among the moderate and severely fvc categories when compared to others, this trend was found to be statistically significant (p<0.05). the involvement of ra/ rv dilatation was significantly more among the participants who had severely reduced fev1 (3050% of predicted) in restrictive lung disease when compared to another group of mildly reduced fev1 (50-79% of predicted). in case of 6-minute walk test; there was a significant difference in pulse rate and spo2 levels observed between pretest and posttest measurements. majority of the participants 19 (38%) walked 250349 meters on 6 min walk test, followed by 13 (26%) who could only walk 150249 meters. (tables 10 and 11) table 1: distribution of subjects based on frequency of symptoms encountered symptoms number (n=50) percent breathlessness 50 100 cough 28 56 joint pain 15 30 fever 5 10 tightness of skin 2 4 table 2: diagnosis of ct-ild diagnosis of ct ild total percentage ctd diagnosed to have ild 17 34% ild diagnosed to have ctd 33 66% total 50 100% table 3: chest x-ray findings chest x-ray findings number percent bilateral lower zone reticular opacities 43 86 bilateral lower zone opacities with bronchiectasis 2 4 bilateral lower zone nodular opacities 2 4 upper zone opacities 3 6 total 50 100 table 4: hrct findings hrct findings number percent non-specific interstitial pneumonia 23 46 usual interstitial pneumonia 27 54 total 50 100 4. discussion as discussed earlier connective tissue diseases encompass a wide range of heterogeneous disorders where lung involvement causes significant morbidity and mortality. even though the pathogenesis of connective-tissue diseases is unknown, the role of autoimmunity in ild associated with connective-tissue disorders is well established. 4 paolo spagnolo, jean-françois cordier, vincent cottin 5 concluded that ra affects approximately 1% of the 576 nuchin et al. / panacea journal of medical sciences 2021;11(3):573–578 table 5: hrct findings with uip and nsip ct –ild uip nsip ra 15 2 systemic sclerosis 4 5 scleroderma 3 4 sarcoidosis 1 3 sle 1 2 polymyositis /dm 1 4 mctd 2 3 total 27 23 table 6: fvc and dlco characteristics number percent fvc < 80% (restriction pattern) 50 100 dlco < 80 reduced 50 100 table 7: fvc fvc (restriction) total percentage mild 27 54% moderate 18 36% severe 5 10% total 50 100% table 8: dlco grading dlco grading number percentage mild (79-60%) 20 40 moderate (59-40%) 23 46 severe (<40%) 7 14 total 50 100 table 9: pasp grading pasp grading number percentage mild (26-40) 25 50 moderate (40-55) 7 14 severe (>55) 3 6 total 35 70 population worldwide, and women are twice as likely as men to be affected, with the peak incidence being observed between the fourth and sixth decade. majority in our study were females (56%) as compared to males (44%). mean age of the study participants was 58.08 ± 11.92 years, ranging from 27 years to 81 yrs. majority were of the age group 61-70 years (21 patients-42%), followed by 51-60 years (16 patients-32%). as described by yang, 6 symptoms considered for diagnosis of ild-ctds were dry cough, wheezing, and chest tightness and velcro-like rales that can be heard at the lung bases bilaterally, and clubbing. patients may also present with joint pain, dry eyes/mouth dry, raynaud phenomenon, central muscle weakness, joint swelling deformation, long-term healing of oral ulcers, morning stiffness, repeated unexplained fever, skin ta bl e 10 :6 m in ut e w al k te st (c om pa ri ng be tw ee n pr ete st an d po st -t es tc ha ra ct er s) c ha ra ct er s p re -t es t( m ea n) p os tte st (m ea n) tva lu e si gn ifi ca nc e p ul se ra te 96 .4 4 12 1. 26 19 .4 51 p < 0. 00 5 s po 2 94 .8 4 88 .4 2 8. 10 2 p < 0. 00 5 nuchin et al. / panacea journal of medical sciences 2021;11(3):573–578 577 table 11: distance walked distance walked 6-mwt number percent > 350mts 18 36 250349mts 19 38 150249mts 13 26 total 50 100 thickening cracking, esophageal reflux. e. bodolay, z. szekanecz 7 studied ild with mctd also described 80% of the study group to have complaints of breathlessness the predominant symptom. ild is a diffuse parenchymal lung disease, which may be secondary to a variety of occupational or environmental exposures including smoking, and can complicate multiple rheumatic or connective tissue diseases (ctds) as described by castelino et al. 8 majority of the participants in our study were exposed to chulha (biofuel) 18(36%), followed by 11(22%) who gave history of smoking (beedi/cigarette). in this study rheumatoid arthritis has higher frequency which comprises 34%, 18% had systemic sclerosis, 14% had scleroderma, polymyositis and mctd constituted 10% each and sarcoidosis and sle constituted 8% and 6% respectively. castelino et al. 8 observed frequency of connective tissue disorder associated with ild was 45% in case of systemic sclerosis and 20-30% with rheumatoid arthritis. in this study rheumatoid arthritis has higher frequency of 34%, followed by 18% in systemic sclerosis, 14% in scleroderma, polymyositis and mctd constituted 10% each and sarcoidosis and sle constituted 8% and 6% respectively. e. bodolay, z. szekanecz 103 describes 96 ild-ctd patients with chest x-rays showing abnormalities consisting of small irregular opacities predominantly in the bases and middle regions in 87/96 cases (90.6%). in this study 96 out of 144 mctd patients (66.6%) had active ild, 75 of this group (78.1%) showed ground glass opacity, 21 patients (21.8%) ground glass opacity with mild fibrosis with hrct. e.j kim et al in their study showed a definite usual interstitial pneumonia pattern in 20 (24%), likely nsip in 19 (23%) and indeterminate in 43 (52%) out of 82 patients with raild. 9 in a study of 63 patients with rheumatoid lung disease conducted by david a. lynch, mb, 26 had a ct pattern suggestive of uip, 19 had a pattern of nsip. 10 bouros d, wells au, nicholson ag, et al. 11 reported the most frequent histopathologic pattern in systemic sclerosis was nsip, observed in 62 of 80 patients (77.5%); nsip was subcategorized as cellular nsip (15/62, 24%) and fibrotic nsip (47/62, 76%). patients with uip (n = 6) and those with end-stage lung (n = 6) were grouped together, making up 12 of 80 patients (15%). in our study participants, opacities were predominantly observed in lower zones in (94%), reticular opacities in 86%, nodular opacities in 4% of patients and reticular opacities with bronchiectasis in 4%. 27 (54%) had usual interstitial pneumonia (uip) and the rest 23 (46%) had nonspecific interstitial pneumonia (nsip). among 17 patients of ra, 15 had uip pattern and 2 had nsip pattern; of the 9 patients of systemic sclerosis 4 had uip pattern and 5 had nsip pattern. in the remainder of the ct-ild participants nsip pattern was predominant. among our study participants whose sputum was tested for culture characteristics, only 3 (6%) showed growth and rest 47(94%) did not show any on culture. among 3 patients who showed growth in sputum 2 of them had bronchiectatic changes in which 1 patient grew pseudomonas and another grew staph aureus. pulmonary function testing of all participants showed a restrictive pattern on fvc and reduced dlco. 7 (14%) of participants had obstruction on pft with restriction. minimum fvc was 42% of predicted and maximum fvc of 78% of predicted. among our study participants 27 (54%) had mild restriction, 18 (36%) had moderate restriction and 5 patients had severe restriction. all study subjects (100%) had reduced dlco with a mean of 54.22ml/min/mmhg. in our study, echocardiography of 35 (70%) participants showed increased pulmonary artery pressure with the rest having normal pressures. mean pressure of 33.76 with max pasp of 65 and minimum pasp of 18. among the participants who had pulmonary hypertension (70% of patients) 50% had mild, 14% had moderate and 6% had severe pulmonary hypertension. among the 35 patients 4 patients had dilated right atrium and right ventricle. bouros d, wells au, nicholson ag, et al. 11 in their study of systemic sclerosis reported that pulmonary hypertension was evident on echocardiography in 12 of 56 participants (21%); in 44 patients, echocardiographic findings were normal; and in the remaining 18 patients, there was no evidence of pulmonary hypertension. chang et al. 12 studied 619 patients of scleroderma with ild and observed mild to moderate pulmonary hypertension in 154 patients (24.9%), and severe pulmonary hypertension in 77 patients (12.4%). of the 36.3% with an elevated rvsp measurement, the mean rvsp was 53.3 ± 16.4 mm hg. ra/rv dilatation was significantly present among our participants who had severely reduced fev1 (30-50% of predicted) when compared to another group of mildly reduced fev1 (50-79% of predicted). the ra/ rv dilation was observed more among the moderate and severely fvc categories when compared to others, this trend was found to be statistically significant. the six-minute walk test (6mwt) provides powerful prognostic information and has recently been applied to ild. as compared to resting lung function tests, desaturation to 88% in a baseline 6mwt, either during 13 or at the end of the test, 14 has emerged as a much more powerful predictor of mortality. in a study of patients with 578 nuchin et al. / panacea journal of medical sciences 2021;11(3):573–578 ipf, desaturation to 88% or below was associated with a median survival of 3.21 years compared with a median survival of 6.63 years in those who did not desaturate. 1,5,6 in the present study there was a significant difference observed between pre-test and post-test measurements regarding pulse and spo2 levels. with mean pulse rate of 96 in pre-test increased to 121 per minute and spo2 level of 94% in pre-test decreased to 88% in post-test. among our study subjects 18 (36%) patients were able to walk more than 350 meters, 19 patients were able to cover distance between 250-350 meters and 13 patients covered distance ranging from 150-250 meters. 5. conclusion our study highlights the clinical profile and lung involvement in the form of respiratory symptoms, radiological changes, echocardiography findings, and changes in pulmonary function and exercise testing in ctd-ild patients. since lung involvement in ctd is associated with significant morbidity and mortality, a high index of suspicion and the ability to identify the various clinical features and effects on physiological testing in ild patients with underlying ctd can help in early diagnosis and treatment. one of the drawbacks of this study was the lack of lung biopsy for histopathological confirmation of ild. further studies with a larger sample size and regular patient follow up are required for a better understanding of ctd-ild in the indian scenario. 6. sources of funding no financial support was received for the work within this manuscript. 7. conflicts of interest no conflicts of interest. references 1. fishman. ’s pulmonary diseases and disorders. 2015;12:1255–1256. 2. marchell rm, judson ma. cutaneous sarcoidosis. semin respir crit care med. 2007;31(4):442–51. doi:10.1055/s-0030-1262212. 3. atzeni f, gerardi mc, barilaro g, masala if, benucci m, sarzi-puttini p. interstitial lung disease in systemic autoimmune rheumatic diseases: a comprehensive review. expert rev clin immunol. 2018;14(1):69–82. 4. jindal sk, agarwal r. autoimmunity and interstitial lung disease. curr opin pulm med. 2005;(5):438–484. 5. spagnolo p, cordier jf, cottin v. connective tissue diseases, multimorbidity and the ageing lung. european respiratory journal. 2016;47(5):1535–1558. 6. hu y, wang ls, wei yr, du ss, du yk, he hp, et al. clinical characteristics of connective tissue disease-associated interstitial lung disease in 1,044 chinese patients. chest. 2016;149(1):201–8. doi:10.1378/chest.15-1145. 7. bodolay e, szekanecz z, devenyi k, galuska l, galuska l, vègh j, et al. evaluation of interstitial lung disease in mixed connective tissue disease (mctd). rheumatology (oxford). 2005;44(5):656–61. doi:10.1093/rheumatology/keh575. 8. castelino f, varga j. interstitial lung disease in connective tissue diseases: evolving concepts of pathogenesis and management. arthritis res ther. 2010;12(4):213. doi:10.1186/ar3097. 9. kim ej, elicker bm, maldonado f, webb wr, ryu jh, uden jhv, et al. usual interstitial pneumonia in rheumatoid arthritis-associated interstitial lung disease. eur respir j. 2009;35(6):1322–28. 10. lynch da. lung disease related to collagen vascular disease. j thorac imaging. 2009;24(4):299–309. doi:10.1097/rti.0b013e3181c1acec. 11. bouros d, wells au, nicholson ag. histopathologic subsets of fibrosing alveolitis in patients with systemic sclerosis and their relationship to outcome. am j respir crit care med. 2002;165(12):1581–6. doi:10.1164/rccm.2106012. 12. chang b, wigley fm, white b. scleroderma patients with combined pulmonary hypertension and interstitial lung disease. j rheumatol. 2003;30(11):2398–405. 13. flaherty kr, andrei ac, murray s. idiopathic pulmonary fibrosis: prognostic value of changes in physiology and six-minutewalk test. am j respir crit care med. 2006;174(7):803–9. doi:10.1164/rccm.200604-488oc. 14. lama vn, flaherty kr, toews gb. prognostic value of desaturation during a 6-minute walk test in idiopathic interstitial pneumonia. am j respir crit care med. 2003;168(9):1084–90. doi:10.1164/rccm.200302-219oc. author biography abhishek nuchin, resident girija nair, professor and hod balaji tuppekar, assistant professor shahid patel, associate professor abhay uppe, professor and hou cite this article: nuchin a, nair g, tuppekar b, patel s, uppe a. clinical profile of patients with interstitial lung disease in connective tissue disorders – an original study. panacea j med sci 2021;11(3):573-578. http://dx.doi.org/10.1055/s-0030-1262212 http://dx.doi.org/10.1378/chest.15-1145 http://dx.doi.org/10.1093/rheumatology/keh575 http://dx.doi.org/10.1186/ar3097 http://dx.doi.org/10.1097/rti.0b013e3181c1acec http://dx.doi.org/10.1164/rccm.2106012 http://dx.doi.org/10.1164/rccm.200604-488oc http://dx.doi.org/10.1164/rccm.200302-219oc 429 too many requests you have sent too many requests in a given amount of time. 47 1 2 associate professor, resident, department of pathology, nkpsims&rc, hingna road, digdoh hills, nagpur 440019. anne_cerry@yahoo.co.in abstract: familial adenomatosis polyposis coli (fap) maybe associated with other epithelial and mesenchymal colonic or extra-colonic neoplasm. we present an unusual case of fap with neurogenic tumor of the small bowel, which occurred synchronously in a 40-year-old male. keywords: familial adenomatosis polyposis, neurogenic tumor, small bowel. pjmsvolume 4 : number 2 : july dec. 2014 case report resected specimen was sent for histopathology. we received a specimen of recto-sigmoid colon measuring 19 cm x8.5 cm x4cm. there were multiple, mostly sessile mucosal polyps varying in size from 0.5 cm x0.5cm to 2 cm x2 cm, and a single large polyp measuring 5 cm x4 cm x4 cm near the distal surgical margin(fig. 1.). the polyps were extending up to the surgical margins. figure 1: .gross specimen of resected sigmoid colon showing multiple sessile polyps and a large polyp near the rectal end (lower part microscopic pathology: sections taken from different areas of the specimen revealed polyps composed of tubular glands lined by mucin secreting epithelium. few cells showed hyperchromatic elongated nuclei. some areas showed abundant mucin pools spilling into the surrounding connective tissue. the largest polypshowed mucosal glands arranged in tubulo-villous pattern. the villi were lined by stratified mucin secreting epithelium.mild to moderate nuclear pleomorphism was seen(fig. 2.). introduction: familial adenomatosis polyposis coli (fap) when detected should be removed surgically as early as possible to prevent the occurrence of colonic carcinoma. rarely fap is associated with other benign or malignant neoplasm. the synchronous occurrence of fap with a neurogenic tumor is very rare. case history: a forty year old male presented with a history of bleeding and mucous discharge per rectum off and on, for the previous two years. these complaints started after a surgery (resection anastomosis of mid small bowel) he had 2 years prior at another institute, for small bowel obstruction by a large tumor mass 20x20cms, attached to the wall of the intestine.on histopathology, it was seen to be arising from the submucosa and was suggestive of gastrointestinal stromal t u m o r ( g i s t ) o f t h e s m a l l b o w e l . h o w e v e r, immunohistochemistry was suggestive of a spindle cell tumor of neurogenicorigin (s-100 positive, c-kit, smooth muscle actin and cd 34 negative). he developed bleeding per rectum and constipation one month after that surgery. a colonoscopy done at that time showed multiple polyps, one of which was biopsied and reported as villous adenomatous polyp. he was advised surgery but was unfit. his father had carcinoma of the stomach. no family screening or genetic testing for gastrointestinal neoplasm in other family members was done. the present computed tomography (ct) scan showed two irregular intra-abdominal lesions in the peritoneum measuring 3 cm each (? recurrence of neoplasm) with mesenteric lymphadenopathy (1 cm x1.5cm). small polypoidal lesions were seen in the sigmoid colon along with circumferential thickening of the wall of the rectum. based on these findings, a clinical diagnosis of multiple colonic polyps with intra-abdominal masses was made and the patient was taken for laparotomy. intraoperatively, there were two retroperitoneal masses adherent to the small bowel mesentery which was inoperable. a 6cm x5cm growth was seen in the rectum. hence only palliative resection of the affected sigmoid colon and rectum (with 2 cm margin distal to the growth)was done, with a colorectal anastomosis. the familial adenomatosis polyposis coli with small bowel neurogenic tumor: a rare synchronous presentation 1 2 wilkinson anne , gohad gaurav pjmsvolume 4 : number 2 : july dec. 2014 case report 48 figure 2: photomicrograph showing colonic polyp with dysplastic lining epithelium (haematoxylin and eosin x400) few of the glands were seen to be invading the underlying connective tissue. inflammatory infiltrate composed of lymphocytes and plasma cells was present in the connective tissue. the final histopathological diagnosis was polyposis coli with villous adenomatous pattern, extending upto the surgical margins, with the largest polyp showing features of a well differentiated mucin secreting adenocarcinoma. he was referred to the oncologist for further treatment. discussion: this rare case demonstrated the synchronous occurrence of a small bowel neurogenic tumorin a patient with familial adenomatosis polyposis coli(fap). the patient was diagnosed with adenomatosis polyposis coli one month after surgery for small intestinal neurogenic tumor, at another hospital. however he came for surgery for fap only two years later, by which time he had developed a well differentiated adenocarcinoma in one of the polyps. a small bowel neurogenic tumor in association with fap has previously not been reported, as per the literature reviewed by us. fap syndrome is characterized by the progressive development of hundreds to thousands of adenomatous polyps in the large intestine. if the colon and/ or rectum are not removed, the development of colonic/ rectal cancer is almost inevitable, as happened in our case. the first description of fap was given by chargelaigne in 1859 and its mendelian dominant trait was recognized and reported by harrison cripps during 1882. in 1890 handford mentioned the association of intestinal cancers with fap (1). patients with fap are born with a germ line mutation in the apc gene on the long arm of chromosome 5q(21-22). it is inherited as autosomal dominant with incomplete penetrance (2). tumors(benign/malignant) frequently develop in other organs as well as in the colon and rectum. for example gastric polyps mainly fundic gland polyps occur in 30-100% of patients whereas gastric adenomas are relatively uncommon (approximately 5% cases) (3). duodenal adenomas mainly in the region of periampullary region occur in 60-90% of fap patients and the incidence increases with age. the occurrence of duodenal periampullary cancer also has been reported and has 4-12% incidence. jejunal adenomas have been detected in 40% patients. lymphoid hyperplasia may present in the ileum of patients with fap (1,3,4).a korean study has found the incidence of gastric cancer as 2.7% and duodenal cancer as 0.7% in fap patients (5). in our case the patient's father had carcinoma of the stomach. in 80% of patients with fap, there is family history of polyps and or colorectal carcinoma, while 20% occurrence is due to spontaneous germ line mutations without prior family history (6).the importance of screening family members for intestinal neoplasm by endoscopy and genetic testing maybe helpful in detecting these lesions early whenever there is a family history of gastrointestinal tract neoplasm, which unfortunately never happened in our patients case. these are several extra-intestinal manifestations in patients with fap syndrome. it can be combined with benign soft tissue tumors and osteoma. a particular serious outcome is the development of diffuse mesenteric fibromatosis also called as desmoids tumor and reported in 4-32% of patients (7). in addition other soft tissue tumors described in fap syndrome include epidermoid cyst, fibromas and lipomas. neoplasms of the adrenal, cns, liver, biliary tract, thyroid and pancreas cancer may occur in patients with this syndrome. gardner's syndrome(colonic adenomatous polyposis, osteomas, soft tissue tumorsepidermoidcysts, f i b r o m a s a n d d e s m o i d t u m o r s ) a n d tu r c o t s syndrome(intestinal polyposis and cns tumors most c o m m o n l y g l i o b l a s t o m a m u l t i f o r m e ( g b m ) , o r medulloblastoma) are associated with fap. congenital hypertrophy of theretinal pigment epithelium (chrpe) is a patch of discoloration in the ocular fundus and is seen in few patients, but is not specific for fap (8-9). the gists are mostly seen in the stomach (40-70%) followed in the order of frequency by small intestine and associated mesentery(20-40%) and colon, rectum, esophagus(<5%). small gists are often detected incidentally. on immunohistochemistry, gists are positive for c-kit. fap has rarely been seen along with gist (10).in our case although the small intestinal tumor resembled gist on histopathology, it was proved to be of neurogenic origin on immunohistochemistr y. schwannomas are rarely encountered in the small bowel. neurofibroma and malignant peripheral nerve-sheath tumors (mpnst) involving the small bowel usually occur in patients with neurofibromatosis ( von recklinghausen's disease) (11). our patient did not pjmsvolume 4 : number 2 : july dec. 2014 case report 49 h a v e c u t a n e o u s o r o t h e r m a n i f e s t a t i o n s o f neurofibromatosis. there is no known association of fap with malignant peripheral nerve sheath tumors (mpnst) as published in a study by evans et al in 2012(12).we were unable to find any published study of the association of neurogenic tumors of the small bowel with fap. this made our case interesting. for the better management of the fap families and patients, early diagnosis is vital. previously patients or family members of high risk fap families were regularly screened using either colonoscopy or sigmoidoscopy with annual follow-up. now a days,the best diagnostic tool available is genetic testing, which enables early detection of the fappredisposition, even before the appearance of polyps in the colonic lumen. these genetic tests involve the isolation of the genomic dna from the tissue or blood of the potential high risk patients, which is then subjected to analysis of apc gene mutations using the pcrtechnique (13-14). conclusion: early diagnosis and prompt management is very essential in patients and family members in cases of fap. references: 1. parks tg, bussey hf, lockhart-mummery he. familial polyposis coli associated with extracolonic abnormalities. gut 1970; 11: 323-329. 3. domizio p, talbot ic, spigelman ad, williams cb, phillips rks. upper gastrointestinal pathology in familial adenomatous polyposis: results from a prospective study of 102 patients. j clinpathol 1990; 43: 738-743. 2. filipitsch t, wolf b, karner hj. results of molecular diagnosis in 30 austrian families with familial adenomatous polyposis. wiener klinwochenschr 2001; 113: 446–450. 4. debinski hs, spigelman and, hatfield a, williams cb, phillips rk. upper intestinal surveillance in familial adenomatous polyposis. eur j cancer 1995: 1149-1153. 5. park sy, ryu jh, park jh, yoon h, kim jy, yoon yb, et al. prevalence of gastric and duodenal polyps and risk factors for duodenal neoplasm in korean patients with familial adenomatous polyposis. gut and liver, 2011; 5: 46-51. 6. osuagwu cc, okafor oc, ezeome er, uche ce, ememonu c, kesieme e. familial adenomatous polyposis with synchronous invasive colonic carcinomas and metastatic ejunal adenocarcinoma in a nigerian male. rare tumors 2010; 2: 189-192. 7. burt rw. hereditary polyposis syndromes and inheritance of adenomatous polyps. semingastrointestin dis 1992; 3:13-21. 8. half e, bercovich d, rozen p. familial adenomatous polyposis. orphanet journal of rare diseases 2009; 4: 1-23. 9. berk t, cohen z, mcleod rs, parker ja. congenital hypertrophy of the retinal pigment epithelium as a marker for familial adenomatous polyposis. diseases of the colon & rectum 1988; 31: 253-257. 10. bassorgun ci, ozbudak ih, erdogan g, elpek go, erdogan o, gelen t. familial adenomatous polyposis associated with gastrointestinal stromal tumor: report of a case. turk j gastroenterol2012; 23: 262-266. 11. agaimy a, vassos n, croner rs. gastrointestinal manifestations of neurofibromatosis type 1 (recklinghausen's disease): clinicopathological spectrum with pathogenetic considerations. int j clinexppathol 2012; 5: 852-62. 12. evans dgr, huson sm, birch jm. malignant peripheral nerve sheath tumors in inherited disease. clinical sarcoma research 2012; 2: 1-5. 13. sameer as, pandith aa, syeed n, siddiqi ma, chowdri na. a rare case of fap in kashmir valley. indian j surg 2011; 73: 221–23. 14. srinivasamurthy m, geethamala k, deepak kumar b, sudharao m. familial adenomatous polyposis coli and adenocarcinoma of the colon: a silent synchronous presentation. archives of international surgery 2012; 2: 101-104. panacea final 2014 65 pjmsvolume 4 number 1: original article jan june 2014 introduction: staphylococcus is one of the major notorious nosocomial pathogen and the increasing and indiscriminate use of antibiotics is leading to the introduction of more and more drug resistant strains. the beta lactamase production, methicillin resistance and inducible clindamycin resistance are some of the important issues related to the drug resistance in staphylococci which decide the choice of antibiotics for treatment as well as eradication of strains. the frequency, type of resistance and the different mechanisms that operate in these isolates vary from place to place (1-3). the beta lactamase production and methicillin resistance has been studied frequently (4-5). in case of inducible clindamycin (imlsb) resistance, 14-15 membered macrolides, lincosamides and streptogramin b induces the activation of the erm gene (6) and confers resistance against them. however, erythromycin (a macrolide) is a more potent inducer of this gene than any other antibiotic in mlsb group, and it can induce this resistance in-vitro as well, unlike clindamycin (a lincosamide), which is a weak inducer and fails to induce resistance in-vitro (1, 6-7). hence, the routine profile of antimicrobial resistance mechanisms in clinical isolates of staphylococci with special reference to inducible clindamycin resistance 1 2 3 thakar yagnesh , nagdeo neena , wanjari pallavi 1 managing director, vishakha clinical microbiology laboratory, nagpur, consultant microbiologist, care hospital, 2 nagpur, associate professor, department of microbiology, nkpsims&rc, digdoh hills, hingna road, nagpur-440019, 3 research associate, vishakha clinical microbiology laboratory, nagpur. yagneshmanisha@gmail.com, vcmlnagpur@gmail.com lab tests fail to detect the presence of inducible clindamycin resistance and gives false results which may lead to clinical failure (8-9). the data in this regards is rather fragmentary (6). therefore, it is always desirable to generate local data and update it regularly for proper treatment and effective eradication strategies for such pathogens. the present study was designed to study the pattern of antimicrobial resistance in clinical isolates of staphylococci. the frequency of occurrence of common mechanisms viz., beta lactamase production, methicillin resistance and inducible clindamycin resistance were also evaluated. a special emphasis was given to study the different phenotypes of clindamycin resistance as obtained by d test. further, the sensitivity of these isolates to rifampicin and pristinamycin, which are recommended drugs for empirical treatment of mrsa, was also assessed. material and methods: a total of 206 isolates of staphylococci obtained from various clinical specimens of patients admitted in various abstract : the presence of multidrug resistance staphylococci and possession of different mechanisms of drug resistance induced us to undertake the study to assess the frequency of different resistance mechanisms and especially the presence of inducible clindamycin resistance. a total of 206 staphylococcal isolates comprising of 142 (68.93%) coagulase positive staphylococci and 64 (31.07%) coagulase negative staphylococci (cons) were tested against antibiotic susceptibility by disk diffusion technique. the beta-lactamase production, methicillin resistance and inducible clindamycin resistance were also determined. all the staphylococci were sensitive to vancomycin(100%), followed by amikacin(97.08%), gentamycin(94.17%), rifampicin(93.20%), amoxyclav(76.69%), clindamycin(76.69%), pristinamycin(69.90%), cephalexin(68.93%), ciprofloxacin(68.93%), and with low sensitivity to erythromycin(58.25%) and ampicillin(1.94%). betalactamase production was seen in 196 (95.15%) of 206 staphylococcal strains. while 32(22.53%) out of 142 were methicillin resistant staphylococcus aureus (mrsa) and 14(21.87%) out of 64 were methicillin resistant coagulase negative staphylococci. inducible clindamycin resistance was seen in 32 (15.53%) of + isolates (12 d and 4 d phenotype). all the three resistance mechanisms were co-existent in 6 (2.91%) of staphylococci while two mechanisms were simultaneously observed in 64 (31.06%) isolates and single mechanism was observed in 128 (62.14%) strains. the results indicate that the staphylococcal isolates in this region are fairly resistant strains, beta-lactamase production is very common, mrsa strains are also frequently encountered and inducible clindamycin resistance can be detected. the d-test is simple and useful for its detection and also for determination of its phenotypes. it is important to notice simultaneous occurrence of these mechanisms of resistance. hence, periodic assessment of all these factors is necessary for control of resistant pathogens. keywords : beta-lactamase, d-test, inducible clindamycin resistance, methicillin resistant staphylococcus aureus. the city were included in the study. each isolate of staphylococcus was identified and characterized to be s t a p h y l o c o c c u s a u r e u s o r c o a g u l a s e n e g a t i v e staphylococcus (cons) in the laboratory by morphology, culture characteristics & standard biochemical tests (10). antimicrobial susceptibility testing: all the strains were then tested against 12 different antibiotics (hi-media): amikacin (30µg), ampicilin (10 µg), amoxycillin+clavulinic acid (30 µg), cefuroxime (30 µg), cephalexin (30 µg), ciprofloxacin (5 µg), clindamycin (2 µg), erythromycin (15 µg), gentamycin (10 µg), pristinamycin (15 µg), rifampicin (5 µg), and vancomycin (30 µg) by kirby-bauer method (11) as per the clsi guidelines (12). beta-lactamase test: all strains were tested for betalactamase production by iodometric method (10). here 0.1ml of penicillin solution (6000µg/ml) was inoculated with 0 a loopful culture of staphylococcus and incubated at 37 c for an hour. then 2 drops of freshly prepared 1% starch solution was added to each tube and mixed well. this was followed by the addition of iodine solution, which gives blue coloration to the solution. if the blue colour decolorized within 10 minutes the strain was declared beta-lactamase positive and if the colour persisted the strain was beta-lactamase negative. detection of methicillin resistance: the methicillin resistance was determined in all the strains using oxacillin discs (2µg) by standard disk diffusion method as per the clsi standards (12). the strains which showed zone diameter less than 10 mm were the methicillin resistant strains. d-zone test: all the strains were subjected to d-zone test to ascertain the presence of inducible clindamycin resistance (1). the procedure in brief is as follows. the erythromycin (15µg) disc was placed at a distance of 15mm, centre to centre, from clindamycin (2µg) disc on a mueller-hinton agar plate previously inoculated with 0.5 mcfarland bacterial suspension. it was then subjected to overnight incubation at 0 37 c, where the flattening of the zone on the inner side around clindamycin, giving it an appearance of d, indicated inducible clindamycin resistance (1). after incubation different phenotypes were observed and interpreted (refer to table 2 for detailed description of phenotypes). results: out of 206 staphylococcal isolates 142 (68.93%) were coagulase positive and 64 (31.07%) were coagulase negative. their antimicrobial susceptibility profile is shown in table 1. the beta lactamase production was observed in 196 (95.15%) of staphylococcal isolates of which 136 (95.77%) coagulase positive staphylococci and 60 (93.75%) coagulase negative staphylococci. out of 142 coagulase positive staphylococci, 32 (22.53%) were methicillin resistant (mrsa) and of the 64 coagulase negative staphylococci 14 (21.87%) had methicillin resistance (mrcons). inducible clindamycin resistance as determined by d-test was seen in 32 (15.53%) ( 24 plus 8, d & d + phenotypes table 1: antimicrobial susceptibility of coagulase positive & coagulase negative staphylococci respectively) of all the isolates. all the 32 d-test positive isolates were coagulase positive staphylococci. of the total 96 erythromycin resistant strains of staphylococci 26 (27.08%) strains were truly sensitive to clindamycin, 38 (39.58%) showed constitutive mlsb resistance and 32 (33.33%) had inducible resistance. the resistant phenotypes as observed by d-test (figure 1) are shown in table 2. the occurrence and co-existence of inducible clindamycin resistance, methicillin resistance and beta lactamase production is shown in table 3. table 3: individual and simultaneous occurrence of different mechanisms of resistance in staphylococcal isolates bl: beta lactamase, mr: methicillin resistant, c+ve: coagulase positive, c-ve: coagulase negative. pjmsvolume 4 number 1: jan june 2014 original article 66 sr. antibiotics coagulase no. positive negative sensitive (sensitive) (sensitive) (n-206) (n-142) (n-64) 1 vancomycin 142 (100%) 64 (100%) 206 (100%) 2 amikacin 138 (97.18%) 62 (96.87%) 200 (97.08%) 3 gentamicin 134 (94.36%) 60 (93.75%) 194 (94.17%) 4 rifampicin 132 (92.95%) 60 (93.75%) 192 (93.20%) 5 pristinamycin 120 (84.50%) 24 (37.5%) 144 (69.90%) 6 cefuroxime 112 (78.87%) 24 (37.5%) 136 (66.01%) 7 amoxyclav 110 (77.46%) 48 (75%) 158 (76.69%) 8 cephalexin 98 (69.01%) 44 (68.75%) 142 (68.93%) 9 clindamycin 106 (74.64%) 52 (81.25%) 158 (76.69%) 10 ciprofloxacin 84 (59.15%) 38 (59.37%) 142 (68.93%) 11 erythromycin 68 (47.88%) 52 (81.25%) 120 (58.25%) 12 ampicillin 4 (2.8%) 0 (0%) 4 (1.94%) coagulase total mechanism no. of isolates no. of isolates total n=206 only one test (c +ve) n=142 (c -ve) n=64 positive bl 80 (55.55%) 46 (71.87%) 126 (61.17%) mr 0 (0.0%) 0 (0.0%) 0 (0.0%) d-test 2 (1.40%) 0 (0.0%) 2 (0.97%) (a) total 82 (57.76%) 46 (71.87%) 128 (62.14%) any two tests positive bl + mr 26 (18.31%) 14 (21.88%) 40 (19.41%) bl + d-test 24 (16.90%) 0 (0.0%) 24 (11.65%) mr + d-test 0 (0.0%) 0 (0.0%) 0 (0.0%) (b) total 50 (35.21%) 14 (21.88%) 64 (31.06%) all three tests positive (c) bl + mr + 6 (4.22%) 0 (0.0%) 6 (2.91%) d-test total (a+b+c) 138 (97.18%) 60 (93.75%) 198 (96.12%) discussion: staphylococci are associated with various infections and their propensity to acquire resistance to various drugs induced us to study the profile and common mechanisms of drug resistance amongst staphylococcal isolated from various specimens. the antimicrobial susceptibility profile in the present study indicates common occurrence of multidrug resistance amongst the both coagulase positive and coagulase negative staphylococci. the frequency of the resistance varies from place to place (1-3). all the strains in the study were uniformly sensitive to vancomycin; but resistance to other antimicrobial agents was variable. all the isolates were particularly more resistant to more frequently and empirically used drugs viz. ampicillin, erythromycin and ciprofloxacin. interestingly, there was not much difference in susceptibility to various antibiotics between coagulase positive staphylococci and cons. cons many times being the part of commensal flora might be having repeated exposure to different antibiotics and would have acquired the resistance. all the isolates in the present study were from the patients admitted in the hospitals, hence it is again expected that they are likely to be more drug resistant. one of the common mechanisms of drug resistance in staphylococci is by production of beta-lactamase enzyme. in the present study the frequency of beta lactamase production was very high, both for coagulase positive as well as coagulase negative staphylococci. similar high prevalence has been reported by others (13). occurrence of mrsa is yet another important aspect of drug resistance in staphylococci. in the present study, 32 (22.53%) of s. aureus isolates were mrsa. the prevalence of mrsa varies greatly from place to place ranging between 20 and 55 per cent (14-15). our prevalence rate of mrsa is in accordance with the prevalence rate reported from this subcontinent (14). in our study mrcons were also detected, nevertheless, the genetic determinant in them is different from that of mrsa (16). clindamycin, which is a lincosamide, serves to be choice of drug in case of skin, soft tissue and bone infections (6). however, widespread use of mlsb (macrolide, lincosamide and streptogramin b) antibiotics is leading to resistance development against it as well. there are two different type genes conferring the resistance against these groups of antibiotics by different mechanims. (i) msra gene mediating drug resistance by efflux mechanism, and (ii) erm gene (erma and ermc) conferring mlsb resistance by target site modification, which may be constitutive mlsb (cmlsb) resistance or inducible mlsb (imlsb) resistance (1,7-9). inducible clindamycin resistance, as studied by d-test, in the present study was observed in 32 (15.53%) of all the 206 staphylococcal isolates. all these 32 isolates were coagulase positive staphylococci. again the prevalence of inducible clindamycin resistance varies greatly (1, 8, 17). the sensitivity to clindamycin was consistent in 110 pjmsvolume 4 number 1: jan june 2014 original article 67 table 2: different phenotypes of imlsb resistance induction no. of resistance clindamycin erythromycin induction test strains phenotype (cli) results (ery) results test description phenotype d 24 inducible mls s r blunted, d-shaped clear b proximal to ery disc. + d 08 inducible mls s r blunted, d-shaped clear b proximal to ery disc and small colonies growing to cli disc in otherwise clear zone neg 26 ms s r clear zone around cli disc.b hd 00 constitutive mls r r two zones of growth appear around cli disc. one zone b is a light, hazy growth extending from the cli disc to the second zone where the growth is much heavier. the inner heavy zone is blunted proximal to the ery disc as in phenotype d. r 38 constitutive mls r r no hazy zone. growth up to cli and ery discs.b total 96 r all ery resistant s 110 no resistance s s clear, susceptible zone diameters. grand total 206 zone around cli disc zone around cli disc figure 1: d-test (1) d: blunted, d-shaped clear zone around cli disc proximal to ery disc. + (2) d : blunted, d-shaped clear zone around cli disc proximal to ery disc and small colonies growing to cli disc in otherwise clear zone. (3) neg: clear zone around cli disc. (4) s: clear, susceptible zone diameters. (5) r: no hazy zone. growth up to cli and ery discs zerythromycin sensitive strains. out of 96 erythromycin resistant strains, clindamycin showed constitutive resistance in as many as 39.58 per cent strains while out of remaining strains only 27.08 per cent were true sensitive and almost one third of erythromycin resistance strains revealed inducible clindamycin resistance. hence, it is indeed very important to d e t e r m i n e i n d u c i b l e c l i n d a m y c i n r e s i s t a n c e i n staphylococcal isolates that are resistant to erythromycin, otherwise, patient may receive clindamycin unnecessarily without any actual therapeutic benefit. however, a standard modification of regular disk diffusion test called as d-test or d-zone test is devised by clsi, is capable detecting the prevalence of inducible mlsb resistance, even in moderately equipped laboratories. this test involves placement of erythromycin and clindamycin disk at a distance of 15mm, from centre to centre, on muellerhinton agar and incubated at 37ºc for 18 to 24 hrs. as the antibiotic diffuses through the media erythromycin induces the erm gene activation, which confers resistance to the organism against both erythromycin and clindamycin. however, this induction is detectable only upto the region of erythromycin diffusion in the media. this causes the blunting of the zone around clindamycin giving it an appearance of a “d” (8, 12). the d-test used in this study is simple, easy to perform, economical and suitable for any moderately equipped laboratory. this method is found to be quite simple and useful to discriminate between phenotypes (figure 1) by us as well as others (1, 18). the three mechanisms of resistance studied in the present study revealed them to be present in as many as 96.12 % of staphylococcal isolates, either singly or together. all these three mechanisms can confer resistance simultaneously to many antibiotics. in our study, in 4.22 % of staphylococcus aureus strains all the three mechanisms were simultaneously existent making them potentially more problematic strains to treat. although the number is very tiny at present, but the existence of such strains by themselves should be cause of concern. the association of different mechanisms has occasionally been described earlier (8). the rifampicin & pristinamycin are empirically administered drugs for such type of multidrug resistant staphylococci. in the present study, it is observed that the sensitivity to rifampicin is good however strains showed substantial resistance to pristinamycin and hence this drug should be cautiously used for empirical treatment in this region. pristinamycin resistance has also been observed by others (19-20). thus, the results indicate that there is high prevalence of multi drug resistant staphylococci in this region, which include beta lactamase producing strains with very high frequency, mrsa as well as mlsb strains. this further confirms the observation that various factors may operate simultaneously for induction of drug resistance in bacteria. hence it becomes necessary to isolate the organism from the clinical specimens and study its antimicrobial susceptibility pjmsvolume 4 number 1: jan june 2014 original article 68 pattern. it is further essential to evaluate the different factors and means by which it acquires the antimicrobial resistance to choose the appropriate antimicrobial agent for therapy and formulate the policy for eradication of drug resistant problematic strains of staphylococci. the generation of such data further helps to formulate the antibiotic policy and also the control measures. references: 1. fiebelkorn kr, crawford sa, mcelmeel ml, jorgensen jh. practical disk diffusion method for detection of inducible clindamycin resistance in staphylococcus aureus and coagulase negative staphylococci. j clin microbiol 2003; 41:4740–4. 2. gaikwad ss, deodhar lp. study of coagulase-negative staphylococci in clinical infections. j postgrad med 1983; 29:162-4. 3. natoli s, fontana c, favaro m, bergamini a, testore gp, minelli s, et al. characterization of coagulase-negative staphylococcal isolates from blood with reduced susceptibility to glycopeptides and therapeutic options. bmc infect dis 2009: 9:83. 4. hartman bj, tomasz a. low affinity penicillin binding proteins associated with beta-lactamase resistance in staphylococcus aureus. j bacteriol 1984; 158:513-6. 5. lucet cj, chevret s, zalenski id, chastang c, regneir b. prevalence and risk factors for carriage of methicillin resistant staphylococcus aureus at admission to intensive care units, a multicentre study. arch intern med 2003; 163:181-8. 6. angel mr, balaji v, prakash jaj, brahadathan kn, matthews ms. prevalence of inducible clindamycin resistance in gram positive organisms in a tertiary care centre. indian j med microbiol 2008; 26(3):262-4. 7. jorgensen jh, crawford sa, mcelmeel ml, fiebelkorn kr. detection of inducible clindamycin resistance of staphylococci in conjunction with performance of automated broth susceptibility testing. j clin microbiol 2004; 42:1800–2. 8. azap ok, arsalan h, timurkaynak f, yapar g, oruc e, gagir u. incidence of inducible clindamycin resistance in staphylococci: first results from turkey. clinical microbiol and infect 2005; 11(7):582-4. 9. steward cd, raney pm, morrell ak, williams pp, mcdougal lk, jevitt l, et al. testing for induction of clindamycin resistance in erythromycin-resistant isolates of staphylococcus aureus. j clin microbiol 2005; 439(4):171621. 10. collee jg, fraser ag, marmion bp, simmons a: mackie & th mccartney practical medical microbiology. 14 ed. (churchill livingstone, elsevier, new delhi, india) 2006. 11. bauer aw, kirby wm, sherris jc, turck m. antibiotic susceptibility testing by a standardized single disk method. am j clin pathol 1966; 45(4):493–6. 12. clinical laboratory and standard institute (clsi). performance standards for antimicrobial disc susceptibility testing; twenty second informational supplement. m100s22. clinical laboratory and standard institute 2012; 32(3): 70-79. 13. efuntoye mo, amuzat ma. beta lactamase production by staphylococcus aureus from children with sporadic diarrhoea in ibadan and ago-iwoye, nigeria. afr j biomed res 2007; 10:95 –7. 14. rajaduraipandi k, mani kr, panneerselvam k, mani m, bhaskar m, manikandan p. prevalence and antimicrobial susceptibility pattern of methicillin resistant staphylococcus aureus: a multicentre study. indian j med microbiol 2006; 24:34-8. 15. centres for disease control and prevention. methicillinresistant staphylococcus aureus infections in correctional facilities-georgia, california, and texas. morb mortal wkly rep 2001–2003; 52:992–5. 16. kaplan s, marlowe em, hogan jj, doymaz m, bruckner da, simor ae. sensitivity and specificity of a rapid rrna gene probe assay for simultaneous identification of staphylococcus aureus and detection of meca. j clin microbiol 2005; 43(7):3438–42. 17. yilmaz g, aydin k, iskender s, caylan r, koksal i. detection and prevalence of inducible clindamycin resistance in staphylococci. j med microbiol 2007; 56:342–5. 18. deotale v, mendiratta dk, raut u, narang p. inducible clindamycin resistance in staphylococcus aureus isolated from clinical samples. indian j med microbiol 2010; 28(2):124-6. 19. keshari ss, kapoor ak, kasturi n, singh dk, bhargava a. emergence of pristinamycin resistance in india. indian j pharmacol 2009; 41(1):47-8. 20. verneuil l, marchand c, vidal js, ze bekolo r, daurel c, lebouvier g, et al. factors associated with emergence of pristinamycin-resistant staphylococcus aureus in a dermatology department: a case control study. british journal dermatology 2010; 163: 329-333. pjmsvolume 4 number 1: jan june 2014 original article 69 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 panacea final 2014 31 clinical correlation between exhaled nitric oxide measurements in patients of asthma with their asthma control questionnaire scores 1 2 tinguria nikita , tayade balkrishna 1 2 intern, professor and head, department of pulmonary medicine, nkpsims&rc, digdoh hills, hingna road, nagpur-440019. nikita.tinguria12@gmail.com abstract: fractional exhaled nitric oxide (feno) is a specific index for the measurement of airway inflammation and asthma control questionnaire score (acq score) is a nonspecific index of asthma control and symptoms for a variety of obstructive diseases. in this study, no simple linear correlation was found between the two. long term monitoring of management and control of atopic allergic bronchial asthma in a larger sample size and correlating it with adequate ics therapy and ongoing treatment, can help to closely evaluate the link between acq and feno levels. only selected atopic-allergic bronchial asthma patients should be considered. keywords: fractional exhaled nitric oxide (feno), asthma control questionnaire score (acq), airway inflammation, asthma control, atopic-allergic asthma. introduction: asthma is a type of obstructive pulmonary disease which involves chronic airway inflammation and an increase in airway hyper responsiveness. bronchial asthma can be defined as a complex syndrome having the characteristic symptoms of wheezing, coughing, chest pain, dyspnoea, along with airway inflammation, decreased airway caliber, impaired lung function, airway hyper responsiveness and airway remodeling (1). bronchial asthma can be of two types: extrinsic (allergic, atopic asthma) and intrinsic (non-atopic asthma). extrinsic asthma: it is the more common form of asthma. it is partially reversible with medication and is always triggered by allergens such as dust, mites, pollens, mold etc. the body's immune system exerts a protective reaction to these allergens and produces antibodies. this results in symptoms such as hay fever, rhinitis, and asthma. these allergens induce a complex reaction in which large amounts of mucus is produced which causes the lung airways to become obstructed, inflamed and swollen.allergic asthma occurs more commonly in children and in individuals with a family history of allergens. symptoms in allergic asthma can be controlled by avoiding allergen exposure, as well as use of bronchodilators and antihistamines. intrinsic asthma: intrinsic asthma on the other hand, is not associated with an allergic reaction. it is triggered by factors such as stress, anxiety, extremes of emotional feelings like laughing or crying or exercise, cold dry air, hyperventilation etc. these factors stimulate a nerve response in the airway passage. non-allergic asthma is seen more commonly in adults, female patients, and with forced expiratory volume in 1 second (fev1) below 80%. interestingly, there is a more frequent association with sinus polyposis. non allergic asthma can be objectively distinguished from allergic asthma based on negative skin tests, whereas positive skin tests show tendencies to produce immunoglobulin e(ige) antibodies (2). intrinsic asthma is also more difficult to treat as the causative agent is unknown.normally, nitric oxide in exhaled air originates from the respiratory epithelium where it is produced by inducible no synthase (inos). inducible no synthase is regulated by signal transducer and activator of transcription (stat-1) under the influence of interferon gamma. in asthmatics, the endogenous fractional exhaled nitric oxide (feno) levels get elevated. nitric oxide therefore plays an intrinsic part of inflammation. the inos expression is up regulated by interleukin -4 and interleukin 13. this occurs through the activation of stat-6 in the bronchial epithelium. feno is therefore a critical and a sensitive marker as it responds rapidly to inflammation after allergen exposure. it also helps predict the response to anti-inflammatory therapy and to monitor the anti-inflammatory effect (3). the assessment of feno gives an accurate diagnosis of airway inflammation in about 80% patients. feno greater than 50 parts per billion (ppb) (greater than 35 ppb) indicates than eosinophilic inflammation and response to corticosteroids is likely (4). feno levels can increase even before the onset of symptoms and is therefore helpful in predicting asthma. the most important element of asthma management is asthma control. the global initiative for asthma (gina) guidelines suggest that asthma control can be divided into three levels: well controlled, partly controlled, and uncontrolled. this can be assessed by the asthma control questionnaire score. the acq ( validated as per elizabeth pjmsvolume 4 number 1: jan june 2014 original article 32 juniper) was used to judge their level of control based on symptoms they had at the time of correlation. it contains 7 questions and the patients were asked to recall their asthma symptoms in the past week which includes day and night symptoms (sleep patterns), limitation of activities, shortness of breath and wheeze along with fev1 predicted and daily bronchodilator use. the patients were then asked to respond to their asthma symptoms based on a 7 point scale (0 no improvement, 6 maximum improvement). the final acq score was therefore the mean score of all the 7 questions, ranging between 0 and 6. the normal control subject had a score of less than 1.0 meaning well controlled asthma. any patient with an acq above 1.0 did not have a well-controlled asthma. not much efforts have been made to correlate the relation between exhaled nitric oxide ( no) measurement in asthmatic patients with their asthma control questionnaire score and hence this study. material and methods: the present study was carried out at nkp salve institute of medical sciences and research center, nagpur in the chest and tb opd. the duration of the study was two months. permission from the institutional ethics committee was taken for this research.the sample size calculated was 42 patients. control subjects were having normal feno between 5-25ppb, and an acq of less than 1. the inclusion/exclusion criterion was as follows: inclusion criteria: known cases of allergic bronchial asthma with demonstrable reversibility in fev1 as per the gina guidelines (namely well controlled, partially controlled and uncontrolled). exclusion criteria: smokers,chronic obstructive pulmonary disease (copd), airway viral infection, allergic rhinitis (concomitant), nitrate-rich diet, spirometric maneuvers, exercise, alcohol consumption, bronchoconstriction, ciliary dyskinesia, hypertension, cystic fibrosis cases were excluded from the study. the materials required to carry out the research included the following: 1. patients of both extrinsic and intrinsic type 2. asthma control questionnaire 3. aerocrine analyser “niox mio” to measure feno levels 4. spiro meter to measure fev1 (forced expiratory volume 1) the participants were administered the acq and the scores were tallied. the feno measurements were followed after this. feno was measured using a chemiluminescence analyzer (niox-system; aerocrine ab; solna, sweden) to measure exhaled no during a slow, single exhalation against an oral pressure o f 5cm h20.20. the procedure was performed repeatedly to obtain two or three reproducible values. normal feno values range between 5-25 ppb. any feno value above 25 ppb indicates eosinophilic airway inflammation. this was then followed by spirometry required for the acq scores. it was performed using a dry wedge spirometer to provide estimates of forced vital capacity (fvc) and fev1. patients who were prescribed corticosteroids had to undergo another feno measurement before and during the antiinflammatory therapy just to check whether the patients were responding well to the therapy. the scores obtained from the acq and the feno values were then evaluated to consult if a clinical correlation existed between the two, to reflect their level of asthma control.the statistical analysis was carried out using the chi square test. the chi square test is used to test the significance of difference between two proportions. results: table 1 and 2 depict the feno value and acq scores in males and females. pjmsvolume 4 number 1: jan june 2014 original article table 1: feno vs acq scores in females age feno value acq score 41 6 2.43 18 6 1.43 26 8 1.9 28 6 1.43 52 14 3 47 16 1 8 12 2.3 60 17 1 59 10 2 28 9 2.5 27 34 1.14 60 20 1.3 45 29 3.14 60 11 1.5 46 33 3 60 24 1.1 43 90 2 30 131 1.14 62 10 2.15 60 11 1.29 31 30 2.4 20 110 2.4 40 18 2.14 55 5 1.9 47 7 2.7 56 6 3 30 13 2.45 33 as from fig. 1, there is no linear, significant clinical correlation between feno measurements and asthma control questionnaire scores i.e. the mean feno value (ppb) = 30 ppb. the mean acq value = 2.01 the ability of feno measurements to reflect the asthma control was investigated. the asthma control questionnaire scores and feno measurements were recorded once in 41 asthma patients between 17-60 years of age. 16 patients with high feno measurements of more than 25ppb, had normal or mild acq scores. this shows that the extent of bronchial airway inflammation is not proportionate with asthma control and symptoms. the data are presented as mean, n(%), fev1 : forced expiratory volume in one second; % predicted chi-square test as applied to asthma patients showed as in table 3, the probability of 5% was adopted as standard. since the chi square value of 20.69 is greater than the probability of 0.05 with x square of 3.84, we conclude that the null hypothesis is rejected and that feno and acq are not equal markers of asthma and that one is superior to the other (table 4). table 3: clinical characteristics of 41 selected asthma patients (as per criteria), using the asthma control questionnaire score (acq) and exhaled nitric oxide fraction (feno) table 4 : chi square distribution in asthma patients discussion : the significance of clinically co-relating feno measurements with acq scores is that one can monitor a patient's airway inflammation by clinically predicting and diagnosing asthma control. feno levels of patients as well as their acq scores are considered as benchmarks in assessing asthma control, and they both have an ability to reflect and predict the improvement or the worsening of asthma control. asthma remains to be a national burden through patient mortality and morbidity, the rising health care costs, as well as employee absenteeism. to prescribe the correct treatment, one needs to infer the extent of airway inflammation and asthma control by assessing the feno levels and the acq scores, respectively. finding out whether feno levels as well as acq scores correlate or not, can help achieve better outcomes in asthmatic patients. they can also help evaluate the outcomes of current therapeutic strategies and can help find newer emerging strategies that can help improve patients achieve asthma control. according to the european respiratory journal, there has been a research on “assessing asthma control: questionnaires and exhaled nitric oxide provide complementary information” by c. lopes. this was the first study done to assess the contribution of feno and asthma control measurement instrument for the variance of asthma pjmsvolume 4 number 1: jan june 2014 original article table 2: feno vs. acq scores in males age feno value acq score 45 147 1.1 19 36 1.1 51 30 1.4 47 126 2.9 60 7 2.9 17 5 2.4 45 39 1.4 51 28 1.7 35 9 3.2 33 12 1.5 55 5 1.32 42 18 2.2 59 30 1.32 40 55 3.5 fig. 1scatter diagram showing relation between feno and acq values in 41 patients normal abnormal total abnormal rate feno 26 15 41 36.5% acq 6 35 41 85.3% total 32 50 82 age in years asthma patients (n=41) females (total and percentage) 28 (67%) atopy all non atopy some rhinitis none acq score 2.01 fev1 % predicted 58.5 feno (ppb) 30 df/prob. 0.10 0.05 0.02 0.01 0.005 0.001 1 2.71 3.84 5.41 6.64 7.88 10.83 2 4.61 5.99 7.82 9.21 10.60 13.82 3 6.25 7.82 9.84 11.34 12.64 16.27 4 7.78 9.49 11.67 13.28 14.86 18.47 5 9.24 11.07 13.39 15.09 16.75 20.51 status and to assess the contribution of feno in the variability of asthma control using factor analysis results. a cross sectional study of 174 consecutive asthma patients was done. (82% female, 70% atopic, 76% non-smokers, and 72% using inhaled steroids). no significant co-relation was found between feno and acq, while feno and fev1 had a weak correlation. the above data supported the hypothesis being that airway inflammation, clinical symptoms and lung function are complementary for the evaluation of asthma status in an individual. however, the cross-sectional study limited the interpretation of the results (5). michilis et al (6) carried out a study on “exhaled nitric oxide and asthma control: a longitudinal study in unselected patients”. in this, acq scores and feno values were recorded once in 341 unselected adult asthma patients. in this the whole population as well as the sub-groups were considered, both inhaled corticosteroid naïve, and low or high to medium ics dose groups. according to the study, the exhaled nitric oxide fraction is significantly related to asthma control over time, and the overall ability of exhaled nitric oxide fraction to reflect asthma control is reduced in patients using high doses of inhaled corticosteroids. exhaled nitric oxide condensate nitrates (not nitrites or feno) relate to asthma control. according to the research, exhaled nitric oxide and exhaled breath condensate no metabolites (nitrite and nitrate) measurements are noninvasive tools to assess airway inflammation. the aim of the research was to investigate the relationship between asthma control and the mentioned bio-markers of inflammation. in the study, 39 non-smoking asthmatic patients aged 21-80 years performed feno measurements, exhaled breath condensate nitrate ebc nitrates), nitrites, and ph measurements. they also answered the acq and act scores. it was found that the act and acq scores had strong correlation. no relationship between act/acq score and feno was found. ebc nitrates were found to be positively related to acq scores, while ebc nitrites were not found to be related to either act or acq. therefore, ebc nitrates were found to be the only biomarker that was significantly related to asthma control, indicating a significant role of ebc nitrates in assessing asthma control (7). as already mentioned above, research has already been carried out on whether feno measurements and acq values correlate or not, and it has been found that they do not tend to correlate ( 34 with each other. however, the purpose of this study was to find out whether feno and acq scores correlate over a short period of time, in unselected patients of both extrinsic and intrinsic type with a large exclusion criteria of smokers, alcohol consumers, allergic rhinitis, chronic obstructive pulmonary disease copd), viral infection, exercise, bronchoconstriction, etc. conclusion: in conclusion, no simple linear correlation exists between feno levels and acq scores in the study. further studies with long term monitoring of management and control of atopic allergic bronchial asthma in a larger sample size correlating with adequate inhaled corticosteroids (ics) therapy and ongoing treatment is needed to closely evaluate the link between acq and feno levels. also, only selected patients should be taken with stricter inclusion criteria of atopic-allergic bronchial asthma. acknowledgement : i would like to thank dr. nilofer mujawar, professor, paediatrics, nkpsims&rc, nagpur for helping out. references: 1. murdoch jr, lloyd cm. chronic inflammation and asthma. mutat res 2010; 690(1-2): 24-39. 2. romanet-manet s, charpin d,magnan a, lanteaume a. allergic vs. non allergic asthma: what makes the difference. euro j of allergy and clin immuno 2002; 57(7): 607-613. 3. alving k, malinovschi a. basic aspects of exhaled nitric oxide. eur resp mon 2010; 49: 1-31. 4. dweik r, boggs p. interpretation of exhaled nitric oxide levels for clinical applications. american j of resp and crit care med 2011; 184: 602-615. 5. lopes c, fonseca j. assessing asthma control: questionnaires and exhaled nitric oxide provide complementary information. eur resp j 2008; 32(5): 14191420. 6. michilis a, baldassarres. exhaled nitric oxide and asthma control: a longitudinal study in unselected patients. eur resp j 2008; 31(3): 539-546. 7. malinovschi a, pizzimenti s. exhaled nitric oxide condensate nitrates (not nitrites or feno) related to asthma control. resp med 2011; 105(7): 1007-1013. ( pjmsvolume 4 number 1: jan june 2014 original article page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 panacea journal of medical sciences 2022;12(1):142–145 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article endometrial fluid study for prevalence of tuberculosis by testing for diagnosis by cb naat culture u tripathi1, mitali gupta2,*, neha katare1, saurabh kumar singh3 1dept. of obstetrics and gynaecology, gajara raja medical college, gwalior, madhya pradesh, india 2dept. of obstetrics and gynaecology, s.p. medical college, bikaner, rajasthan, india 3dept. of pulmonary medicine, gajara raja medical college, gwalior, madhya pradesh, india a r t i c l e i n f o article history: received 22-03-2021 accepted 20-05-2021 available online 30-04-2022 keywords: endometrial fluid tuberculosis & cb naat culture a b s t r a c t background: the frequency of genital tb is 0.69% in evolved nations and 19% in non-industrial nations. the fallopian tube is most regularly influenced followed by endometrium and cervix. it is optional to tb concentrate somewhere else in body brought about by mycobacterium tuberculosis. history of essential fruitlessness in a lady whose assessment uncovers no evident reason and gives family ancestry or individual history of tb emerges doubt of genital tb. objective: 1: to study the prevalence rate and risk factors for endometrial tb in infertile females; 2: to study clinical and reproductive profile of women diagnosed with endometrial tb; 3: to study the importance of cb naat over other diagnostic tests in diagnosing tb. design: hospital based cross sectional study done on 100 subjects for one and a half year (june 2017 to july 2019). setting: labour room. minor ot. opd procedure: 2-5 ml endometrial fluid was retrieved on day 1/2 of menses using pipelles cannula. it was transferred to falcon tube and cb naat analysis was done using cartridge. results: out of 100 cases, 4 were detected to be positive for endometrial tb. out of them, 3 fell in age group of 30-39 years; all belonged to upper middle socioeconomic status. 3 cases had achieved menarche at >14 years of age and one had oligomenorrhoea. outcome measure: number of patients testing positive for endometrial tb by cb naat culture. conclusion: genital tb is a major cause of infertity and is generally underestimated because of asymptomatic nature of infection and diagnostic challenges. large multicentric studies are needed to estimate the magnitude of female genital tb. our study confirmed the usefulness of cb naat compared to chest x-ray and smear microscopy for early diagnosis of suspected endometrial tb. its simplicity, sensitivity, speed and automation makes this technique a very attractive tool for diagnosis of mycobacterial tb. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction tb stays a significant medical issue in many agricultural nations though genital tb is liable for a critical extent of females who present with fruitlessness. tb influences right * corresponding author. e-mail address: mitaligupta1604@gmail.com (m. gupta). around half of the populace in third world countries. 1–3 the pervasiveness of extra pulmonary tb in india is 20%. commonness of genital tb is 9-10% of extra pulmonary tb. the fallopian tube is influenced in practically every one of the cases followed by endometrium and cervix. 4,5 it happens in the most monetarily beneficial age of 15-45 years causing fruitlessness in 44-74% of people influenced. https://doi.org/10.18231/j.pjms.2022.027 2249-8176/© 2022 innovative publication, all rights reserved. 142 tripathi et al. / panacea journal of medical sciences 2022;12(1):142–145 143 a background marked by essential fruitlessness in a lady in whom assessment uncovers no evident reason and who gives a family ancestry or individual history of tb ought to excite doubt of genital tb. 6–8 the historical backdrop of helpless general wellbeing which is persevering over months or years and related with weight reduction, unnecessary exhaustion, second rate fever, or obscure lower stomach inconvenience is regularly found in patients with genital tb. cartridge based nucleic corrosive intensification test (cbnaat), explicit for mycobacterium tuberculosis, has been as of late presented for discovery of tb. 9–11 it has an additional benefit of identifying rifampicin opposition as it focuses on the rpob quality of mycobacterium, which is the basic quality related with rifampicin resistance. 12,13 2. materials and methods the study was presented to institutional ethical committee (iec) for ethical clearance, after getting clearance form iec the study was started. the data were collected from the women using a semi structured questionnaire. the socio-demographic factors will be taken by direct interview. after enrolment, detailed history was obtained regarding demographic details, gynaecological symptoms, and past history of tb. details of previous investigations and treatment were noted to rule out other causes of infertility. explanation of procedure to all women participating in study was done. consent from every women participating in this study was taken after telling the patient to urinate for the purpose of bladder evacuation, the patient was put in dorsal position, sim’s posterior vaginal wall speculum was used to visualise the cervix and vagina. anterior lip of cervix held with vulsellum. the endometrial fluid was obtained through the use of pipelle’s cannula which was inserted through the cervix into the uterine cavity. by twirling the cannula while moving it in and out, the fluid was aspirated and collected into a sterile glass vial containing normal saline. similarly, multiple samples were aseptically collected and stored at 28oc until transport. all these samples had to be transported within 4 hours of collection. approximately 2-5 ml sample was collected for each case preferably on day 1 or day 2 of menses. the sample was then transferred to falcon tube. each falcon tube was labelled indicating name of the patient, type of fluid, patient central registration number and date of collection of fluid. after the above procedure, cb naat sampling, the procedure was done. 2.1. inclusion criteria 1. all cases of infertility who are suspected to have endometrial tb i.e. having manifestations of endometrial tb. 2. all cases of infertility whether primary or secondary infertility. fig. 1: falcon tube fig. 2: cb naat machine 2.2. exclusion criteria 1. critically ill patients and those who are not willing to give consent. 2. those who underwent surgery or are currently taking treatment for att. 3. results out of 100 cases selected of infertility, maximum number of cases fell in the range of 20-29 years of age. this age group corresponds to the middle of the reproductive age group. about one fourth of the cases fell in the range of 30-39 years of age group while none of the infertile patients were noticed above the age of 50 years. out of these 100 cases, 144 tripathi et al. / panacea journal of medical sciences 2022;12(1):142–145 4 were detected positive for endometrial tb by cb naat. out of these 4, 3 were found in the age group of 30-39 years and one in the age group of 20-29 years. table 1: distribution of cases according to age age groups (yrs) no of cases percentage positive for cb naat 20-29 72 72 1 30-39 26 26 3 40-49 2 2 0 50-59 0 0 0 >60 0 0 0 tb and socioeconomic status are closely linked. malnutrition, overcrowding, poor air circulation and sanitation factors associated with socioeconomic status increase both the probability of becoming infected and the probability of developing clinical disease. out of 100 infertility cases, maximum belonged to upper middle class (92%) i.e a score of 16-25 on kuppuswamy scale, while only few (8%) belonged to lower middle class (a score of 11-15) on kuppuswamy scale. also out of 4 positive cases, maximum (75%) belonged to upper middle class and only one (25%) was from lower middle class. kuppuswamy scale considers three parameters – education of head of the family, occupation of the head of the family and monthly income of the family. table 2: socioeconomic status socioeconomic status no of cases percentage positive for cbnaat upper 0 0 0 upper middle 92 92 3 lower middle 8 8 1 lower 0 0 0 4. discussion a total of 100 cases were selected for the study. these cases were comprised of infertility cases (whether primary or secondary) or those manifesting the signs or symptoms of endometrial tuberculosis e.g. menorrhagia, oligomenorrhoea, metomenorrhegia, lymphadenopathy, anemia and underweight. out of which, 4 cases came out to be positive for endometrial tb by cb naat culture. 14–16 they had no evidence of pulmonary tb as shown by their chest x ray and other modalities. this clearly shows that cb naat is more sensitive than other tests. in each group, age, marital life, socioeconomic status, age at menarche as well as at first intercourse were analysed for any co relation between cb naat positive and cb naat negative patients. our study findings suggest that cb naat has higher sensitivity for detection of extra pulmonary tb. 17–19 the who 2012 has also recommended the cb naat for routine use under programmatic conditions. in our study, there is statistically significant relationship between cb naat positive patients and socioeconomic status. the association between poverty and health is well documented. 20,21 the founders of social medicine have established the powerful relationship of poverty and ill health that was attributed to abysmal housing, overcrowding, insanitation and poor working conditions. 22 5. conclusion it is clearly evident from our study that the majority of patients were from upper middle class and their education was up to primary class. cb naat has detected 4 positive cases while chest x-ray was not sensitive and could not detect even a single case as positive. cb naat detects endometrial tb with greater efficacy than other modalities, also helping in early diagnosis in less than 2 hours. it also detects rifampicin resistance with high specificity and can be used for screening for mdr tb so that early therapy can be started thus decreasing the incidence of mdr tb. who recommends cb naat for diagnosis of pulmonary and extra pulmonary tb. genital tb is a significant reason for fruitlessness in ladies and predominance is by and large disparaged in view of the asymptomatic idea of the contamination and analytic difficulties. genital tb is an ignored sickness, a vague clinical picture and restricted traditional test represent this issue. conclusion is troublesome and as often as possible deferred prompting significant effect on the genitourinary parcel system. 23 enormous multi centric considers are expected to appraise the size of fgtb and to recognize the most delicate test for determination. clinicians should know about this significant reason for barrenness and feminine brokenness in ladies. evaluating for genital tb should be a piece of assessment of fruitlessness and feminine abnormalities. 24 the greater part of the patients present in cutting edge stage with scarring, extreme fibrosis and grips and treatment results, particularly as to fruitlessness are poor. thus early finding and right treatment is fundamental to keep away from difficulties and to re-establish richness. our examination affirmed the convenience of the cb naat contrasted with chest x-beam and smear microscopy for the early conclusion of suspected endometrial tb. its straight forwardness, affect ability speed and mechanization make this method an alluring instrument for conclusion of mycobacterium tuberculosis. 6. conflict of interest no conflict of interest. 7. source of funding none. tripathi et al. / panacea journal of medical sciences 2022;12(1):142–145 145 references 1. ejeta e, legesse m, ameni g, raghvendra hl. global epidemiology of tb:past,present and future. sci, technol arts res j. 2013;2(2):97– 104. 2. woods gl, washington ja. mycobacteria other than mycobacterium tuberculosis: review of microbiologic and clinical aspects. rev infect dis. 1987;9(2):275–94. doi:10.1093/clinids/9.2.275. 3. raizada n, sachdeva k, sreenivas a, vadera b, gupta r, parmar m, et al. feasibility of decentralized deployment of xpert mtb/rif test as lower level of health system in india. plos one. 2014;9(2):e89301. doi:10.1371/journal.pone.0089301. 4. woods gl, washington ja. mycobacteria other than mycobacterium tuberculosis: review of microbiologic and clinical aspects. rev infect dis. 1987;9(2):275–94. 5. rozati r, agirisr, rajeshwari cn. evaluation of women with infertility and genital tuberculosis. j obstetgynecol india. 2006;56:423–6. 6. lawn sd, nicol mp. xpert mtb/rif assay: development, evaluation and implementation of a new rapid molecular diagnostic for tuberculosis and rifampicin resistance. future microbiol. 2011;6(9):1067–82. doi:10.2217/fmb.11.84. 7. ojo ba, akanbi aa, ofimayo ms, jimoh ak. endometrial tuberculosis in the nigerian middle belt;an eight year review. tropicaldoctor. 2008;38(1):3–4. 8. emenbolu jo, anyanwu do, wab e. genital tuberculosis in infertile women in northern nigeria. west afr j med. 1993;12(4):211–2. 9. tortoli e, russo c, piersimoni c, mazzola e, monte pd, pascarella m, et al. clinical validation of xpert mtb/rif for the diagnosis of extrapulmonary tuberculosis. eur respir j. 2012;40(2):442–7. 10. sharma jb. current diagnosis and management of female genital tuberculosis. j obstet gynaecol india. 2015;65(6):362–71. doi:10.1007/s13224-015-0780-z. 11. schaefer g. female genital tuberculosis. clin obstet gyanecol. 1976;19(1):223–39. doi:10.1097/00003081-197603000-00016. 12. sharma jn, roy kk, pushparaj m, gupta n, jain sk, malhotra n, et al. genital tuberculosis: an important cause of asherman’s syndrome in india. arch gynaecol obstet. 2008;277(1):37–41. 13. bahadur a, malhotra n, mittal s, singh n, gurunath s. second-look hysteroscopy after antitubercular treatment in infertile women with genital tuberculosis undergoing in vitro fertilization. int j gynaecol obstett. 2010;108(2):128–31. doi:10.1016/j.ijgo.2009.08.031. 14. hoeppe le, kettle r, eisenhut m, abubakar i. guidelines development group. tuberculosis-diagnosis, management, prevention and control: summary of updated niee guidance. bmj. 2016;352:h6747. doi:10.1136/bmj.h6747. 15. diagnostic standards and classification of tuberculosis in adults and children. this official statement of the american thoracic society and the centers for disease control and prevention was adopted by the ats board of directors, july 1999. this statement was endorsed by the council of the infectious disease society of america, september 1999. am j respire crit care med. 2000;161(4):1376–95. doi:10.1164/ajrccm.161.4.16141. 16. sengupta vb. gynaecology for postgraduate and practitioners. india: elsevier; 2007. 17. chakravarty bn. genital tuberculosis-ovarian function and endometrial receptivity. in: mukherjee g, tripathy s, tripathy s, editors. genital tuberculosis, 1st edn. new delhi: jaypee brothers medical publishers (p) limited;; 2010. p. 27–42. 18. chen d, yang jh, lin kc, chao k, ho hn, yang ys, et al. the significance of cytokines, chemical composition, and murine embryo development in hydrosalpinx fluid for predicting the ivf outcome in women with hydrosalpinx. hum reprod. 2002;17(1):128–33. doi:10.1093/humrep/17.1.128. 19. dam p, shirazee hh, goswami sk, ghosh s, ganesh a, chaudhary k, et al. role of latent genital tuberculosis in repeated ivf failure in the indian clinical setting. gynaecol obstet invest. 2006;61(4):223–7. doi:10.1159/000091498. 20. shah hv, sannananja b, baheti ad, udare as, badhe pv. hysterosalpingography and ultrasonography findings of female genital tuberculosis. diagn interv radiol. 2015;21(1):10–5. doi:10.5152/dir.2014.13517. 21. ahmadi f, zafarani f, sharzad gs. hysterosalpingographic appearances of female genital tract tuberculosis: part ii: uterus. int j fertil steril. 2014;8(1):13–20. 22. netter a, musset r, lambert a, solomon y, montbazet g. tubeculousendo-uterine symphysis; an anatomo clinical and radiologically characteristic syndrome. gynecol obstet (paris). 1955;54(1):19–36. 23. farrokh d, layegh p, afzalaghaee m, mohammadi m, restegar yf. hysterosalpingographic findings in women with genital tuberculosis. iran j reprod med. 2015;13(5):297–304. 24. khurana a, sahi g. oc14.04: ultrasound in female genital tuberculosis: a retrospective series. ultrasound obstet gynecol. 2013;42(s1):28. doi:10.1002/uog.12660. author biography u tripathi, associate professor mitali gupta, senior resident neha katare, senior resident saurabh kumar singh, associate professor cite this article: tripathi u, gupta m, katare n, singh sk. endometrial fluid study for prevalence of tuberculosis by testing for diagnosis by cb naat culture. panacea j med sci 2022;12(1):142-145. http://dx.doi.org/10.1093/clinids/9.2.275 http://dx.doi.org/10.1371/journal.pone.0089301 http://dx.doi.org/10.2217/fmb.11.84 http://dx.doi.org/10.1007/s13224-015-0780-z http://dx.doi.org/10.1097/00003081-197603000-00016 http://dx.doi.org/10.1016/j.ijgo.2009.08.031 http://dx.doi.org/10.1136/bmj.h6747 http://dx.doi.org/10.1164/ajrccm.161.4.16141 http://dx.doi.org/10.1093/humrep/17.1.128 http://dx.doi.org/10.1159/000091498 http://dx.doi.org/10.5152/dir.2014.13517 http://dx.doi.org/10.1002/uog.12660 original article panacea journal of medical science, january – april 2015:5(1);33-39 33 outcome of fiber optic bronchoscopy in sputum smear negative pulmonary tuberculosis choudhary s1, tayade bo2, kharbade s3, sontakke a1, khan s4, abraham r5 abstract: bronchoscopy is very useful for diagnosing sputum smearnegative pulmonary tuberculosis (ssn-ptb). our aim is to find out the diagnostic yield of fiber optic bronchoscopy in sputum smear negative under rntcp and radio logically suspected new cases of pulmonary tuberculosis and the complications of fiber optic bronchoscopy. a crosssectional prospective study in which consecutive 108 patients was carried out in patients whose two sputum smear for acid fast bacilli was negative and chest x-ray suggestive of pulmonary tuberculosis were included into the study. fiber optic bronchoscopy was carried out in all patients. the yield for tuberculosis was 78 %( 85/108) i.e. made a final diagnosis of tuberculosis.29 (26.85%), 41(37.96%) and 30(27.78%) patients had positive afb smear on bronchial brush, broncho alveolar lavage and post bronchoscopy sputum of which 11(12.94%), 22(25.88%) and 13(15.29%) patients had exclusive diagnosis from the respective procedures. the immediate yield combining positive smear samples from different procedures and histopathological evidence of caseating granuloma in present study is 56%(61/108). in broncho alveolar lavage culture 57/108(57.08%) were confirmed tuberculosis diagnosis and 24(28.4%) patients had exclusive diagnosis on bronchial culture. bilateral, advanced, and non cavitatory disease had 52, 53 and 64 patients diagnosed as pulmonary tuberculosis and was more as compared to different site, extent and type of disease on chest x-ray which were initially negative for tuberculosis. our study suggests that fibre-optic bronchoscopy and its procedure can provide excellent material for early as well as confirming the diagnosis in suspected patients of pulmonary tuberculosis when smears of expectorated sputum do not reveal mycobacteria and helps in diagnosing different diseases and disorders having clinical picture mimicking tuberculosis. keywords: sputum smear-negative, pulmonary tuberculosis, chest xray, fiber optic bronchoscopy, bronchial washings, bronchial biopsies. 1associate professor, 2professor, 3senior resident, 4 assistant professor, 5junior resident, department of pulmonary medicine, nkp sims & rc, digdoh hills, nagpur 440019. drsumerchoudhary91@gmail.com introduction: tuberculosis (tb) is a disease known since time immemorial. every four seconds individual contracts tuberculosis and one of them dies every 10 seconds (12). the most widely used tool of diagnosis of pulmonary tuberculosis is sputum examination and chestx-ray. suptum smear and culture examinations still remain the gold standard in the diagnosis of pulmonary tuberculosis (3-5). acid-fast bacilli (afb) smears of respiratory specimens (at least two or more specimens) are important for the prompt diagnosis of ptb, but afb smears have poor sensitivity (30–70%) despite high specificity (98–99%).mycobacterial cultures are more sensitive than afb smears (80– 85%), but culture results usually require 3–8 weeks (6). it is also known that in many patients, this stringent criterion cannot be satisfied due to factors like :(a) lack of sputum production, (b) low bacterial yield, and (c) incorrect or improper sampling. serological immune markers are also not a reliable indicator for diagnosis of disease. according to the global tuberculosis report 2013, there were 1.29 million notified tuberculosis cases in india in 2012 out of which about 30% were smear negative cases (7). these sputum smear-negative pulmonary tuberculosis (ssn-ptb) poses a common problem faced by the clinicians. early diagnosis would help in curtailing the mortality and morbidity of disease. however, even after meticulous sputum examination the bacteriological choudhary s et al. outcome of fiber optic bronchoscopy in sputum smear negative pulmonary… panacea journal of medical science, january – april 2015:5(1);33-39 34 positive yield is only between 16% to 50 % (8).this means patients having signs and symptoms along with chest x-ray consistent with pulmonary tuberculosis are sputum negative. if these patients were left untreated, 64% of them would require chemotherapy within twelve months (9) .in 1965, the advent of flexible bronchoscope revolutionized the practice of pulmonary tuberculosis. in such patients bronchoscope is tried for rapid and early diagnosis of the underlying pathology. aims and objectives: 1. assess the role of fiber optic bronchoscopy in sputum negative patients with high clinical suspicion of pulmonary tuberculosis. 2. to confirm the diagnosis of pulmonary tuberculosis in sputum negative pulmonary tuberculosis. 3 .to correlate fiber optic bronchoscopy diagnosed positive and negative patients and different chest xray presentations. 4. role of fiber optic bronchoscopy in early diagnosis of sputum negative pulmonary tuberculosis and to confirm other diseases. 5. to study the risk associated with the procedure. materials and methods: inclusion criteria: patients above age of 15 years, these patients are those who are afb negative, however chest x-ray and clinical profile points towards pulmonary tuberculosis. exclusion criteria: patients with bleeding diathesis, history of myocardial infarction or arrhythmia, extra-pulmonary tuberculosis, history of anti-tubercular treatment (att) for more than one month, and those with severe dyspnoea were excluded from the study. hiv-positive and non-cooperative patients were also excluded. chest x-ray classification of disease: two respiratory physicians evaluated chest radiographs independently without access to other information. the radiological classification of disease extent was as follows (10): 0= no disease. 1= mild/minimal ptb (when the lesions did not cross the area above the sternal cartilage of the second rib on one side); 2= moderate/intermediate ptb (when moderately advanced lesions could be seen in one or both lungs, with disseminated lesions of low to moderate density extending throughout one lung or the equivalent in both lungs, or dense, confluent lesions limited to one-third of the volume of one lung); and 3=severe/extensive well advanced ptb (when the lesions were even more extensive). on the chest xrays, lungs were also divided into upper, middle and lower zones, which were delimited by the upper border of the second and fourth anterior ribs, and all six zones were assessed for findings indicative of tuberculosis. parenchymal disease was categorized as unilateral or bilateral. criterion for active and inactive disease: the presence of lymphadenopathy, pleural disease, or miliary abnormalities was noted. lung parenchymal abnormalities were classified as “inactive” or “potentially active”. a grading of “inactive disease “denoted isolated fibrotic (reticular) abnormalities or calcified and/or sharply defined tuberculomata. abnormalities compatible with “potentially active disease” included consolidation (air broncho grams), an impression of patchy fluffy shadowing (with or without an admixture of fibrotic changes), a miliary pattern, pleural effusion or non-calcified opacities with an indistinct border. if previous radiographs were available, serial appearances were taken into account. in cases with divergent assessments, final grades were reached by consensus. procedure: all procedures were carried out as per the international recommendations. prior to the procedure an informed written consent was obtained from the patient. the procedure was carried out electively with the patient nil orally for four to six hours. patients were pre-medicated 30-45 minutes prior to bronchoscopy with 0.6 mg atropine and nebulization was done with two per cent xylocaine via nebulizer. bronchoscopy was carried out under local anesthesia. olympus bf type it 240 video bronchoscope was used. a thorough examination of the bronchial tree was carried out. bronchial segments which were thought from the chest radiograph to be the site of active or inactive tb were washed with 40 ml normal saline. bronchial washing was performed by instilling 0.9% isotonic saline at room temperature through the internal channel of the fibreoptic bronchoscope and aspirated into a trap connected to suction tubing. usually 15-30 ml of fluid was instilled with each washing and about one-fourth to half of this volume was retrieved in the suction trap. up to one-fourth of the instilled amount retrieved was considered successful. the bronchial washings were sent for afb staining, afb culture by bactec, and cytology and cell count. tran’s bronchial lung biopsy (tbb) was done with the biopsy forceps and sent for histopathological examination. in cases where an end bronchial growth was seen washing, brushing and bronchial biopsy (bb) were performed. post procedure care: after the procedure, the patient was observed for development of pneumothorax, hemorrhage, infection and cardiac arrhythmias for 24-48 hours. the first sputum sample after bronchoscopy (postchoudhary s et al. outcome of fiber optic bronchoscopy in sputum smear negative pulmonary… panacea journal of medical science, january – april 2015:5(1);33-39 35 bronchoscopic sputum) was collected and sent for analysis along with bronchial washings. diagnostic yield: a early/immediate diagnosis of sputum smearnegative ptb by fob was defined as a diagnosis of ptb through methods that yielded results within 1 week: (1) positive afb smear on bronchial brush (bs)+bronchioalveolar lavage(bal)+post brochoscopy sputum(pbs) (2) caseating granuloma upon cytology/ biopsy. in cases diagnosed by cytology/biopsy active ptb was confirmed as caseation granuloma.a final diagnosis of ‘nontb’was accepted when an alternative diagnosis was reached. type of study: this is a prospective, cross sectional study. study place: department of pulmonary medicine, n.k.p.salve institute of medical sciences and research center and lata mangeshkar hospital, digdoh hills hingna nagpur. ethical issues: study was approved by institutional ethics committee. results: patient’s characteristics: figure 1: sex of patients table 1: mean age patients characteristics mean age study group 43.76 ± 15.43 male 43.48 ± 14.42 female 44.47 ± 19.25 table 2: symptoms characteristics symptoms characteristics frequency percent cough 98 90.74 expectoration 78 72.22 fever 72 66.67 constitutional symptoms 60 55.56 breathlessness 30 27.78 haemoptysis 04 03.70 chest pain 04 03.70 mean duration of symptoms 2.1 months table 3: chest x-ray site of disease chest x-ray frequency (n=108) percentage tb diagnosed percent right 65 60.19 52/65 80 left 37 34.26 29/37 78.37 bilateral 6 5.55 04/6 66.67 table 4: chest x-ray extent of disease chest xray extent of disease frequency (n=108) percent tb diagnosed percent mild/mini mal 68 62.96 53/68 77.94 moderate 29 26.85 23/29 79.31 extensive/ advanced 11 10.08 9/11 81.81 figure 2: chest x-ray type of disease table 5: tuberculosis confirmed and chest x-ray disease type chest x-ray type of disease tb diagnosed percent cavitatory 21/28 75% non cavitatory 64/80 80% table 6: bronchoscopic findings/results in study group bronchosopic features frequency (n=108) percent congestion and hyperemia 41 37.96 granulomata and tubercles with caseous material 21 19.44 narrowing of segmental opening 19 17.59 ulceration and erosion 16 14.81 bleeding from bronchus 7 6.48 necrotic red patches with sloughed mucosa 6 5.56 endobronchial growth 5 4.63 multiple findings in some patients 0 10 20 30 40 50 60 70 80 male female 0 10 20 30 40 50 60 70 80 cavitatory non cavitatory choudhary s et al. outcome of fiber optic bronchoscopy in sputum smear negative pulmonary… panacea journal of medical science, january – april 2015:5(1);33-39 36 the bronchoscopic findings were as follows: congestion and hyperemia in majority 41 (37.96%) patients, 21 (19.44%) patients had granulomata and tubercles with caseous material,19 (17.59%) patients had narrowing of segmental opening, uceration and erosion was seen in 16(14.81%) patients this was the most common finding in patients of cavitatory disease, bleeding from the bronchus in 7(6.48%) patients , 6 (5.56%)patients necrotic red patches with sloughed mucosa and endobronchial growth was seen in 5(4.63%) patients.(table 6) table 7: diagnostic yield of fiber optic bronchoscopy in new sputum negative pulmonary tuberculosis specimen positive results percent 95%ci exclusively positive specimens brush smear 29/108 26.85 18.32-35.37 11 12.94 bal smear 41 /108 37.96 28.62-47.29 22 25.88 post bronchoscopic sputum smear 30/108 27.78 19.15-36.40 13 15.29 biopsy histopathology(tbb+bronchial biopsy) 39/56 69.64 57.35-81.92 15 17.65 bronchoalveolar lavage culture 57/108 52.78 43.17-62.39 24 28.24 through bronchoscope, brush smear, bronchial aspirate, and bronchial alveolar lavage (bal) were collected and smeared for zn staining for afb in all the 108 patients from the affected segment of the lung sent for cytological examination.bal was sent for culture. in selected patients transbronchial biopsy and bronchial biopsy were done. after bronchoscopy, pbs was also taken for zn staining for afb. in study group of 108 patients, 29 (26.85%) patients were positive for afb by zn staining from bs, 41 (37.96%) patients were positive in bal smear and 30 (27.78%) patients were positive on pbs smear. 57(52.78%) patients were positive for tuberculosis on culture of the pbs specimen. in 56 patients in whom biopsy was done 39(69.64%) patients showed evidence of tuberculosis on histopathology reports of biopsy specimens. 11(12.94%),22(25.88%),13(15.29%),15(17.65%) and 24(28.24%) patients were exclusively positive for mycobacterium tuberculosis in bs,bal smear,pbs,biopsy and bal culture respectively.(table7) table 8: result of microscopic examination of bronchial specimens cytological findings frequency percent normal 17 15.74 non specific chronic inflammation 34 31.48 caseating granuloma 15 13.88 non caseating granuloma 14 12.96 acute inflammation 15 13.88 malignancy 06 5.56 cytology revealed normal findings in 17(15.74%) patients, nonspecific chronic inflammation in 34(31.48%) patients, caseating granuloma in 15(13.88%) patients, non caseating granuloma in 14(12.96%) patients, 15(13.88%) patients acute inflammation and remaining 6(5.56%) patients’ features of malignancy. (table 8) table 9: diagnostic yield of bronchoscopic specimens (n=108) disease diagnosed frequency percent pulmonary tuberculosis patients diagnosed 1. with smear (bs+bal+pbs) 46 42.59 2. with bal culture 24 22.22 3. with biopsy(tbb+bb) 15 13.89 total 85 78.70 other diseases patients diagnosed 1. malignancy 6 5.56 2. bacterial pneumonia 17 15.74 total 23 21.30 choudhary s et al. outcome of fiber optic bronchoscopy in sputum smear negative pulmonary… panacea journal of medical science, january – april 2015:5(1);33-39 37 when all results were combined together it was found that in the study group of 108 patients, 85(78.70%) patients could be diagnosed as a case of pulmonary tb, while 23 (21.30%) patients had a diagnosis other than pulmonary tb. immediate/early diagnosis was made in 61(56.48%) 95% ci 46.93-66.02 patients, whereas 24(22.22%) 95%ci 14.22-30.22, patients were diagnosed exclusively by broncho alveolar lavage culture. (table 9). discussion: the challenge to the respiratory physicians is to diagnose patient of tuberculosis with symptoms and radiography features suggestive of tuberculosis however having negative sputum smear (11). these sputum smear-negative pulmonary tuberculosis (ssnptb) still remains a common problem faced by the clinicians. culture results in these patients’ leads to a delay in treatment, on the other hand, empirical treatment initiation in these patients increase the number of unnecessary treatment. flexible fibreoptic bronchoscopy provides material, aspirate as well as biopsy, from localized affected areas of lung aiding in early diagnosis of smear negative tuberculosis (12, 13). in the present prospective analysis, we have shown the diagnostic yield of bronchoscopy in smear negative pulmonary tuberculosis. in present study 37.96% of cases showed congestion with hyperemia of bronchial mucosa on bronchoscopy, 14.81% of patients had erosion, ulceration and granulation on bronchoscopy, segmental narrowing was observed in 17.59% patients, 4.63%of patients with intra-luminal growth were diagnosed as malignancy and later confirmed by the cytological examination of bronchial washing fluid as adenocarcinoma. similarly, purohit sd et al (1983) reported generalized congestion/hyperemia in most of the patients (14). wallace jm et al (1981) reported congestion of mucosa in 86% with no significant correlation of endoscopic findings with mycobacterial positivity (15). purohit et al (14) reported ulceration in 64% of patients; 60% had frothy secretion for the bronchus. a moderate hyperemia of bronchial mucosa was observed in all the patients. kulpati et al (8) observed the coating of mucosa of involved segments with yellowish white secretions in almost all patients and also revealed mild to moderate hyperemia after bronchial wash. segmental bronchus was narrowed in 20% patients, and ulceration was seen in 20% patients. similar observations were made by panda et al (16) according to their study, 44% had normal bronchial mucosa, 21% had unhealthy mucosa with granulations, 35% had discharge of mucous from bronchus, 5% had growth, 3% had external compression and three per cent had bleeding from bronchus and some cases had multiple findings. the smear results 64.81% of bronchial aspirate/washing/brush were comparable with the studies of sarkar et al (1980) and so et al (1982) who reported it as 67% and 38% respectively and much higher compared to the study of wallace et al (1981), who reported it as13% (15,17-18). the results of stained smear examination of bronchial washing was confirmed by culture in 100% of cases in the present study, which is comparable to the studies by kulpati et al.(8) (100%), danek and bower (19) (95%), sarkar et al.(20) (87%), uddenfeldt and lundgren (83%) (21). in this study, bronchial washing-culture was positive for acid fast bacilli in 52.78%patients , similar to that reported by kulpati et al (8) kvale et al.(22) could grow acid fast bacilli only in one third of the patients of suspected tuberculosis. kato et al (23) reported that higher concentration of lidocaine had an inhibitory effect on mycobacterial growth. though we did not culture the biopsy material, bacilli were grown in 20%, 60%, and 41% in studies of wallace et al (15), funahashi et al (24) and danek and bower (19) but this was not the only diagnostic evidence in any of the studies and did not influence the diagnostic contribution of other methods. wallace et al. (15) and danek and bower (19) had reported 95% culture positivity of specimens obtained by flexible fibreoptic bronchoscopy and therefore negative culture provided strong evidence against tuberculosis. on chest x-ray bilateral, advanced, and non cavitatory disesase had 52, 53 and 64 patients diagnosed as pulmonary tuberculosis and was more as compared to different site, extent and type of disease as classified initially. in the present study no major complication or mortality was observed, only minor complications were observed, in 23 patients (sinus tachycardia-8, pneumothorax-4, minimal haemoptysis <10ml -11) for which no active management was required. contrary to the present study pereira w et al (1978) observed major complications in 1.7% of the procedures with one death yielding a mortality 0.1%, however reporting minor complications including vasovagal reactions, fever, cardiac arrhythmias, bleeding, obstruction of airway, nausea, vomiting, pneumothorax, psychotic reactions and apnoea occurred in 6.5% of the procedures (25). choudhary s et al. outcome of fiber optic bronchoscopy in sputum smear negative pulmonary… panacea journal of medical science, january – april 2015:5(1);33-39 38 in various previous studies flexible fibreoptic bronchoscopy in combination with transbronchial lung biopsy provided early diagnosis in 60% to 85% of smear negative pulmonary tuberculosis. in our study flexible fibreoptic bronchoscopy provided the diagnosis in 78.70% of patients which is similar to the previous studies. comparison of the present study with previous studies in literature. conclusion: the diagnostic yield of flexible bronchoscope is determined by indication of its use and the skills of endoscopist as well as the pathologist. in patients where expectoration is negligible and high suspicion, who’s sputum is negative fiber optic bronchoscope and broncho alveolar lavage, analysis for afb, along with culture would help in rapid and precise diagnosis that will reduce the risk of nosocomial transmission of tb. fob is also more useful in the diagnosis of end bronchial tb, which can be seen as normal in hrct, and fob may be superior in the differential diagnosis of tuberculosis with other commonly encountered diseases such as pneumonia or lung cancer (33). our study suggests that fibre-optic bronchoscopy can provide excellent material for diagnosis of suspected cases of pulmonary tuberculosis when smears of expectorated sputum do not reveal mycobacteria. fibre-optic bronchoscopy combined with trans bronchial lung biopsy helps in early diagnosis of smear negative pulmonary tuberculosis and differentiation of other disorders where clinical picture mimics tuberculosis in our setup rntcp plays a major role in treatment of tuberculosis. however under rntcp programme there is no provision of sputum culture in new sputum smear negative patients nor there is provision of bronchoscopy based diagnosis of these patients. the financial constraints limit most of the underprivileged section of society to undertake this procedure. hence there is need to formulate guidelines where the respiratory physician can make a definitive diagnosis without increasing the number of unnecessary treatment in new sputum negative tuberculosis patients. acknowledgement: i am thankful to dr manoj talapalliwar assistant professor department of preventive and social medicine (p.s.m), nkp sims rc & lmh for helping me in statistical analysis. references: 1. narain jp.tuberculosis epidemiology and control. new delhi: who regional office for south east asia; 2001:p248. 2. dye c, scheele s, dolin p, pantania v, raviglione mc.global burden of tuberculosis: estimated incidence prevalence and mortality by country. who global surveillance and monitoring project. jama1999; 282:67-86. 3. park, j.e. and park k. text book of preventive and social medicine-12th ed. jabalpur. banarasidas bhanot, 1989; 132. 4. roberts g.d: bacteriology and bacteriological diagnosis of tuberculosis. david schlosberg ed. tuberculosis, 2nd ed, new york. springer verlag publishing company, 1988: 2324. 5. new delhi tuberculosis centre: annual report 1987. 6. foulds j, o’brien r: new tools for the diagnosis of tuberculosis: the perspective of developing countries. int j tuberc lung dis 1998, 2:778–783 7. world health organization. global tuberculosis report 2013. 8. kulpati dd, heera hs, diagnosis of sputum smear negative tuberculosis by flexible bronchoscopy.indian j tuber 1986; 33:179-82. 9. hong kong chest service, tuberculosis research cenlre, madras, india and british medical research council. -sputum smears negative pulmonary tuberculosis -controlled trial of 3 months and 2 months regimen of chemotherapy. first report. lancet, 1979, 1: 1361-1363. 10. crofton j, seaton a, seaton d, leitch ag. crofton and douglas's respiratory diseases. oxford: blackwell; 2000. author year of publication country yield for tuberculosis % (no. of cases) immediate diagnosis % (no. of cases) danek et al.(19) 1979 usa 95 (39/41) 34 (14/41) uddenfeldt et al.(21) 1981 sweden 83 (25/30) ns so et al.(18) 1982 hong kong 94 (61/65) 65 (42/65) stenson et al.(26) 1983 usa 66 (8/12) 42 (5/12) russel et al.(27) 1986 usa 100 (25/25) 12 (3/25) kulpati et al.(8) 1986 india 60 (20/33) 40 palenque et al.(28) 1987 spain 34 100 (50/50) 34 (17/50) wongthim et al.(29) 1989 thailand 76 (54/71) 75 (53/71) khoo et al.(30) 1989 uk 26 (9/35) 9 (3/35) zainudin et al.(31) 1991 malaysia 100 (33/33) 55 (18/33) fujii et al.(32) 1992 japan 91 (29/32 44 (14/32) present study 2014 india 78 (85/108) 56(61/108) choudhary s et al. outcome of fiber optic bronchoscopy in sputum smear negative pulmonary… panacea journal of medical science, january – april 2015:5(1);33-39 39 11. chawla r, pant k, jaggi op, et al. fiberoptic bronchoscopy in smear negative pulmonary tuberculosis. eur respir j 1998; 1: 804-6. 12. dolin pj, raviglione mc, kochi a (1994) global tuberculosis incidence and mortality during 19902000. bull world health organ 72: 213-220. 13. dhanragir h .the changing spectrum of tuberculosis. experta medica 1995 ; 2. 6. 14. purohit sd, sisodia rs, gupta pr, sarkarsk and sharma tn. fiber optic bronchoscopy in diagnosis of smear negative pulmonary tuberculosis. lung india, 1983; i (4):143-146. 15. wallace jm, deutsch al, harsell jh and moser km. bronchoscopy and transbrochial biopsy in evaluation of patients with suspected active tuberculosis. the american journal of medicine june 1981; 70:11891194. 16. pande bn, rajan ke, jena j, nema sk, murali m, patel ap. diagnostic yield from flexible fibreoptic bronchoscopy in sputum smear negative pulmonary tuberculosis cases. indian j tuberc. 1995; 42:207–9. 17. sarkar sk, sharma tn, purohit sd, gupta ml and gupta pr. the diagnostic value of routine culture of bronchial washings in tuberculosis. br. j. dis. chest, 1982; 76:358-360. 18. so sy, lam wk, yu dy. rapid diagnosis of suspected pulmonary tuberculosis by fiber optic bronchoscopy. tubercle, 1982; 63(3): 195-200. 19. danek sj, bower js. diagnosis of pulmonary tuberculosis by flexible fibreoptic bronchoscopy. am rev respir dis. 1979; 119:677–9. 20. sarkar sk, sharma gs, gupta pr, sharma rk. fibreoptic bronchoscopy in the diagnosis of pulmonary tuberculosis. tubercle. 1980 jun;61(2):97-9. 21. uddenfeldt m, lundgren r. flexible fibreoptic bronchoscopy in the diagnosis of pulmonary tuberculosis. tubercle. 1981 sep;62(3):197-9. 22. kvale pa, johnson mc, wroblewski da. diagnoses of tuberculosis, routine cultures of bronchial washings are not indicated. chest. 1979; 76:140–2. 23. kato h, fukuhara t, mashimo k, matsushima s, saito t. transbronchial bacteriological culture study using flexible fibreoptic bronchoscope: a bacteriological study of lidocaine solutions. j jpn bronchoesophagol soc. 1978; 29:291–8. 24. funahashi a, lohaus gh, politis j, hranicka lj. role of fibreoptic bronchoscopy in the diagnosis of mycobacterial diseases. thorax. 1983; 38:267–70. 25. pereira w, kovnat dm and snider gl. a prospective cooperative study of complications following flexible fiber optic bronchoscopy. chest, 6 june 1978; 73:813816. 26. 16. stenson w, aranda c, bevelaqua fa. transbronchial biopsy culture in pulmonary tuberculosis. chest.1983; 83:883–4. 27. russell md, torrington kg, tenholder mf. a ten-year experience with fibreoptic bronchoscopy for mycobacterial isolation: impact of the bactec system. am rev respir dis. 1986; 133:1069–71. 28. palenque e, amor e, bernaldo de quiros jc. comparison of bronchial washing, brushing and biopsy for diagnosis of pulmonary tuberculosis. eur j clin microbiol. 1987; 6:191–2. 29. wongthim s, udompanich v, limthongkul s, charoenlap p, nuchproyoom c. fibreoptic bronchoscopy in diagnosis of patients with suspected active pulmonary tuberculosis. j med assoc thai.1989; 72:154–9. 30. khoo kk, meadway j. fibreoptic bronchoscopy in rapid diagnosis of sputum smears negative pulmonary tuberculosis. respir med. 1989; 83:335–8. 31. zainudin bm, wahab sufarlan a, rassip cn, ruzana ma, tay am. the role of diagnostic fibreoptic bronchoscopy for rapid diagnosis of pulmonary tuberculosis. med j malaysia. 1991; 46:309–13. 32. fujii h, ishihara j, fukaura n, kashima n, tazawa h, nakajima h, et al. early diagnosis of tuberculosis by fibreoptic bronchoscopy. tubercle lung dis. 1993; 73:167–9. 33. araz o, akgun m, saglam l, ozden k, mirici a: the diagnostic value of bronchoscopy in smear negative cases with pulmonary tuberculosis.tuberk toraks2008, 56:150–157. 429 too many requests you have sent too many requests in a given amount of time. review article panacea journal of medical science, january – april 2015:5(1)7-13 7 nuance of nucleated rbcs (normoblastemia) in peripheral blood film akhtar s1, mahure s2 abstract: nucleated rbcs (nrbcs) are immature rbcs normally they are not seen in the peripheral blood after the neonatal period. their presence in peripheral blood of children and adults signifies bone marrow damage or stress and potentially serious underlying disease. the presence of numerous nrbcs increases the wbc count in automated hematology analyzers. most analyzers generate suspect flags for identifying abnormal cells, and the samples involved should be reviewed manually. unfortunately, analyzers may not detect low levels of nrbcs. we recommend correcting the wbc count with even 1 nrbc/100 wbcs and reporting “occasional nrbc seen.” this alerts clinicians for the significance of unexplained normoblastemia. keywords: nucleated rbcs, peripheral blood, normoblastemia. 1assistant professor, 2professor, department of pathology, nkp sims & rc, digdoh hills, hingna road nagpur -440019. akhtar_lmh@rediffmail.com introduction: usually nucleated rbcs are present in the peripheral blood of normal infants up to the fifth day of life. at birth, 3 to 10 nrbcs per 100 wbcs are present (1, 2). premature birth and fetal hypoxia can cause increase in nrbc’s number (3). after the neonatal period, the presence of nrbcs in the peripheral blood is usually associated with malignant neoplasm’s, bone marrow diseases, and other serious disorders (2, 4, 5). the bone marrow has a special architecture its disruption leads to obvious changes. normal mature bone marrow cells are deformable, so they can squeeze through small “portholes” in the endothelium to enter the peripheral circulation (6). normoblasts and immature granulocytes, however, are less deformable and rarely enter the circulation. their presence in the peripheral blood indicates that the mechanism of bone marrow barrier has been disrupted or extramedullary hematopoietic mechanism has been activated. there are various mechanism associated with this conditions i.e. nrbcs in peripheral blood (normoblastemia) and importantance to report their existence. mechanisms: the mechanisms of normoblastemia are not completely obscure but may be classified as shown in the (table: i) it will helpful to attribute the condition to a single process, it is important to understand that multiple interrelated mechanisms are frequently involved. hyposplenism and asplenia: hyposplenism reflects the developmental immaturity of the reticuloendothelial system and is a reported cause of physiologic normoblastemia of neonates (6, 7) because normoblasts that escape from the marrow are normally cleared by the spleen, their presence in the peripheral blood suggests a hyposplenic state. in patients with myeloproliferative disorders, cellular overload may incapacitate splenic function (2, 5) the same phenomenon develops in patients with sickle cell disease in which abnormal rbcs flood the splenic machinery. moreover, marrow stress and release of many normoblasts can overcome the ability of a normal spleen to clear them from circulation. this occurs with hypoxia, hemolytic anemia, anemia under treatment, megaloblastic anemia, ineffective erythropoiesis, collagen vascular diseases, malignant neoplasms, and chemotherapy treatment (4) the most useful and sensitive indicator of splenic function, however, the presence of howelljolly bodies (rbc inclusions) in the peripheral blood film. the presence of normoblasts, although useful, may be nonspecific. acanthocytes; target cells, stippled cells, and fragments are also nonspecific findings (8). anemia and compensatory erythropoietin: in every types of severe anemia i.e. hemolytic, nutritional or anemia of blood loss normoblastemia is caused by hypoxic erythropoietin-induced compensatory erythropoiesis.8 the reduced oxygen carrying capacity of anemic blood causes tissue hypoxia, the main stimulus for rbc production. when hypoxia occurs, the kidneys produce erythropoietin if akhtar s et al. nuance of nucleated rbcs (normoblastemia) in peripheral blood film panacea journal of medical science, january – april 2015:5(1)7-13 8 it increased markedly, results in intense marrow erythropoietic activity. whether marrow erythropoiesis is effective or ineffective depends on the underlying cause of the anemia. with effective erythropoiesis, the resulting accelerated compensatory activity produces prominent reticulocytosis, polychromasia, immature granulocytes (at times), and occasional nrbcs in the peripheral blood. these cells lineage and quantity or conditions are depends on the severity of the anemia and marrow response. if the marrow response is exaggerated, nrbcs are abundant with many “stress” reticulocytes, causing pseudomacrocytosis.when erythropoiesis is ineffective, and nrbcs may be prematurely released into the peripheral blood without reticulocytosis.dysplastic rbc changes may occur, as shown by the appearance of macro-ovalocytes and teardrop cells in the peripheral blood(5-6,8-10). hypoxia: the condition which reduces the quantity of oxygen transported to the tissues causes an increase in the rate of rbc production. as normoblastemia occurs in response to hypoxia in both anemia and cardiopulmonary disorders, the cause of hypoxia may differ in these conditions. in anemia, hypoxia results when the reduced hemoglobin concentration causes a corresponding decline in the oxygen carrying capacity of the blood (11-12). cardiopulmonary hypoxia, however, may involve numerous mechanisms, including failure of the blood to absorb oxygen from the lungs, inadequate ventilation of alveoli, or right-toleft intrapulmonary shunting of the blood. impaired cardiovascular circulation leading to an inadequate supply of oxygenated blood to the tissues may also cause hypoxia (13-14). because some patients with cardiopulmonary disorders have pulmonary emboli or coronary thrombosis complications, the presence of normoblasts in these disorders may indicate unfavorable prognosis (8). the concentration of hemoglobin also differs in these hypoxic situations. in cardiopulmonary hypoxia, the hemoglobin level is either high or within the reference interval, whereas in anemic hypoxia, it is much lower (9). the rate of rbc production, however, is not controlled by hemoglobin concentration; it appears to vary with the ability of the cells to transport oxygen to the tissues in response to a demand. thus, if the oxygen supply is less than the tissues demand, more rbcs are produced, which, in turn, results in a higher hemoglobin level until the supply of oxygen meets the demand. in cases of transient increases in oxygen demand (a hypoxic stimulus), normoblastemia, if present, disappears with relief of the hypoxia. accordingly, a hypoxic stimulus should be suspected whenever normoblastemia is accompanied by a normal to high hemoglobin level and mild to moderate polychromasia (13-15). bone marrow invasion and replacement: marrow replacement can occur in association with a primary hematologic disease such as leukemia, myeloma, or lymphoma. it can also be the result of secondary injury invading tumor cells, the presence of sarcoidosis, or infectious agents such as mycobacterium and fungi (6). both primary and secondary reactions can produce marrow fibrosis (myelofibrosis), which changes the normal marrow micro architecture. this disruption may break down the marrow-blood barrier, causing untimely and disorderly release of nrbcs and progenitor cells into the circulation (10). similarly, extensive marrow infiltration and replacement may cause mechanical “crowding out” of normal hematopoietic cells, leading to their escape into the peripheral blood and lodgment in other organs such as the spleen, liver, and lymph nodes. this process may contribute to extramedullary hematopoiesis. the initial peripheral blood picture may present unexplained normoblastemia, mild macrocytosis, giant platelets, myelocytes, thrombocytopenia, and, possibly, leucopenia with or without teardrop cells or blast cells (9). extra-medullary hematopoiesis: recognized clinically as splenomegaly or hepatomegaly, extramedullary hematopoiesis appears to be caused by anemia, marrow replacement associated with acute leukemia, or other nonhematopoietic infiltrative processes (myelophthisis) (11). presumably, hematopoietic stem cells are displaced from the marrow into the spleen or liver where they proliferate to cause hepatomegaly and splenomegaly. splenomegaly also occurs when the marrow has been dispossessed by fibrosis. because the spleen does not retain immature cells as efficiently as normal marrow, it may release nrbcs, peripheral blood smear from a patient with myelofibrosis shows many teardrop rbcs and a myelocyte. chronic hematopoietic malignancies (5) reveal always immature granulocytes, megathrombocytes, and occasional blast cells into the peripheral blood, resulting in leukoerythroblastosis or the coexistence of myeloid precursors and nrbcs in the peripheral blood (12). teardrop cells may be present. a leukoerythroblastic reaction may also be seen without marrow infiltration in normal newborns as well as in patients with thalassemia major with severe hemolytic crisis, hemorrhage, postsplenectomy, septicemia, 16 and therapy with granulocyte colony-stimulating factor (g-csf). in addition, when bone marrow reserve is unable to meet the demand for accelerated erythropoiesis (as in chronic hemolytic anemia or longstanding anemia), blood cells may form in tissues akhtar s et al. nuance of nucleated rbcs (normoblastemia) in peripheral blood film panacea journal of medical science, january – april 2015:5(1)7-13 9 other than the bone marrow.8 this extramedullary hematopoiesis represents a reversion of the involved tissues to their fetal blood-forming function, although this compensatory activity may also occur in myelophthisic anemia with fibrosis. thus, differentiating between chronic hemolytic anemia and myelophthisic anemia with fibrosis is difficult without the patient’s clinical history. leukoerythroblastosis is evident in peripheral blood films, and teardrop cells may or may not be present. teardrop cells are not usually seen in leukoerythroblastic reactions associated with hemorrhage, infection, or g-csf therapy. they can be found in severe iron deficiency anemia, thalassemia, megaloblastic anemia, hemolytic anemia, leukemia, myelofibrosis, and drug-induced heinz body formation (16). teardrop cells may reflect dyspoiesis and thus are not specific for a single condition. although the exact mechanism of teardrop cell formation is unclear, the formation of these cells from inclusion-containing rbcs is well documented. as cells with large rigid inclusions try to pass through the small splenic sinus openings, parts with large inclusions get pinched, causing the cells to stretch with irreversible loss of their shape. the result is teardrop cells. moreover, teardrop cell formation represents the cells tortuous circulation through deformed marrow sinuses and diseased splenic cords. the presence of teardrop cells in the peripheral blood is thus significant and should alert morphologists to search for occasional nrbcs, megathrombocytes, stippled cells, immature granulocytes, or blast cells that would constitute conclusive evidence of myeloid metaplasia or leukoerythroblastosis (9, 16). other mechanisms: why normoblastemia occurs with these disorders remains mysterious. although the marrow-blood barrier appears to break down, the cause of the breakdown is unknown (9). most of the disorders involved complex conditions that causes systemic diseases and influence bone marrow response. these diseases include uremia, sepsis, liver disease, and thermal injury (12). role of the laboratory: laboratory professionals play an important role in detecting nrbcs when they review cbc and wbc differential results obtained by automated hematology analyzers. most analyzers generate suspect flags, (e.g., wbc*r, nrbc, review slide, blasts) to help identify abnormal wbcs, and samples with flags should be microscopically examined. although most instruments have >80% specificity for nrbc flags, they cannot consistently detect <5% nrbcs (12). the number of nrbcs in a 100or 200wbc differential count are reported as the number of nrbcs per 100 wbcs. in addition, the corrected wbc count is reported. it is also good practice to manually scan all blood films of new patients (without a diagnosis) for abnormalities that may not have been flagged (4, 6, 9). correction of wbc count in normoblastemia : recognizing nrbcs is an important role as their presence affects the wbc count, because only a few nrbcs can have ominous implications in some patients. we therefore recommend that wbc counts with even 1 nrbc/100 wbcs be corrected and reported. this will alerts clinicians for the significance of unexplained normoblastemia. the correction can be made with a simple formula: corrected wbc count, x 10 9 /l= wbc count, x 10 9 / l / (1+ (nrbc/100wbcs)) computerized laboratory systems do these calculations automatically. recent advances in hematology analyzers and their widespread use will improve manually correcting wbc counts (17-18). therefore, setting a threshold of more than 4 or 5 nrbcs/100 wbcs before correcting the wbc count does not make clinical sense. in addition, many authors (16) advocate different correction formulae and cutoff values. we recommend correcting the wbc count with even 1 nrbc/100 wbcs and reporting “occasional nrbc seen” with <1 nrbc/100 wbcs. comments: the presence of nrbcs in blood does not offer a diagnosis of disease; it may give invaluable clues to the presence of a serious condition. homeostatically, nrbcs in blood symbolize a compensatory response to an excessive demand on the blood-forming organs (marrow stress) such as in severe anemia or hypoxia. clinically, nrbcs may represent marrow fibrosis, marrow replacement by leukemic cells or metastatic tumor cells, or extramedullary hematopoiesis. their presence indicates the extent to which bone marrow reacts to stress and disease. a recent technological breakthrough enables new hematology analyzers to identify nrbcs separately from wbcs (17-18) with this technology, more cells per specimen are characterized, and the new data might show that “rare” nrbcs occur more frequently than previously thought and that the significance of this should be revisited. moreover, except for grossly abnormal results, manual correction of wbc counts may become unnecessary. the classification of mechanisms associated with normoblastemia (see table-i), although useful, is oversimplified because it emphasizes only the predominant cause of the disorders listed. in many conditions, more than one mechanism is operative akhtar s et al. nuance of nucleated rbcs (normoblastemia) in peripheral blood film panacea journal of medical science, january – april 2015:5(1)7-13 10 (fig.1 & fig. 2). the severe hemolytic anemia of the newborn (erythroblastosis fetalis) in which the severe stress of anemia and hypoxia on marrow erythropoiesis is the primary cause of normoblastemia (19). the combination of marrow stress with the immaturity (hyposplenism) of the reticuloendothelial system and the availability of extramedullary hematopoiesis probably accounts for the extreme normoblastemia or leukoerythroblastosis.similarities to this are evident in leukemia, myelophthisic anemia, or myelofibrosis; although the primary cause of normoblastemia in these conditions is the crowding out of hematopoietic cells or the disruption of marrow architecture, concurrent anemia,hyposplenism, or extramedullary hematopoiesis may also contribute to normoblastemia. fig-1:leishman stained peripheral smear showing nrbcs (normoblastemia) and various associated conditions e.g, amalaria,b-thalaseamia,c-macrocytic anemia,d-leucoerythroblastic reaction,e-leukemia,f-microangiopathic haemolytic anemia,g-haemolytic anemia,h-iron def.anaemia,i-myelofibrosis,j-bm myelodysplasia,k-megalolastic anemia,l-preleukemia, a b c d e f g h i j k l akhtar s et al. nuance of nucleated rbcs (normoblastemia) in peripheral blood film panacea journal of medical science, january – april 2015:5(1)7-13 11 fig-2:leishman stained peripheral smear showing nrbcs (normoblastemia) and various associated conditions e.g, mhaemorrhage,n-myeloproliferative deasease,o-thalsaemia,p-bm megaloblastic anemia,q-polycythemia vera ,r-anaemia of chronic desease,s-new born,t-dyserythropoitic desease ,u-severe pulmonary deases,v-anaemia under treatment,w-bm dyserythropoitic desaese ,x-plasma cell in myeloma . furthermore, in cardiopulmonary disorders, normoblastemia is more pronounced when anemia is also present. therefore, it should be easier to differentiate one disorder (mechanism) from the other by considering the total clinical picture. although studies show that even 1 nrbc in the peripheral blood of adults may indicate a serious disease, (4,20,21) clinicians and laboratory professionals do not agree on its clinical significance, especially when unsupported by other data. the differing views are probably due more to perception than reality. in primary health care units, normoblastemia is rare and may signify a pathologic condition. in contrast, ormoblastemia is a common finding in an acute care hospital. as a result, nrbcs may be perceived as ordinary cells of questionable clinical significance; in these cases, the importance of normoblastemia is relative and depends on the type of hospital and patient population. we believe that unexplained normoblastemia is important because it offers invaluable insight into disease processes or progressions that occur in conditions such as metastatic carcinoma, bone marrow conditions, systemic infections, m n o p q r s t u v w x akhtar s et al. nuance of nucleated rbcs (normoblastemia) in peripheral blood film panacea journal of medical science, january – april 2015:5(1)7-13 12 and cardiopulmonary complications. the presence of normoblastemia with certain clinical conditions may indicate that a bone marrow examination is necessary to rule out hematologic malignant neoplasms or unsuspected blood disorders. when viewed in this context, one nrbc may lead to more timely medical intervention, thus increasing the chance of a positive outcome(2). conclusion: the findings of the normoblastemia may be diagnostic and prognostic aid to physician in the above mentioned and discussed conditions of clinical circumstances. table 1: mechanisms and conditions associated with normoblastemia hyposplenism, asplenia (4, 6-8) sickle cell anemia newborn (physiologic) splenectomy essential thrombocytosis hemolytic anemia malaria anemia, compensatory erythropoiesis (5, 6, 8,9,10) severe anemia (any cause) hemolytic anemia iron deficiency anemia megaloblastic anemia hemorrhage anemia under treatment microangiopathic hemolytic anemia thalassemia major hypoxia (89, 11-16) severe pulmonary disease congestive cardiac failure cyanotic heart disease marrow invasion, replacement (6,9-10) preleukemia leukemia lymphoma neuroblastoma myelodysplasia myelofibrosis plasma cell myeloma myeloproliferative disorder gaucher and other storage disease granuloma (ie, tuberculosis) collagen vascular disease fungal infection histiocytosis tumor cell presence sarcoidosis osteopetrosis extramedullary hematopoietic (5, 8, 9,11,12,16) myelophthisis osteopetrosis myeloid metaplasia myelofibrosis chronic hemolytic anemia polycythemia vera leukemia other (9, 12) uremia akhtar s et al. nuance of nucleated rbcs (normoblastemia) in peripheral blood film panacea journal of medical science, january – april 2015:5(1)7-13 13 sepsis liver disease diabetic ketoacidosis inflammatory bowel disease renal transplant thermal injury chemotherapy references: 1. green dw, mimouni f. nucleated erythrocytes in healthy infants and in infants of diabetic mothers. j pediatr. 1990; 116:129-131. 2. miller dr, baehner rl. blood diseases of infancy and childhood. 7th ed. st louis, mo: mosby; 1995:39-40. 3. hanlon-lundberg km, kirby rs.nucleated red blood cells as a marker of acidemia in neonates. am j obstet gynecol. 1999; 181:196-201. 4. sills rh, hadley rar. the significance of nucleated red blood cells in the peripheral blood of children. am j pediatr hematol oncol. 1983; 5:173-177. 5. schwartz so, stanbury f. significance of nucleated red blood cells in peripheral blood: analysis of 1496 cases. jama. 1954; 154:1339-1340. 6. leblond p, lacelle p,weed ri. cellular deformity: a possible determinant of normal marrow release of maturing erythrocytes from the bone marrow. blood. 1971; 37:40-46. 7. lee rg, bitchell tc, foerster j, et al, eds. in: wintrobe’s clinical hematology. 9th ed. philadelphia, pa: lea & febiger; 1993:316-317. 8. dacie jv, lewis sm. practical hematology. 8th ed. new york, ny: churchill livingstone; 1995:115-116. 9. alter bp, young ns. the bone marrow failure syndromes. in: nathan dg, oski fo, eds.hematology of infancy and childhood. 5th ed. philadelphia, pa: saunders; 1998:309-311. 10. erslev aj.anemia associated with marrow infiltration. in: beutler e, lichtman ma, coller bs, et al, eds. williams hematology. 5th ed. new york, ny: mcgraw-hill; 1995:516-518. 11. custer rp. an atlas of the blood and bone marrow. 2nd ed. philadelphia, pa: saunders; 1974:22-25, 123136. 12. retief fp. leukoerythroblastosis in the adult. lancet. 1964;1:639-642. 13. bennett jc, plum f, eds. cecil textbook ofmedicine. 20th ed. philadelphia, pa: saunders; 1996:453, 466469. 14. fauci as, braunwald e, eds.harrison’s principles of internal medicine. 14th ed. new york, ny: mcgrawhill; 1998:205-209. 15. ward hp,holman j. the association of nucleated red cells in the peripheral smear with hypoxemia. ann intern med. 1967; 67:1190-1194. 16. stiene-martin ea, lotspeich-steininger ca, koepke ja, eds. clinical hematology principles, procedures, correlations. 2nd ed. philadelphia, pa: lippincottraven; 1998:93, 339-340, 463-465. 17. paterakis g, kossivas l, kendall r, et al. comparative evaluation of the erythroblast count generated by threecolor fluorescence flow cytometry, the abbott celldynr 4000 hematology analyzer, and microscopy. lab hematol. 1998;4:64-70. 18. kim yr, yee m, metha s, et al. simultaneous differentiation and quantitation of erythroblasts and white blood cells on a high throughput clinical haematology analyzer. clin lab haematol. 1998;20:21-29. 19. hermansen m c.nuclrated red blood cells in the fetus and new born.arch dis child fetal neonatal ed 2001;84:211-215. 20. seiverd ce. hematology for medical technologists. 5th ed. philadelphia, pa: lea & febiger; 1983:143144. 21. medical news: nucleated rbcs in blood of adults should be cause for concern. jama. 1978; 239:91. panacea journal of medical sciences 2022;12(1):172–176 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article evaluation of suspected adverse drug reactions of oral anti-diabetic drugs in a tertiary care hospital of bihar, india: an observational study saajid hameed1, pankaj kumar1,*, manish kumar1, lalit mohan1, harihar dikshit1 1dept. of pharmacolgy, indira gandhi institute of medical sciences, shiekhpura, patna, bihar, india a r t i c l e i n f o article history: received 10-04-2021 accepted 28-07-2021 available online 30-04-2022 keywords: adverse drug reaction diabetes mellitus oral antidiabetic drugs a b s t r a c t background: diabetic patients generally require life-long treatment and continuous follow up. in spite of their benefit of achieving glycemic control, there are many safety concerns with antidiabetic drugs such as gastrointestinal side effects, metabolic complications, central nervous system (cns) symptoms, musculoskeletal problems, genito-urinary disorders like uti, development of peripheral oedema, weight gain etc. aim: to highlight pattern of adverse drug reactions with use of oral anti-diabetic drugs. materials and methods : all suspected adverse drug reaction reporting form having any anti-diabetic drug as suspected cause of adr were collected. the reported adrs on the notification forms, after being confirmed by the physician-in-charge, were assessed for causality using who-umc causality categories14, preventability using modified-schumock and thornton scale15 and severity using modified hartwig and siegel scale. statistical analysis: the data from the forms was presented in tabular form and data will be interpreted by using microsoft excel 365 software. results: adverse drug reaction related to gastrointestinal system were most reported adrs (41.31%). among gi adverse events, nausea was mostly reported adr and it was mostly associated with dpp4 inhibitors. hypoglycemia was most frequently observed in patients taking sulfonylureas. causality assessment according to who-umc criteria showed 61.68% adrs had probable causality while 37.43% had possible causality and only 0.90% had certain causality. most of the adrs in our study were nonpreventable (57.78%) & were of mild to moderate grade. conclusion: hypoglycemia continues to be major concern in patients taking anti-diabetic medications and sulfonylureas were commonest drugs responsible for it. as anti-diabetic medication is generally taken for lifetime, the risk of development of adverse effects related to concurrent related co-morbidities of patients shouldn’t be ignored while prescribing. the physician should report these adverse effects to adr monitoring centre, so that proper signal could be generated for the welfare of the society. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction diabetes is a metabolic disorder characterized by hyperglycemia due to defects in either insulin secretion, insulin action or both of them. the chronic complications of diabetes are associated with long-term end organ damage, organ dysfunction, and multiorgan failure cause due to * corresponding author. e-mail address: pankajjlnmch@gmail.com (p. kumar). microvascular and macrovascular pathophysiology. 1 the management principles of diabetes comprise of prevention of risk factors, screening of high-risk population and proper life-style modification for individuals in the pre-diabetic state. pharmacological treatment is the most important option for these patients. 2 the conventional options for type 2 diabetes mellitus include drugs that have been commonly prescribed for long time such as https://doi.org/10.18231/j.pjms.2022.032 2249-8176/© 2022 innovative publication, all rights reserved. 172 hameed et al. / panacea journal of medical sciences 2022;12(1):172–176 173 biguanides, sulfonylureas, α-glucosidase inhibitors, meglitinides, thiazolidinedione (tzd), dipeptidyl peptidase 4 (dpp-4) inhibitors and sodium glucose co-transport 2 (sglt-2) inhibitors. drugs continue to be the most common interventions used to achieve glycemic control but drugs themselves have their adverse effect and can adversely have impact on mental and social health. in spite of their benefit of achieving glycemic control, there are many safety concerns with antidiabetic drugs such as gastrointestinal side effects, metabolic complications, central nervous system (cns) symptoms, musculo-skeletal problems, genito-urinary disorders like uti, development of peripheral oedema, weight gain etc. 3,4 adverse drug reactions (adrs) has been defined by world health organization (who) as any response to a drug which is noxious and unintended and occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function. but this definition has excluded overdose (from either accidental or intentional), drug abuse, treatment failure and errors in drug administration. 5–7 diabetic patients generally require life-long treatment and continuous follow up but due to lack of knowledge and awareness many of them continue or discontinue their medications without regular monitoring of blood sugar level. 8–10 so, they are prone to develop adverse drug reactions and detection of adr in these patients becomes nearly impossible. therefore, the medications should be individualized for each patient according to hba1c level and expected long-term benefit with specific safety concerns, as well as by considering fixed dose combinations including side effects, compliance, expense, concurrent co-morbidities etc. 11,12 the detection of adverse drug reactions (adrs) has become important due to introduction of large number of drugs in the last two decades. adverse drug reactions generally occur daily in hospitals adversely affecting patient’s life but are often unreported causing considerable morbidity and mortality. attention must be given in identifying the development of spurious sign and symptoms in patient with higher risk and concurrent comorbidities. drugs most commonly responsible the adr should be suspected first. increased supply of drugs in the market, promotion by pharmaceutical representatives and an upward trend in polypharmacy are contributing factors for increases evidence and complexities of adrs worldwide. adverse drug reactions can lead to loss of patient’s confidence on treatment leading to negative emotions toward their physician and discontinuation on treatment and engagement in self-treatment options, which may consequently precipitate additional adrs and increase mortality and morbidity in population. 12,13 this study was planned to highlight pattern of adverse drug reactions with use of oral anti-diabetic drugs. 2. materials and methods this study will be conducted at department of pharmacology, igims patna, after approval by institutional ethics committee of igims, patna (bihar). 2.1. study design observational study. 2.2. study duration 6 months. 2.3. source of data adverse drug reaction monitoring centers (amc), department of pharmacology, igims patna, (bihar). 2.4. materials all suspected adverse drug reaction reporting form having any anti-diabetic drug as suspected cause of adr. 2.5. inclusion criteria suspected adverse drug reaction reporting form having any anti-diabetic drug as suspected cause of adr. 2.6. exclusion criteria adverse drug reaction due to overdosing, ckd patients, intensive care patients and gestational diabetic patients were excluded. 2.7. study design all suspected adverse drug reaction reporting form having any anti-diabetic drug as suspected cause of adr were collected. the reported adrs on the notification forms, after being confirmed by the physician-in-charge, were assessed for causality using who-umc causality categories, 14 preventability using modified-schumock and thornton scale 15 and severity using modified hartwig and siegel scale. 16 the data from the forms was presented in tabular form and data will be interpreted by using microsoft excel 365 software. 3. results and discussion adverse drug reaction related to gastrointestinal system were most reported adrs (41.31%). among gi adverse events, nausea was mostly reported adr and it was mostly associated with dpp-4 inhibitors. singh et al. found that most commonly prescribed observed adrs in their study were related to endocrine and gastrointestinal system. 17 there is much controversy regarding mechanisms responsible for gastrointestinal adverse effects in patients 174 hameed et al. / panacea journal of medical sciences 2022;12(1):172–176 table 1: frequency of different adverse drug reactions (adrs) among different anti-diabetic drugs. type of adr no of adrs % of adrs associated drugs (no of adrs) nausea 99 29.64 sitagliptin (53), linagliptin (19), metformin (11), glimepiride (4), canagliflozin (7), voglibose (5) hypoglycemia 51 29.64 glimepiride (27), sitagliptin (9), metformin (6), canagliflozin (3), voglibose (2), linagliptin (4) urinary tract infection 18 5.39 canagliflozin (11), metformin (3), voglibose (1), glimepiride (2), sitagliptin (1) fever 21 6.29 canagliflozin (13), metformin (4), linagliptin (2), voglibose (2) respiratory tract infection 15 4.49 sitagliptin (9), linagliptin (3), canagliflozin (3) weight gain 33 9.88 glimepiride (22), pioglitazone (6), metformin (5) constipation 12 3.59 metformin (4), pioglitazone (3), glimepiride (3), sitagliptin (2) diarrhea 18 5.39 metformin (5), voglibose (11), sitagliptin (2) hyperglycemia 9 2.69 metformin (4), glimepiride (2), sitagliptin (2), linagliptin (1) abdominal pain 9 2.69 sitagliptin (3), voglibose (3), metformin (2), glimepiride (1) cough 6 1.80 sitagliptin (3), linagliptin (2), canagliflozin (1) edema 7 2.10 pioglitazone (4), metformin (2), sitagliptin (1) dizziness 6 1.80 glimepiride (3), sitagliptin (2), metformin (1) insomnia 6 1.80 metformin (2), glimepiride (2), sitagliptin (1), voglibose (1) pruritus 9 2.69 glimepiride (4), metformin (3), voglibose (2) arthralgia 9 2.69 sitagliptin (7), linagliptin (2) back pain 6 1.80 sitagliptin (5) linagliptin (1) total 334 100 table 2: distribution of suspected adrs according to who-umc causality categories type of adr number of adr certain (%) probable/likely (%) possible (%) nausea 99 0 (0.00) 62 (62.63) 37 (37.37) hypoglycemia 51 2 (3.92) 31 (60.78) 18 (35.29) urinary tract infection 18 0 (0.00) 12 (66.67) 6 (33.33) fever 21 0 (0.00) 13 (61.90) 8 (38.10) respiratory tract infection 15 0 (0.00) 10 (66.67) 5 (33.33) weight gain 33 1 (3.03) 17 (51.52) 15 (45.45) constipation 12 0 (0.00) 7 (58.33) 5 (41.67) diarrhea 18 0 (0.00) 13 (72.22) 5 (27.78) hyperglycemia 9 0 (0.00) 6 (66.67) 3 (33.33) abdominal pain 9 0 (0.00) 5 (55.56) 4 (44.44) cough 6 0 (0.00) 4 (66.67) 2 (33.33) edema 7 0 (0.00) 4 (57.14) 3 (42.86) dizziness 6 0 (0.00) 3 (50.00) 3 (50.00) insomnia 6 0 (0.00) 2 (33.33) 4 (66.67) pruritus 9 0 (0.00) 7 (77.78) 2 (22.22) arthralgia 9 0 (0.00) 6 (66.67) 3 (33.33) back pain 6 0 (0.00) 4 (66.67) 2 (33.33) total 334 3 (0.90) 206 (61.68) 125 (37.43) table 3: distribution of adrs based on preventability using modified-schumock and thornton scale categories number of adrs (n=334) % of adrs definitely preventable adrs 103 30.84 probably preventable adrs 38 11.38 non-preventable adrs 193 57.78 hameed et al. / panacea journal of medical sciences 2022;12(1):172–176 175 table 4: distribution of adrs based on severity using modified hartwig and siegel scale categories number of adrs (n=334) % of adrs mild 132 39.52 moderate 197 58.98 severe 5 1.50 of diabetes mellitus taking oral anti-diabetic drugs. gastrointestinal symptoms are commonly reported adverse events in patients taking oral hypoglycemic drugs. 18 however, gastrointestinal symptoms are also very common in the world and many persons who are not taking medication also suffer from these, so a causal relationship is very difficult to prove in these adrs. furthermore, there is conflicting observations among previous studies done regarding possible risk factors for gastrointestinal side effects in diabetes patients; 19–21 and the most of the studies were lacking proper methodology. in our study, metformin was frequently associated with diarrhoea. this association between use of metformin and diarrhoea is not a new finding. a questionnairebased survey was done on 285 diabetic patients in which it was found that metformin was the most common cause of chronic diarrhoea and faecal incontinence, 20% of the patients taking metformin reported these adverse effects. 22 recently, lysy et al. 23 also found that the commonest cause of severe diarrhoea in their survey of 861 patients taking anti-diabetic medications. however, these studies haven’t investigated on other possible risk factors, like complications related to diabetes mellitus, adequate glycaemic control, sex, age distribution, or use of other concurrent medications, so authenticity of the findings can’t be confirmed. the mechanisms of pathogenesis of diarrhoea by taking metformin is not clear. dandona et al. has hypothesized that increase in intestinal motility caused by metformin can be the reason. 22 hypoglycaemia was most frequently observed in patients taking sulfonylureas. hypoglycaemia is a major limiting factor for use of sulfonylureas. in various studies, there is significant variations in prevalence and severity of hypoglycaemia caused by sulfonylureas. 24–26 in a recently conducted observational study, 27 the yearly risk for development of hypoglycaemia caused by use of sulfonylurea was 1.8% (180 per 10,000 person-years). higher hypoglycaemia risk was associated with long-acting formulations of the drug, chronic kidney disease, old age group and infrequent use of sulfonylureas. in a recent systematic review, 25 the risks of development of hypoglycaemia with the use metformin was reported to be between 0 and 21%. since metformin has no direct action on insulin release, risk of hypoglycaemia is generally low. arthralgia and back pain were reported from the patients taking dpp-4 inhibitors. studies conducted among patients with inflammatory disorders have found that decrease in dpp-4 levels are was related with more severity. 28 furthermore, busso et al. found in their study that increased level of technetium was found the synovial exudative fluid of mice who were genetically deficient with dpp-4 enzyme. 29 in some other studies, it has been found that levels several inflammatory mediators (including sdf-1 a\b) are decreased by dpp-4. sdf-1 a\b plays a vital role in the pathogenesis of inflammatory disorders and sdf-1 is also confirmed as a pro-inflammatory marker. 30 causality assessment according to who-umc criteria showed 61.68% adrs had probable causality while 37.43% had possible causality and only 0.90% had certain causality. shanthi et al. found that 64% of the adrs caused by antidiabetic drugs in their study were probable. 31 in another study conducted in a tertiary care hospital it was found that 73.33% of adr were possible. 32 most of the adrs in our study were non-preventable (57.78%) & were of mild to moderate grade. shanthi et al. found that most of the adrs in their study were not preventable (63%) as per modified schumock and thornton preventability scale and no severe adr was reported in their study. 31 4. conclusion gastrointestinal adverse effects were mostly related to dpp4 inhibitors whereas diarrhoea was frequently reported by patients taking metformin. hypoglycaemia continues to be major concern in patients taking anti-diabetic medications and sulfonylureas were commonest drugs responsible for it. there were some reports of back pain and arthralgia with the use of dpp-4 inhibitors and some other studies also reports evidences of hyperalgesia caused by dpp-4 inhibitors. the adverse effects should be taken into account while prescribing to patients with related co-morbid conditions. as anti-diabetic medication is generally taken for lifetime, the risk of development of adverse effects related to concurrent related co-morbidities of patients shouldn’t be ignored while prescribing. the physician should report these adverse effects to adr monitoring centre, so that proper signal could be generated for the welfare of the society. 5. acknowledgement we are thankful to the healthcare workers (faculty members) of igims, patna for their support. 176 hameed et al. / panacea journal of medical sciences 2022;12(1):172–176 6. conflict of interest no conflict of interest. 7. source of funding none. references 1. harrison t, kasper d. harrison’s principles of internal medicine. 18th edn. new york: mcgraw-hill medical publ. division; 2012. p. 2968– 3002. 2. brian rw, nicki rc, stuart hr, ian dp. davidsons principle and practice of medicine. 22nd edn. new york: churchil livingstone elsevier publication; 2014. p. 797–830. 3. parthasarathi g, nyfort-hansen k, milap cn. a text book of clinical pharmacy practice.2nd edn. universities press private limited; 2012. p. 104–10. 4. revikumar kg, miglani bd. a text book of pharmacy practice. 1st edn. maharashtra: career publications; 2009. p. 233–57. 5. raschetti r, morgutti m, menniti-ippolito f, belisari a, rossignoli a, longhini p, et al. suspected adverse drug events requiring emergency department visits or hospital admissions. eur j clin pharmacol. 1999;54(12):959–63. 6. soumya ma, sreelekshmi bs, smitha s, jiji kn, arun s, uma d, et al. drug utilization pattern of anti-diabetic drugs among diabetic outpatients in a tertiary care hospital. asian j pharm clin res. 2015;8(2):144–6. 7. sivasankari v, manivannan e, priyadarsini sp. drug utilization pattern of anti-diabetic drugs in a rural area of tamil nadu, south india-a prospective, observational study. int j pharm bio sci. 2013;4(1):514– 9. 8. alam m, aqil m, shah qs, kapur p, pillai k. utilization pattern of oral hypoglycemic agents for diabetes mellitus type 2 patients attending out-patient department at a university hospital in new delhi. pharmacol pharm. 2014;5(7):636–45. 9. bhattacharjee a, gupta mc, agrawal s. adverse drug reaction monitoring of newer oral anti diabetic drugs-a pharmacovigilance perspective. int j pharmacol res. 2016;6(4):142–51. 10. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care. 2012;35(1):64–71. doi:10.2337/dc12-s064. 11. idf diabetes atlas. idf.org. 2013. [cited 31 january]. . available from: https://idf.org/e-library/epidemiology-research/diabetes-atlas/ atlas-6thedition.html. 12. ramachandran a, snehalatha c. current scenario of diabetes in india. j diabetes. 2009;1(1):18–28. 13. patidar d, rajput m, nirmal n, savitri w. implementation and evaluation of adverse drug reaction monitoring system in a tertiary care teaching hospital in mumbai, india. interdiscip toxicol. 2013;6(1):41–6. doi:10.2478/intox-2013-0008. 14. the use of the who-umc system for standardised case causality assessment. available from: https://www.who.int/medicines/areas/ quality_safety/safety_efficacy/whocausality_assessment.pdf?ua=1. 15. schumock gt, thornton jp. focusing on the preventability of adverse drug reactions. hosp pharm. 1992;27(6):538. 16. hartwig sc, siegel j, schneider p. preventability and severity assessment in reporting adverse drug reactions. am j hosp pharm. 1992;49(9):2229–32. 17. singh a, dwivedi s. study of adverse drug reactions in patients with diabetes attending a tertiary care hospital. j med res. 2017;145(2):247–9. doi:10.4103/ijmr.ijmr_109_16. 18. davidson mb, peters al. an overview of metformin in the treatment of type 2 diabetes mellitus. am j med. 1997;102(1):99. doi:110. doi: 10.1016/s0002-9343(96)00353-1. 19. feldman m, schiller lr. disorders of gastrointestinal motility associated with diabetes mellitus. ann intern med. 1983;98(3):378– 84. doi:10.7326/0003-4819-98-3-378. 20. spångéus a, el-salhy m, suhr o, eriksson j, lithner f. prevalence of gastrointestinal symptoms in young and middle-aged diabetic patients. scand j gastroenterol. 1999;34(12):1196–202. doi:10.1080/003655299750024706. 21. clouse re, lustman pj. gastrointestinal symptoms in diabetic patients: lack of association with neuropathy. am j gastroenterol. 1989;84:868–72. 22. dandona p, fonseca v, mier a, beckett ag. diarrhea and metformin in a diabetic clinic. diabetes care. 1983;6(5):472–4. doi:10.2337/diacare.6.5.472. 23. lysy j, israeli e, goldin e. the prevalence of chronic diarrhea among diabetic patients. am j gastroenterol. 1999;94(8):2165–70. doi:10.1111/j.1572-0241.1999.01289.x. 24. uk prospective diabetes study (ukpds); group: effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (ukpds 34). lancet . 1998;352(9131):854–65. doi:10.1016/s0140-6736(98)07037-8. 25. bolen s, feldman l, vassy j, wilson l, yeh hc, marinopoulos s, et al. systematic review: comparative effectiveness and safety of oral medications for type 2 diabetes mellitus. ann intern med. 2007;147(6):386–99. doi:10.7326/0003-4819-147-6200709180-00178. 26. uk prospective diabetes study (ukpds) group: intensive bloodglucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (ukpds 33). lancet . 1998;352(9131):837–53. doi:10.1016/s0140-6736(98)07019-6. 27. van staa t, abenhaim l, monette j. rates of hypoglycemia in users of sulfonylureas. j clin epidemiol. 1997;50(6):735–41. doi:10.1016/s0895-4356(97)00024-3. 28. saito t, ohnuma k, suzuki h, dang nh, hatano r, ninomiya h, et al. polyarthropathy in type 2 diabetes patients treated with dpp4 inhibitors. diabetes res clin pract. 2013;102(1):e8–12. 29. busso n, wagtmann n, herling c, chobaz-peclat v, bischof-delaloye a, so a, et al. circulating cd26 is negatively associated with inflammation in human and experimental arthritis. am j pathol. 2005;166(2):433–42. 30. takashi s, yoshito h, sae n, rina i, haruka k, kenji y, et al. acute onset of rheumatoid arthritis associated with administration of a dipeptidyl peptidase-4 (dpp4) inhibitor to patients with diabetes mellitus. diabetol int. 2010;1(2):90–2. 31. shanthi m, madhavrao c. study of adverse drug reaction and causality assessment of antidiabetic drugs. int j basic clin pharmacol. 2019;8(1):56–60. doi:10.18203/2319-2003.ijbcp20185158. 32. palanisamy s, kumaran k, rajasekaran a. a study on assessment, monitoring and reporting of adverse drug reactions in indian hospital. asian j pharm clin res. 2011;4(3):112–6. author biography saajid hameed, junior resident pankaj kumar, junior resident manish kumar, associate professor lalit mohan, additional professor harihar dikshit, professor and head cite this article: hameed s, kumar p, kumar m, mohan l, dikshit h. evaluation of suspected adverse drug reactions of oral anti-diabetic drugs in a tertiary care hospital of bihar, india: an observational study. panacea j med sci 2022;12(1):172-176. http://dx.doi.org/10.2337/dc12-s064 https://idf.org/e-library/epidemiology-research/diabetes-atlas/atlas-6thedition.html https://idf.org/e-library/epidemiology-research/diabetes-atlas/atlas-6thedition.html http://dx.doi.org/10.2478/intox-2013-0008 https://www.who.int/medicines/areas/quality_safety/safety_efficacy/whocausality_assessment.pdf?ua=1 https://www.who.int/medicines/areas/quality_safety/safety_efficacy/whocausality_assessment.pdf?ua=1 http://dx.doi.org/10.4103/ijmr.ijmr_109_16 http://dx.doi.org/110. doi: 10.1016/s0002-9343(96)00353-1 http://dx.doi.org/110. doi: 10.1016/s0002-9343(96)00353-1 http://dx.doi.org/10.7326/0003-4819-98-3-378 http://dx.doi.org/10.1080/003655299750024706 http://dx.doi.org/10.2337/diacare.6.5.472 http://dx.doi.org/10.1111/j.1572-0241.1999.01289.x http://dx.doi.org/10.1016/s0140-6736(98)07037-8 http://dx.doi.org/10.7326/0003-4819-147-6-200709180-00178 http://dx.doi.org/10.7326/0003-4819-147-6-200709180-00178 http://dx.doi.org/10.1016/s0140-6736(98)07019-6 http://dx.doi.org/10.1016/s0895-4356(97)00024-3 http://dx.doi.org/10.18203/2319-2003.ijbcp20185158 429 too many requests you have sent too many requests in a given amount of time. original research panacea journal of medical science, may – august 2015:5(2);73-77 73 a comparative study of bipolar hemi-arthroplasty and total hip joint replacement for the treatment of grade iii osteonecrosis of femoral head mankar sh1, dwidmuthe sc2, mohammad faizan3, sakhare r3 abstract: total hip arthroplasty (tha) is considered as gold standard for treatment of advanced (grade iii & iv ficat arlet) osteonecrosis (avn) of femoral head. we conducted this prospective study to compare results of bipolar hemi-arthroplasty against total hip arthroplasty in patients with grade iii avascular necrosis of femoral head.36 patients with grade iii osteonecrosis of femoral head were included in this study. at an average 4 years, 16 patients with average age of 44 years (21-56 years) in tha group and 15 patients with average age of 43 years (28-45 years) in bha group were available for analysis. the average increase in hhs in tha group was 47.3points (s.d. 4.8) and 38.9 (s.d. 2.7) in bha group with t value 5.4(p-0.0001). all the patients in bha group had fair to good results. in tha group eight excellent, five good and one had fair to poor result after the surgery fair to poor results were seen in one patient in tha with dislocation in early postoperative period. bha group had one case of superficial infection at operative site. very higher incidence of groin pain and activity limitation was seen in patients with bha. tha is a better surgical option for treatment of grade iii osteonecrosis of femoral head. because of risk of groin pain, loosening, proximal migration, progression of disease and compromised function after bha, we do not recommend it in patients with grade iii osteonecrosis. keywords: avascular necrosis, bipolar hemi-arthroplasty, total hip arthroplasty. 1professor and head, 2associate professor, 3lecturer, department of orthopaedics, nkp salve ims & lata mangeshkar hospital, dig doh hills nagpur, pin-440019, india. nagpurkneeclinic@gmail.com introduction: osteonecrosis of femoral head is a progressive disease that affects patients in 3rd to 5th decade of life and if left untreated leads to complete detoriation of hip joint(1). avn is the result of loss of blood supply to femoral head due to many causes such as alcohol abuse, sickle cell disease, systemic steroids, caissons disease, gauchers disease ,renal osteodystrophy and trauma. ficat and arlet (2) have classified avn according to radiological changes. treatment of avn of femoral head varies according to stage of the disease. ficat arlet stage i, ii a may be treated with core decompression with or without secondary bone grafting procedure. the treatment stage iib is controversial. they are reports of good results with osteotomies of proximal femur in selected researchers. the results of osteotomies are not that reproducible. stage iii & stage iv femoral osteonecrosis are treated with total hip replacement and bipolar hemi-arthroplasty(3). there are conflicting reports about success of bha in stage iii avn(4-5). they quote advantage of bone preservation, less morbidity, less chances of dislocation and chances of conversion to tha at later date. many researchers have reported complications with bha like, protrusio acetabulo, anterior thigh pain, loss of mobility in bipolar bearing (6). we conducted this prospective study to compare medium term results of bipolar hemi-arthroplasty and total hip arthroplasty in patients with stage iii osteonecrosis of femoral head. we also analysed average cost of each procedure. materials & method: the prospective study was conducted at this hospital between jan 2006 to may 2013. patients with stage iii avn, consenting to participate in the study was included. patients with stage i, ii, iv avn were excluded. all the patients included the study were divided into two groups after explaining them pros and cons of each form of treatment. patients decided the type of surgery they want to undergo. group a consisted with who underwent thr and group b consisted of patients who underwent bhr. each patient was thoroughly examined preoperatively. hip function was noted with harris hip score and pain was evaluated with visual analogue scale (vas). at the start of the study 36 patients were included in the study, 20 patients in tha group and 16 in bha group. patients were allocated to different mankar sh a comparative study of bipolar hemiarthroplasty and total hip joint replacement for the treatment… panacea journal of medical sciences, may – august 2015:5(2);73-77 74 groups according to their willingness and affordability for these surgeries. four patients from tha group and one patient from bha group lost to follow up at 6 month. they were excluded from the study. at the end of study we had 16 patients in tha group and 15 in bha group. ethics: the study was approved by institutional ethical committee. written informed consent was obtained from each participant in the study. surgical technique: all the surgeries were done under spinal epidural anaesthesia. epidural catheter was kept for 48 hours for post operative pain relief and early mobilization. intravenous antibiotics, second generation cephalosporins, were given preoperatively, one hour prior to surgery and for two days thereafter. sutures were removed at average 10 days. physiotherapy was started at day one, in the form of static quadriceps, ankle pumps, and chest physiotherapy. ambulation with support was allowed on day two as per pain tolerance. early out the bed ambulation was encouraged. ankle pumps, elastic stockinet and early ambulation were used to prevent development of deep vein thrombosis. low molecular weight heparin was not used routinely except in high risk patients. average hospital stay was 14 days. all the patients were evaluated clinically at every three month till 12 months, every year thereafter. hhs and vas were determined at each visit. statistical analysis: the data obtained was analysed by calculating mean, standard deviation. the results were compared between two groups by using paired t test to calculate p value and t value. the difference was considered significance if p<0.005. results: tha group had 20 patients initially. four patients were lost to follow up so 16 patients were available for analysis at average 48 months (12-60 months) postoperatively. tha group had 12 male and four 4 female patients with average age of 44 years (21-56 years). the bha group had 16 patients initially and fifteen were available at average follow up of 48 months (12-60 months). bha group had 12 male and 3 females with average age of 43years (28-45 years). tha group had average operative operating time of 133minutes (110-145 minutes) with 737 ml of average blood loss. bha group had average operating time of 89 minutes (80-95 minutes) with 360 ml average blood loss. pain – v.a.s. (visual analogue scale) vas scores in tha group improved from 6.125 to 0.5. vas scores in bha group improved from 5.625 to 2.375. average postoperative flexion in tha group was from 116.875 degrees as compared 129.375 degrees in bhr group. average rotation in tha group was 25.625 degrees and 30.625 degrees in bha group. the average hhs in tha group increased from 41.4(standard deviation 7.3) to 88.6(standard deviation 5.6) (t value 6.5, p0.ooo1) after the surgery. the average hhs in bha group increased from 45.8(s.d. -2.4) to 84.7(s.d.-1.4) after the surgery (t value 5.4, p-0.0001). the average increase in hhs in tha group was 47.3points (s.d. 4.8) and 38.9 (s.d. 2.7) in bha group with t value 5.4(p-0.0001). the thr group had statistically significant improvement as compared to bha group. (table no.1) the results graded according to harris hip score: (91 to 100) – excellent (81 to 90) – good (71 to 80) – fair (61 to 70) – poor. all the patients in bha group had good results. in tha group eight excellent, five good and one had fair to poor result after the surgery. fair to poor results were seen in one patient in tha with dislocation in early postoperative period. the hip was reduced under anaesthesia and flexion at hip was restricted for first month in this patients. this patient had pain in the operated hip limiting their activities. bha group had one case of superficial infection at operative site, which was managed with debridement and antibiotics without any residual sequele. (chart no.1). table 1: harris hip score. harris hip score in tha group harris hip score in bha group pre post increased hhs pre post increased hhs 1 49 95 46 49 86 37 2 49 95 46 49 83 34 3 34 89 55 44 83 39 4 34 86 52 44 83 39 mankar sh a comparative study of bipolar hemiarthroplasty and total hip joint replacement for the treatment… panacea journal of medical sciences, may – august 2015:5(2);73-77 75 5 49 93 44 49 83 34 6 34 77 43 44 86 42 7 49 89 40 44 84 40 8 36 89 53 44 86 42 9 49 93 44 46 86 40 10 49 93 44 49 86 37 11 34 86 52 49 86 37 12 34 86 52 44 83 39 13 49 93 44 44 86 42 14 34 76 42 44 84 40 15 43 89 46 44 86 42 16 36 89 53 mean 41.4 88.6 47.3 mean 45.8 84.7 38.9 s.d. 7.3 5.6 4.8 s. d. 2.4 1.4 2.7 t value 6.5 5.9 t value 5.4 p value 0.00001 0.00001 p value 0.0 chart: 1 discussion: bipolar hemi-arthroplasty has been in been used as treatment for advanced cases of avn femoral head. the published literature is full of conflicting results with this procedure. alonge to et al (5) evaluated results of cementless bipolar hemi-arthroplasty done for secondary osteoarthritis resulting from osteonecrosis of femoral head in sickle cell disease in six patients. they reported good results with this procedure with advantage of avoiding damage to acetabulum and ease of revision surgery if needed in future. we had six patients with sickle cell disease in our group, two in bhr group and four in thr. all this patients had good to fair results at last follow up. the patients with sickle cell disease usually presents late with advanced changes of arthritis warranting tha in most of the cases. nagai i et al(8) from japan the long-term results of bipolar endoprosthetic replacement in 12 patients (12 hips) 12 to 18 years after surgery. these patients had ficat stage iii nontraumatic osteonecrosis of the femoral head. 11 of 12 patients did not required any 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 pre post pre post tha bha m e a n h h s s co re mankar sh a comparative study of bipolar hemiarthroplasty and total hip joint replacement for the treatment… panacea journal of medical sciences, may – august 2015:5(2);73-77 76 revision surgery for first ten years. three patients underwent revision to thr at 3, 17 and 17 years for prosthesis migration. they concluded that the original bateman endoprosthesis was effective in delaying the need for total hip replacement for more than 10 years in patients with ficat stage iii nontraumatic osteonecrosis of the femoral head. tsumura h (9) studied 36 hips in 30 patients with osteonecrosis of the femoral head who were treated with bipolar hip arthroplasty followed up for average 7.7 years radiographically, there was minimal migration in group i. there was a statistical significance in superior migration between subgroups with and without osteolysis in group ii (p < .01).they emphasized that bipolar hip arthroplasty is indicated for ficat stage ii or iii in osteonecrosis of the femoral head. we did not analyse the radiological osteolysis routinely in our study. we did not have any case of superior migration of prosthesis at 48 month follow up. it is recommended to use modular bipolar prosthesis with possibility of future conversion to tha using same femoral stem. sulaiman alazzawi et al (10) in their study of concluded that conversion to total hip replacement from bipolar replacement for femoral neck fracture is low. in their study out of 164 patients only one patient underwent conversion to tha at the end of one year. rest three patient underwent conversion to tha for infection, dislocation and fracture. none of the patient in our study underwent revision to thr at average follow up of four year. kim et al (4) conducted to a study to effect of bipolar arthroplasty on acetabular erosion, joint motion and osteolysis in 134 patients. the mean degeneration rate of acetabular cartilage was 0.34 ± 0.35 mm/year. they observed that the outer bearing motion was dominant, but decreased over time. in addition, the degeneration rate of cartilage and the decline rate of outer bearing motion of the osteolysis group were significantly higher than those of the control group. they recommended close observation is needed in cases of high degeneration rate of cartilage and rapid decline of outer bearing motion due to possibility of osteolysis. we did not analyse the movement of bipolar bearing in all patients, we did in three patients. all these three patients showed loss of movement in inner bearing at an average 2 years without affecting good clinical outcome. moriya m et al (6) evaluated results of bha done for steroid -induced osteonecrosis of femoral head in 27 patients followed for ten years, japan orthopaedic association (joa) hip score. kaplan-meier survivorship was calculated to examine revision arthroplasty failure rate. radiographic analysis of loosening included radiolucent lines and osteolysis of the acetabulum or femur. joa hip score increased from 53 points (preoperative) to 87 points (final follow-up). survival rates were 96.8 % and 78.6 % at ten and 15years, respectively. prosthesis loosening occurred on the acetabular side in five hips (13.5 %). no femoral-component loosening was observed. bha had poor results in patients with association research circulation osseous (arco) stage iv onfh and in patients’ over 40 years of age. they recommended bha for patients with arco stage iv onfh or for patients under 40 years of age. these findings are consistent with our study. none of the patient in our study had femoral stem loosening in both the groups. acetabular loosening was seen in two patients in thr group but was not significant enough warranting revision. cao cf et al (11) reviewed clinical and radiological results of bipolar hip arthroplasty with a cementless porous-coated anatomic femoral component in 86 hips at mean of 5.2 years utilizing harris hip score and radiographic evaluation based on the criteria of the hip society. at the mean follow-up of 5.2 years, the average harris hip score was 96.1 ± 2.1 (range, 67-100) points, pain score 42.6 ± 6.3 (range, 32-54) points and functional score 45.5 ±4.7 (range, 29-56) points. they reported pain in the anterior part of the thigh in five hips (5.81%), revision of the femoral component because of aseptic loosening and periprosthetic fracture in two hips (2.33%). twentyseven femoral components (31.4%) had associated slight pedestal formation. no osteolytic lesions of the femur were identified. nonprogressive pelvic osteolysis was identified in four hips, none of the lesions being ≥2mm in diameter. they concluded that an anatomically designed prosthesis can provide good clinical results, with low incidence of thigh pain and loosening of the component. in our study, vas scores improved better in tha group as compared to bha group. four patients in bha group complained of anterior thigh pain, but were able to carry out their routine activities. lee sb et al (12) from japan in their prospective study compared the results of cementless bipolar arthroplasty to cementless total hip replacement for ficat stage iii osteonecrosis of femoral head, age, gender matched group of patients. they found better postoperatives scores with total hip replacement group as compared to bipolar group. they recommended total hip replacement because of more incidences of gluteal and groin pain and migration in these patients with bipolar hemi-arthroplasty. we had more incidence of groin pain in patients with bha as compared to tha. the overall patient satisfaction was more in patients in total hip arthroplasty. the activity limitation was more in bipolar group. mankar sh a comparative study of bipolar hemiarthroplasty and total hip joint replacement for the treatment… panacea journal of medical sciences, may – august 2015:5(2);73-77 77 the limitation of the present study is small sample size, shorter duration of follow up, lack of radiological follow up and lack of randomisation. however this study highlight that even today in this subcontinent cost of prosthesis remains the deciding factor. bha is still commonly used as a cheaper alternative to tha. conclusion: bipolar arthroplasty in patients with grade iii osteonecrosis of femoral head gives fair to good results as compared to good to excellent results with tha. because of risk of groin pain, loosening, proximal migration, progression of disease and compromised function after bha, we do not recommend it in patients with grade iii osteonecrosis. tha remains the gold standard for treatment of advances osteonecrosis of femoral head. we however recommend long term randomised trial to compare the results of this two procedure. references: 1. canale st, beaty jh, campbells operative orthopaedics, in: miscellaneous nontraumatic disorders, mosby elsevier, philadelhpia,2008. 2. ficat rp, arlet j, necrosis of the femoral head. in: hungerford ds, ed. ischemia and necrosis of bone, baltimore: williams & wilkins; 1980. 3. temitope 0. alonge, , wuraola a. shokunbi, the choice of arthroplasty for secondary osteoarthritis of the hip joint following avascular necrosis of the femoral head in sicklers nigeria journal of the national medical association vol. 96, no. 5, may 2004, 678-682 4. kim ys, kim yh, hwang kt, choi iy. the cartilage degeneration and joint motion of bipolar hemiarthroplasty. . int orthop. 2012 oct;36(10):2015-20 5. alonge to, shokunbi wa. the choice of arthroplasty for secondary osteoarthritis of the hip joint following avascular necrosis of the femoral head in sicklers. j natl med assoc. 2004 may;96(5):678-81. 6. moriya m, uchiyama k, takahira n, fukushima k, yamamoto t, hoshi k, itoman m, takaso m. evaluation of bipolar hemi-arthroplasty for the treatment of steroid-induced osteonecrosis of the femoral head. int orthop. 2012 oct;36(10):2041-717. 7. harris wh. traumatic arthritis after of the hip joint after dislocation and acetabular fractures: treatment by mold arthroplasty. an end-result study using a new method of result evaluation. j.bone joint surg am 1969:51:737-55. 8. nagai i, takatori y, kuruta y, moro t, karita t, mabuchi a, nakamura k. nonself-centering bateman bipolar endoprosthesis for nontraumatic osteonecrosis of the femoral head: a 12to 18-year follow-up study. j orthop sci. 2002;7(1):74-8. 9. tsumura h, torisu t, kaku n, higashi t. fiveto fifteen-year clinical results and the radiographic evaluation of acetabular changes after bipolar hip arthroplasty for femoral head osteonecrosis. j arthroplasty. 2005 oct;20(7):892-7. 10. sulaiman alazzawi, mrcs, walter b sprenger de rover, mrcs*, 11. cao cf, zhou jj, pang jh, chen xq. a five-year clinical and radiographic follow-up of bipolar hip arthroplasty with insertion of a porous-coated anatomic femoral component without cement. orthop surg. 2011 may;3(2):88-94. 12. lee sb, sugano n, nakata k, matsui m, ohzono k. comparison between bipolar hemi-arthroplasty and tha for osteonecrosis of the femoral head. clin orthop relat res. 2004 jul;(424):161-5. panacea journal of medical sciences 2022;12(2):430–435 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a study of critical value analysis at hematology and biochemistry sections of laboratory in a multispeciality hospital shubha h.v1,* 1dept. of pathology, sapthagiri institute of medical sciences and research centre, chikkabanavara, chikkasandra, bangalore, karnataka, india a r t i c l e i n f o article history: received 27-08-2022 accepted 04-10-2022 available online 17-08-2022 keywords: critical value notification critical call out critical alert short message service (sms) turn around time (tat) a b s t r a c t background: the issue of laboratory critical value (cv) reporting has gained importance in the recent times due to the national focus on patient safety. critical value notification (cvn) has become an essential part of accreditation procedures for medical laboratories, including the universally accepted international organization for standardization (iso) 15189: 2012. aims and objectives: our study aimed to analyze the critical value data in hematology and biochemistry sections of the laboratory, to compare the frequencies of critical values for different parameters and to suggest measures for improving the effectiveness and operational efficiency of the critical value notification process. materials and methods: our study was a retrospective, cross-sectional, descriptive study done over a period of one year six months (january 2020 to june 2021). the parameters chosen for cvn included platelets, hemoglobin and international normalized ratio (inr) from hematology section and creatinine, glucose, sodium, potassium and calcium from the biochemistry section. a test result that was significantly outside the normal range and that required immediate communication was considered as a “critical value (cv)”. both verbal (through telephone) and non-verbal [through short message service (sms)] communication processes for cvn were implemented in our lab. we also followed the practice of cv “read-back” by the person who was informed over the phone. results: a total of 2199 critical values were reported. a maximum of 1224 (55.7%) critical values were recorded from the emergency department. cvs were highest from biochemistry (1898, 86.3%) section. analyte most commonly notified was creatinine (1151, 52.3%). cvns were maximum in the morning shifts (1378, 62.7%). conclusions: implementation of the critical alert short message service (sms) send outs has greatly helped us in reducing the cv turn around time (tat). our study has successfully demonstrated the importance of both verbal and non-verbal communication processes for notification of cvs. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction the identification and timely communication of critical values are still considered as essential elements of good laboratory performance. the issue of laboratory critical value (cv) reporting has gained importance in the recent * corresponding author. e-mail address: drshubhahv@gmail.com (shubha h.v). times due to the increasing focus on patient safety worldwide. critical value notification (cvn) has become an integral part of accreditation procedures for medical laboratories, including the universally agreed international organization for standardization (iso) 15189: 2012. 1 cvn is of utmost importance to instantly communicate the cvs to clinicians for faster diagnostic approach and quick changes in the patient management decisions. the joint commission https://doi.org/10.18231/j.pjms.2022.081 2249-8176/© 2022 innovative publication, all rights reserved. 430 shubha h.v / panacea journal of medical sciences 2022;12(2):430–435 431 (jc) defines a critical test as “a test that requires immediate communication of result irrespective of whether it is normal, significantly abnormal or critical”. 2 this definition is also shared by many other organizations such as the clinical and laboratory standards institute (clsi) and the royal college of pathologists (rcp). 3,4 critical value is instead defined by the jc as “a test result that is significantly outside the normal range and may represent life-threatening values”. 2 in small laboratories, the selection of critical value limit ranges, preparation of a standard list or target turn around time (tat) for reporting of critical results is very difficult due to the absence of consensus in laboratory community. 5 it is, therefore, important that the laboratories must make an agreement on the list of parameters and the critical value limits of each of them, which should be established and followed by each laboratory. this helps in eliminating the problem of diluting the urgency of the critical value call due to expansion of critical call out lists. 5,6 the college of american pathologists (cap) checklist states about the importance of documentation that the cv results have been notified to caregivers. moreover, the cap com.30100 states that electronic transmission of cvs is acceptable. the laboratories must confirm the receipt of cv result by the intended recipient and no read back is required. 7 2. aims and objectives 1. to analyze the critical value (cv) data in hematology and biochemistry sections of the laboratory. 2. to compare the frequencies of critical values for different parameters. 3. to suggest measures for improving the effectiveness and operational efficiency of the critical value notification (cvn) process. 3. materials and methods the present study was of a retrospective, cross-sectional, descriptive design spanning over a period of one year six months (january 2020 to june 2021). in the present study we aimed to analyze the critical value data in the hematology and biochemistry sections of our laboratory and compare the frequencies of critical values for different parameters. a total of 75,156 tests were performed during the study period. the test requests were received from out-patient departments (opd) which included master health checkups, in-patient departments [intensive care units (icus), wards and operation theatres] and emergencies. out of 75,156 tests, 16530 and 20638 tests were from hematology and biochemistry sections respectively. a total of 2199 critical values were reported from these two sections. 3.1. critical value notification process the list of parameters from hematology and biochemistry sections which were selected for the critical value notification (cvn) and also their critical value limit ranges were developed after discussing with the treating physicians, surgeons, icu and emergency doctors as per their requirements for management of patients. accordingly, the parameters which were selected by the laboratory for cvn included platelets, hemoglobin and international normalized ratio (inr) from hematology section and creatinine, glucose, sodium, potassium and calcium from the biochemistry section. the analytical reliability of cvs were checked and then after ruling out the pre-analytical errors, the laboratory technologists ensure the validation of the result by repetition of test or by recalibration of the parameter if necessary and/or by checking the quality control (qc) results. once the result is validated, and it is in the critical range (upper or lower), the laboratory technologists notify the value to the responsible caregiver (treating physicians, surgeons, icu/ emergency doctors, nursing staff or the consultants) telephonically and at the same time the result is also entered in the critical value call out log sheet. details such as the accession number, parameter, care area, person’s name who informs the critical value, person’s name to whom the critical value is notified, contact number, date and time of call out, the examination result conveyed with the measuring unit and reference range, examination result confirmed by “read back” are entered. laboratory also follows the practice of cv “read-back” by the person who was informed over the phone. the critical value call out log is then signed by the laboratory head/ pathologist in-charge. in order to facilitate and speed up the process of cvn especially of the opd patients, we also have developed an in-house laboratory information system (lis) software which automatically flags the test results requiring cvn as the critical value limit ranges of the parameters requiring cvn are tagged with the lis. short message service (sms) are sent to the concerned treating doctors whose phone numbers are linked with the lis. we also can monitor whether the sms is forwarded or failed to the responsible caregivers. in case, if the sms is not forwarded, then the lab technologist notifies the cv to the concerned caregiver telephonically and enters the details in the critical call out log sheet. 3.2. statistical analysis the obtained parameters were evaluated using the descriptive statistical analysis. the statistical analyses were done using the ibm spss (statistical package for the social sciences v 20.0) and microsoft office excel 2007 software. 432 shubha h.v / panacea journal of medical sciences 2022;12(2):430–435 4. r esults the present study was a retrospective study conducted in the hematology and biochemistry sections of laboratory at fortis multispeciality hospital, bangalore. the lab received blood samples from out-patient departments (opds) including master health checkups, in-patient departments [intensive care units (icus), wards and operation theatres (ots)] and emergencies. a total of 2199 critical values were reported by the lab. a maximum of 1224 (55.7%) critical values were recorded from the emergency department followed by ipd (900, 40.9%) and opd (75, 3.4%) departments (table 1). a total of 75,156 tests were performed in the lab over a period of one year and six months (january 2020 to june 2021). the parameters which were selected by the laboratory for cvn were platelets, hemoglobin and international normalized ratio (inr) from hematology section and creatinine, glucose, sodium, potassium and calcium from the biochemistry section. the critical value limit ranges of different parameters are shown in table 2. out of 75,156 tests, hematology tests constituted a total of 16,530 (21.9%) and biochemistry tests accounted for 20,638 (27.4%). out of 16,530 hematology tests, platelets, hemoglobin and inr together accounted for 13696 tests and out of 20,638 biochemistry tests, creatinine, glucose, sodium, potassium and calcium accounted for 15,566 tests. critical values constituted 2.92% of the total test results (75,156) reported by the lab. majority of the critical values were resulted in the biochemistry (1898, 86.3%) section. hematology accounted for only 13.7% (301 test results) of the critical alert values (table 3). the analytes most commonly notified for critical value were creatinine (1151, 52.3%), followed by potassium (350, 16%), sodium (200, 9.1%), glucose (167, 7.6%) and platelets (165, 7.5%) (table 3). critical value notifications were maximum in the morning shifts (1378, 62.7%) and minimum in the night shifts (100, 4.5%) (figure 1). the following measures were implemented in our laboratory for improving the effectiveness and operational efficiency of the critical value notification process: 1. an in-house laboratory information system (lis) software was developed which automatically flags the test results requiring cvn and sends short message service (sms) to the concerned caregivers. we also monitored whether the sms was forwarded or failed to the responsible caregivers. in case, if the sms was not forwarded, then the lab technologist notified the cv to the concerned caregiver telephonically and also entered the details in the critical call out log sheet. implementation of the critical alert short message service (sms) send outs to deliver the cvs greatly helped us in reducing the cv turn around time (tat) especially in the out-patient department area. electronic communication of cvs also has avoided the possible errors in communication and has shortened the notification times. 2. incorporating the mechanism of delta checks (i.e., to detect any change in the present test result from previous results) into lis which serves as a second flagging layer, in addition to an electronic critical value alert. 3. training the laboratory staff for the policy of laboratory critical value notification process and documenting the same in the log sheets. 4. long and complex list of critical values were avoided and a concise list was prepared as increased number of calls may weaken the urgency of critical value call leading to unnecessary interference for clinicians. 5. the established list of critical values were regularly reviewed, revised and updated in consultation with the clinicians. fig. 1: distribution of critical value data in each shift 5. discussion the present study was conducted over a period of one year six months (january 2020 to june 2021). a total of 75,156 tests were performed during the study period. the critical value notification was highest in the emergency area (55.7%). majority of the critical values were resulted in the biochemistry (1898, 86.3%) section. hematology accounted for only 13.7% (301 test results) of the critical alert values. the analytes most commonly notified for critical value were creatinine (1151, 52.3%), followed by potassium (350, 16%), sodium (200, 9.1%), glucose (167, 7.6%) and platelets (165, 7.5%).table 4 shows the comparison of frequencies of critical values of our study with that of the others. thus, this study focusses on the need for analysing the critical value frequencies in laboratories to identify the parameters with highest critical values. laboratories must list out the parameters for cvn and set the cv limit ranges in consultation with the clinicians. this helps to modify clinical management of the patients and thus can be very useful for both clinicians and patients. moreover, this will shubha h.v / panacea journal of medical sciences 2022;12(2):430–435 433 table 1: distribution of the critical values byclinical care areas. clinical care area total no. of critical values percentage opd with master health check ups 75 3.4 ipd (icu, wards, ots) 900 40.9 emergency 1224 55.7 total 2199 100 table 2: list of critical value limit ranges of different parameters in hematology and biochemistry sections. s.no. parameter lower limit upper limit hematology 1. platelets 40,000/cumm 10,00,000/cumm 2. hemoglobin 6.0 g/dl 20 g/dl 3. inr >5 biochemistry 1. creatinine >3.0 mg/dl 2. glucose 50 mg/dl 400 mg/dl 3. sodium 120 meq/l 160meq/l 4. potassium 2.5 mmol/l 6.0 mmol/l 5. calcium 6.5 mg/dl 13.0 mg/dl table 3: distribution of critical values for different parameters tested s.no. parameter total test volume critical test results percentage of critical test results percentage of test volume with a critical result hematology 1. platelets 5580 165 7.5 2.95 2. hemoglobin 4916 66 3.0 1.34 3. inr 3200 70 3.2 2.18 total hematology 13696 301 13.7 biochemistry 1. creatinine 8428 1151 52.3 13.65 2. glucose 3421 167 7.6 4.88 3. sodium 1678 200 9.1 11.91 4. potassium 1704 350 16.0 20.53 5. calcium 335 30 1.3 8.95 total biochemistry 15566 1898 86.3 total 29262 2199 100 serve as an important tool to initiate a healthy interaction between the clinicians and the laboratory staff and in turn, will prove beneficial in the long term. 8 appropriate and timely management of patients largely depends on the clinical communication. ambiguous communication or failure to communicate on time can cause delayed treatment and also the patient’s safety is threatened. 11 numerous reports have proved the ability of information technology to speed up the process of critical value reporting. 12,13 automatic communication with the responsible provider due to increasing use of information technology (it) has proved to reduce the cv reporting time. in a study conducted by lynn tj et al., in order to improve communication between clinical providers and the laboratory, the secure text messaging (stm) for cvn was implemented. 14 in our study too, the use of sms to deliver cvs was efficient and reliable. our results are consistent with the study conducted by lynn tj et al., that employed technology to automate the cvn process. an electronic reporting system potentially could create dangerous delays in communication if not properly put into use. the system needs to have an “acknowledgment” function such that the laboratory can ensure that the responsible caregiver received the result. electronic systems also require an intense procedure so that lack of acknowledgment of the critical test result elicits an alternative way for communication. 5 in the present study, we monitored whether the sms was forwarded or failed to the responsible caregivers. in case, if the sms was not forwarded, then the lab technologist notified the cv to the concerned caregiver telephonically and entered the details in the critical call out log sheet. one of the major challenges in cvn process lies in the opd area because unlike inpatients, there is no fixed patient location to which the cv can be telephonically notified.5 introduction of critical alert sms send outs in opd cases 434 shubha h.v / panacea journal of medical sciences 2022;12(2):430–435 table 4: table showing comparison of our study with other studies s. no. study duration total tests total no. of critical values percentage of critical values to total tests sections included no. of analyt-es analyte with highest frequency 1. namrata bhutani et al. 8 2 months 183056 11875 6.5 emergency biochemistry 8 (in adults) potassium (2933,8.3%) 2. desai kn et al. 9 24 months 90,000 19423 21.6 hematology (h) and clinical pathology (cp) h-9 cp-2 hematologyhemoglobin (5212, 26.8%) cpurine ketone bodies (3100, 16.0%) 3. dighe as et al. 5 12 months 14000000 37503 0.25 biochemistry (bc) and hematology (h) bc-14 h-6 bc-potassium (7955, 21.2%) h-partial thromboplastin time (ptt) (5467, 14.6%) 4. agarwal r et al. 10 25 months 478,980 1187 0.25 clinical chemistry 6 sodium (249, 20.97%) 5. present study 18 months 75,156 2199 2.92 biochemistry (bc) and hematology (h) bc5 h-3 bccreatinine (1151, 52.3%) h-platelets (165, 7.5%) has helped a lot to inform the cv to the concerned doctor in our study. telephonic communication of the cv to the clinicians definitely has reduced the time needed for diagnosis and to commence treatment, hence decreasing the associated morbidity and mortality. it was also observed that the cvns were highest in the morning shifts (1378, 62.7%) and minimum in the night shifts (100, 4.5%). this may be attributed to the increased test volume during the peak working hours in mornings and active communication process due to increased number of technical staffs in the morning shifts. similar findings were observed in a study by desai kn et al. 9 this study has also emphasized on the measures to improve the cvn process. agarwal r et al. have highlighted on the importance of cvn policy which includes list of parameters for which cv should be notified, laboratory staff responsible for notifying cv and the person to whom cv will be notified, tat and the communication method. they have also mentioned about the maintenance of a log book for the same. 10 in the present study too we gave importance on maintaining the critical call out logsheets which had similar details as mentioned by agarwal r et al. in a study by saffar h et al., it was suggested that routine repeat of hematology and biochemistry critical test result was not necessary and it may adversely affect the patient safety measure. 15 cvn process implemented through a well-planned approach, rather than a commitment for clinical laboratories, is a right for the patient in order to ensure safety. it also plays a pivotal role in healthcare systems and has proved to be both cost saving and life saving. 16 6. conclusion the efficient and timely communication of critical test results is an essential responsibility of laboratories. information technology (it) is increasingly becoming an essential component of medical laboratories, thus unwinding interesting perspectives also for the immediate communication with the clinicians. the critical value notification was highest in the emergency area (55.7%) and in the biochemistry section (86.3%) in our study. implementation of the critical alert short message service (sms) send outs to deliver the cvs has greatly helped us in reducing the cv turn around time especially in the out-patient department area. our study has successfully demonstrated the importance of both verbal and non-verbal communication processes for notification of cvs. it has also highlighted on the significance of employing innovative new measures to improve the cvn process. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest shubha h.v / panacea journal of medical sciences 2022;12(2):430–435 435 references 1. lippi g, mattiuzzi c. critical laboratory values communication: summary recommendations from available guidelines. ann transl med. 2016;4(20):400. doi:10.21037/atm.2016.09.36. 2. joint commission. 2016 national patient safety goals [accessed 22 september 2016]. available from: https://www.jointcommission.org/ hap_2016_npsgs. 3. clinical and laboratory standards institute (clsi). management of criticaland significant-risk results, 1st edition. clsi guideline gp47. available from: http://shop.clsi.org/c.1253739/site/sample_ pdf/gp47ed1_sample.pdf. 4. campbell c, caldwell g, coates p, flatman r, georgiou a, horvath ar, et al. consensus statement for the management and communication of high risk laboratory results. clin biochem rev. 2015;36(3):97–105. 5. dighe as, rao a, coakley ab, lewandrowski kb. analysis of laboratory critical value reporting at a large academic medical center. am j clin pathol. 2006;125(5):758–64. doi:10.1309/r53x-vc2u5ch6-tng8. 6. lundberg gd. when to panic over abnormal values. med lab observer. 1972;4:47–54. 7. commission on laboratory accreditation. 2018 laboratory general checklist. northfield, il: college of american pathologists; 2018. 8. bhutani n, bhutani n. a study of analysis of critical values at emergency biochemistry laboratory in a tertiary care hospital in india. j evolution med dent sci. 2020;9(12):957–60. doi:10.14260/jemds/2020/206. 9. desai kn, chaudhari s. analysis of critical values in nabl (national accreditation board for testing and calibration laboratories) accredited hematology and clinical pathology laboratory. annf appl bio-sci. 2017;4(1):a14–8. doi:10.21276/aabs.2017.1317. 10. agarwal r, chhillar n, tripathi cb. study of variables affecting critical value notification in a laboratory catering to tertiary care hospital. indian j clin biochem. 2013;30(1):89–93. doi:10.1007/s12291-013-0409-x. 11. the joint commission for the accreditation of healthcare organizations. accreditation manual for pathology and clinical laboratory services. chicago, il: the joint commission for the accreditation of healthcare organizations; 2018. 12. bates dw, pappius e, kuperman gj, sittig d, burstin h, fairchild d, et al. using information systems to measure and improve quality. int j med inform. 1999;53:115–24. 13. tate ke, gardner rm, weaver lk. a computerized laboratory alerting system. computers med pract. 1990;7(5):296–301. 14. lynn tj, olson je. improving critical value notification through secure text messaging. j pathol inform. 2020;11:21. doi:10.4103/jpi.jpi_19_20. 15. saffar h, abdollahi a, hosseini as, farsani mt, hajinasrollah g, mohaghegh p, et al. necessity of routine repeat testing of critical values in various working shifts. iran j pathol. 2020;15(3):161–6. doi:10.30699/ijp.2020.99403.1980. 16. campuzano g. critical values in the clinical laboratory: from theory to practice. med lab (ed ital). 2011;17(07-08):331–50. author biography shubha h.v, assistant professor cite this article: shubha h.v. a study of critical value analysis at hematology and biochemistry sections of laboratory in a multispeciality hospital. panacea j med sci 2022;12(2):430-435. http://dx.doi.org/10.21037/atm.2016.09.36 https://www.jointcommission.org/hap_2016_npsgs https://www.jointcommission.org/hap_2016_npsgs http://shop.clsi.org/c.1253739/site/sample_pdf/gp47ed1_sample.pdf http://shop.clsi.org/c.1253739/site/sample_pdf/gp47ed1_sample.pdf http://dx.doi.org/10.1309/r53x-vc2u-5ch6-tng8 http://dx.doi.org/10.1309/r53x-vc2u-5ch6-tng8 http://dx.doi.org/10.14260/jemds/2020/206 http://dx.doi.org/10.21276/aabs.2017.1317 http://dx.doi.org/10.1007/s12291-013-0409-x http://dx.doi.org/10.4103/jpi.jpi_19_20 http://dx.doi.org/10.30699/ijp.2020.99403.1980 panacea journal of medical sciences 2022;12(1):73–76 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article evaluation of serum vitamin d3 level in vitamin d3 supplemented 9 to 12 months old children in a tertiary care hospital tanmay mondal1, pradip saha2, sudip saha1,* 1dept.of paediatrics, chittaranjan seva sadan hospital, kolkata, west bengal, india 2dept. of cardiology, institute of post graduate medical education and research, kolkata, west bengal, india a r t i c l e i n f o article history: received 04-04-2021 accepted 16-08-2021 available online 30-04-2022 keywords: vitamin d3 electrochemiluminescence immunoassay vitamin d deficiency a b s t r a c t introduction: vitamin d deficiency has emerged as a significant public health problem throughout the world. even in the indian context, it has been reported to be present in majority of children in spite of wide availability of sunlight. our objective was to evaluate serum vitamin d3 level in vitamin d3 supplemented 9 to 12 months old children in a tertiary care hospital. materials and methods: a cross sectional study was conducted in the patients aged 9 months to 12 months attending out patient department and ward of tertiary care mother and child hospital, department. of paediatrics between april, 2019 to march, 2020.blood sample was collected and analysed by the electrochemiluminescence immunoassay (eclia) with the help of hitachi elecsys cobas e411 to estimate 25-oh-d level after getting proper consent. result: the study done among 100 vitamin d3 supplemented 9 to 12 months old children in a tertiary care hospital resulted standard error 0.0952 and standard deviation 0. 9522. the children who had regularly taken vitamin d3 at 400iu/day since birth showed minimum vitamin d3 level at 22.34ng/ml and maximum vitamin d3 level found is 98.18ng/ml with a mean value of 40.67ng/ml that is sufficient. conclusion: in our study we have found that if children are given vitamin d3 regularly since birth at 400iu/day the attain desired serum vitamin d3 level irrespective of the brand/preparation. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction vitamin d deficiency is a very common nutritional deficiency 1 and also the most common undiagnosed medical conditions in the world. vitamin-d is a hormone that is active throughout the whole body to regulate calcium and bone metabolism. it also decreases the risk of chronic diseases including auto immune diseases, some malignancies, cardiovascular and infectious diseases. it has been estimated that nearly 1 billion people worldwide have vitamin d deficiency or insufficiency. 2 in india majority of population lives in areas receiving ample sunlight throughout the year, but still vitamin d deficiency is very * corresponding author. e-mail address: sudipsaha1973@gmail.com (s. saha). common in all the age groups and both sexes across the country. 3–5 the prevalence of vitamin d deficiency now is 50-90 % in the indian subcontinent and is attributed to low dietary calcium along with the skin colour and changing lifestyle. 3 vitamin d is deficient in breastfed infants at one end and in older children dietary calcium deficiency at the other end. between these two extremes, it is likely that vitamin d insufficiency and decreased calcium intake or relatively high phytate intake combine to induce vitamin d deficiency and rickets, which sometimes may be the most frequent cause of rickets globally. 6 vitamin d deficiency is defined as serum level of 25(oh)d less than 20ng/dl. it has been estimated the serum 25(oh)d level of 20ng/dl meet the needs of at least 97.5% of entire population across https://doi.org/10.18231/j.pjms.2022.014 2249-8176/© 2022 innovative publication, all rights reserved. 73 74 mondal, saha and saha / panacea journal of medical sciences 2022;12(1):73–76 all age groups in developed countries. 7 hence it has been concluded by institute of medicine (iom) that 25(oh)d levels >20ng/dl indicates vitamin d sufficiency. 8 serum 25(oh)d levels between 12-20ng/ml(30-50nmol/l) as insufficient and <12ng/ml (<30nmol/l) as deficient. 9 the best available indicators of vitamin d status is 25(oh)d which is the major circulating form of vitamin d with half-life of 2-3 weeks. the recommended vitamin d intake is 400iu/day in infants less than 1 year and 600 iu/day in children more than 1 year of age. (10-12) post supplementation the level of vitamin d3 has not been evaluated so far. so, there is immediate need to assess the bio-availability and requirement of vitamin d3 in children aged at 9 to 12 months. 2. materials and methods it was a crosssectional study done in the opd and ward of a tertiary care hospital between april,2019 to march,2020. the study was conducted among 100 children aged between 9 months to 12 months, who have received vitamin d3 400 iu/day. 2.1. exclusion criteria the patients who are critically sick & hemodynamically unstable or with known metabolic bone disease or chronic disease known to be associated with bone abnormalities, gut (inflammatory bowel disease, celiac disease), chronic liver disease and metabolic and endocrine diseases or on concurrent medication which is likely to interfere with vitamin d metabolism (phenytoin, phenobarbitone, carbamazepine, isoniazid, rifampicin) and parents not giving consent. after obtaining detailed informed consent, the children were undertaken for study. a pre-designed proforma was filled which included a detailed history, systemic examination, investigations. 4 ml of clotted blood was collected and analysed by the electrochemiluminescence immunoassay (eclia) with the help of hitachi elecsys cobas e411 to estimate 25-ohd level. the data were entered into the microsoft excel enterprise 2007 spreadsheet. the analysis of the available data was done by using ibm spss statistics for windows, version 22.0. armonk, ny: ibm corp. 2013. 3. results and analysis 100 total children taken for the study of which 47 were male and 53 were female. the table 1 shows that the study done among 100 vitamin d3 supplemented 9 to 12 months old children in a tertiary care hospital resulted standard error 0.0952 and standard deviation 0.9522 the children who were regularly given vitamin d3 at 400iu/day since birth showed minimum vitamin d3 level at 22.34ng/ml and maximum vitamin d3 level at 98.18ng/ml with a mean value of 40.67ng/ml. the table 2 shows that among 47 male children mean vitamin d3 level is 41.29ng/ml where standard deviation is 9.61 and mean standard error is 1.40. among 53 girl children mean vitamin d3 level is 40.13ng/ml where standard deviation is 14.08 and standard error is 1.93. test statistics showed p>0.05, therefore there is no gender preponderance. the table 3 shows that the study done among 100 vitamin d3 supplemented 9 to 12 months old children showed mean values does not differ a lot among different age groups. vitamin d deficiency is commonly being detected in india as well as worldwide.studies from various parts of india and among all age groups from neonates to adolescents aswell as pregnant and lactating mothers have reported vitamin d deficiency. a study done by v.jain at the all india institute of medical sciences, new delhi, revealed 98 infants born at term with appropriate weight aged 2.5 to 3.5 months, revealed that vitamin d deficiency and insufficiency was found to be high in breastfed infants. 10 another study conducted by harinarayanan cv & joshi sr. showed that vitamin d deficiency is epidemic in india despite of plenty of sunshine. 3 wagner cl et al. showed that circulating 25-hydroxyvitamin d levels in fully breastfed infants on oral vitamin d supplementation showed mean value of 43.6ng/ml and 42.5ng/ml at the age of 4 months and 7 months respectively. 11 in their study as defined by circulating 25(oh) d levels <20 ng/ml, 24 infants out of the 33 infants (72.7%) had evidence of deficiency at one month of age. the change in values between 1 and 4 months and 1 and 7 months was statistically significant (p ≤ .0001). as predicted, no statistically significant differences were observed between months 4 and 7 (p =.66). repeated measures anova indicated overall significance (p < .0001). no toxicity was detected in the infants based on serum calcium, phosphorus, and creatinine levels, neither any adverse health effects were seen with vitamin d supplementation. they concluded that 400iu per day of an oil emulsion vitamin d3 preparation is effective in raising the infants’ levels to the desired target of >30 ng/ml. infant’s 25(oh)d levels consistently and significantly increased to a plateau by three months of therapy on the daily oil emulsion preparation dispensed as 400iu per day. overall, the infant’s circulating 25(oh)d levels increased 37% above baseline. it is not surprising that the infants who are almost solely dependent on the mother for their vitamin d have corresponding deficiency. their findings in that study support the recent recommendation of starting vitamin d supplementation in all breastfed infants within the first few days after delivery. the 400 iu/day dose was adequate in helping the infant maintain adequate vitamin d status during the six-month study period. this result correlates with our study which has shown mean mondal, saha and saha / panacea journal of medical sciences 2022;12(1):73–76 75 table 1: descriptive statistics of age and vitamin d3. n= 100 n minimum maximum mean std. deviation statistic statistic statistic statistic std. error statistic age in months 100 9.0 12.0 10.320 .0952 .9522 vitamin d3 level 100 22.34 98.18 40.6797 1.21489 12.14892 valid n (listwise) 100 table 2: sex wise distribution of vitamin d3. n=100 gender number vitamin d3 level (mean value) std. deviation std. error mean test statistics male 47 41.2917 9.61888 1.40306 t=0.473 df=98 p>0.05(0.638)female 53 40.1370 14.08953 1.93535 table 3: distribution of vitamin d3 in the study according to age age grade vit d level mean n std. deviation std. error of mean range 9 months age 41.8786 22 10.16069 2.16627 42.44 10 months age 42.6797 36 11.31673 1.88612 59.48 11 months age 37.6037 30 14.14733 2.58294 75.84 12 months age 40.1717 12 12.41245 3.58317 38.13 total 40.6797 100 12.14892 1.21489 75.84 value of 40.67. in our study 100 children were included; among them 47 are boys and 53 girls who uninterruptedly had taken d3 supplementation. in our study the children who regularly took vitamin d3 at 400iu/day since birth showed minimum vitamin d3 level at 22.34ng/ml and maximum vitamin d3 level at 98.18ng/ml with a mean value of 40.67ng/ml that is sufficient. in the recent past the recommendation for vitamin d supplementation regarding infants was 200 iu/daily, the dosage was calculated based on the evidence that 200 iu/d allows to keep the level of 25(oh) d on the level of 11ng/ml. 12 however, in connection with recent knowledge of normal vitamin d status, the recommendation was revised. the recommended vitamin d intake is 400iu/day in infants less than 1 year and 600 iu/day in children more than 1 year of age. 7,13,14 4. conclusion vitamin-d as a hormone is active throughout the whole body to regulate calcium and bone metabolism. various studies at different times revealed poor vitamin d status irrespective of age, sex, and geography. vitamin d concentration in breast milk is low and inadequate for the needs of the growing infant. 400 iu of vitamin d has been shown to maintain serum 25(oh)d concentrations at approximately around 50 nmol/l in breastfed infants. thus, for all new-borns, 400 iu of vitamin d supplementation is recommended up to one year of age; it is also recommended, that supplementation should be started in the first few days of life. in our study we have found that if children are given vitamin d3 regularly since birth at 400iu/day they attain desired serum vitamin d3 level irrespective of the brand or preparation. it would have been better study if we could have done a double blinded randomised control trial between two groups of children, one group without vitamin d3 supplementation and another group with vitamin d3 supplementation subject to ethical clearance. 5. sources of funding no financial support was received for the work within this manuscript. 6. conflicts of interest no conflicts of interest. references 1. holick mf. vitamin d: extraskeletal health. rheum dis clin north am. 2012;38(1):141–60. doi:10.1016/j.rdc.2012.03.013. 2. holick mf. vitamin d deficiency. n engl j med. 2007;357(3):266– 81. doi:10.1056/nejmra070553. 3. harinarayanan cv, joshi sr. vitamin d status in india -its implications and remedial measures. j assoc physicians. 2009;57:40– 8. 4. marwaha rk, sripathy g. vitamin d and bone mineral density of healthy school children in northern india. indian j med res. 2008;127(3):239–44. 5. harinarayan cv. prevalence of vitamin d insufficiency in postmenopausal south indian women. osteoporos int. 2005;16(4):397–402. doi:10.1007/s00198-004-1703-5. 6. pettifor jm. nutritional rickets: deficiency of vitamin d, calcium or both? am j clinnutr. 2004;80(6):1725–9. doi:10.1093/ajcn/80.6.1725s. 7. ross ac, manson je, abrams sa, aloia jf, brannon pm, clinton sk, et al. the 2011 report on dietary reference intakes for calcium and vitamin d from the institute of medicine: what http://dx.doi.org/10.1016/j.rdc.2012.03.013 http://dx.doi.org/10.1056/nejmra070553 http://dx.doi.org/10.1007/s00198-004-1703-5 http://dx.doi.org/10.1093/ajcn/80.6.1725s 76 mondal, saha and saha / panacea journal of medical sciences 2022;12(1):73–76 clinicians need to know? j clin endocrinol metab. 2011;96(1):53– 8. doi:10.1210/jc.2010-2704. 8. gordon cm, de peter k, feldman ha, grace e, emans sj. prevalence of vitamin d deficiency among healthy adolescents. arch pediatr adolesc med. 2004;158(6):531–7. doi:10.1001/archpedi.158.6.531. 9. munns cf, shaw n, kiely m, specker bl, thacher td, ozono k, et al. global consensus recommendations on prevention and management of nutritional rickets. j clin endocrinol metab. 2016;101(2):394–415. doi:10.1210/jc.2015-2175. 10. jain v, gupta n, kalaivani m, jain a, sinha a, agarwal r, et al. vitamin d deficiency in healthy breastfed term infants at 3 months & their mothers in india: seasonal variation & determinants indian. j med res. 2011;133(3):267–73. 11. wagner cl, howard c, hulsey tc, lawrence ra, taylor sn, will h, et al. circulating 25-hydroxyvitamin d levels in fully breastfed infants on oral vitamin d supplementation. int j endocrinol. 2010;p. 235035. doi:10.1155/2010/235035. 12. misra m, pacaud d, petryk a. vitamin d deficiency in children and its management: review of current knowledge and recommendations. pediatrics. 2008;122(2):398–417. doi:10.1542/peds.2007-1894. 13. aloia jf. the 2011 report on dietary reference intake for vitamin d. where do we go from here? j clin endocrinol metab. 2011;96(10):2987–96. doi:10.1210/jc.2011-0090. 14. heaney rp, holick mf. why the iom recommendations for vitamin d are deficient. j bone miner res. 2011;26(3):455–67. doi:10.1002/jbmr.328. author biography tanmay mondal, senior resident pradip saha, assistant professor sudip saha, associate professor cite this article: mondal t, saha p, saha s. evaluation of serum vitamin d3 level in vitamin d3 supplemented 9 to 12 months old children in a tertiary care hospital. panacea j med sci 2022;12(1):73-76. http://dx.doi.org/10.1210/jc.2010-2704 http://dx.doi.org/10.1001/archpedi.158.6.531 http://dx.doi.org/10.1210/jc.2015-2175 http://dx.doi.org/10.1155/2010/235035 http://dx.doi.org/10.1542/peds.2007-1894 http://dx.doi.org/10.1210/jc.2011-0090 http://dx.doi.org/10.1002/jbmr.328 429 too many requests you have sent too many requests in a given amount of time. panacea final 2014 45 taste recognition threshold in different phases of menstrual cycle 1 1 1 2 3 khobragade rahul , wakode santosh , tadas swati , wakode naina , kale ashok 1 assistant professor, department of physiology, government medical college & hospital, nagpur – 440003, 2 assistant professor, nkp salve institute of medical sciences, digdoh hills, hingna, nagpur 3 440019, professor & head, department of physiology, shri vasantrao naik government medical college, yavatmal – 445001 drkrahul78@rediffmail.com. abstract: taste, a neurochemical modality, plays an important role in maintaining appropriate nutritional balance. taste threshold vary with age and sex of the individual. taste threshold also varies with the phase of menstrual cycle. the aim of the present study was to assess the relationship between different phase of menstrual cycleand taste threshold for four basic taste modalities (i.e. sweet, salt, sour and bitter). we studied taste threshold in 50 female subjects. the study was carried out in 3 phases,i.e. menstrual, follicular and luteal phases. the taste threshold was evaluated using 7 different serially half diluted concentrations of glucose (2.00 m0.031 m), nacl (1.00 m 0.0156 m), citric acid (0.05 m0.0007 m) and quinine sulphate (0.001 m0.000015 m). all taste modalities show alternation in different phases of menstrual cycle (p<0.05) except for sour (p>0.05). thus the cyclical variations of hormones during menstrual cycle affect the taste threshold. keywords: taste threshold, menstrual phase, follicular phase, luteal phase. introduction: taste, a neurochemical modality, plays an important role in maintaining appropriate nutritional balance (1). considerable variation is found in the distribution of four basic types of taste buds in various species and amongst the individual of a given species (2).taste thresholds of women are generally lower than those of men and they vary during different phases of menstrual cycle with increased sensitivity at mid-cycle (3). female hormones undergo quantitative changes during critical periods of their life i.e. menstrual cycle, pregnancy and menopause. the menstrual cycle is a time of many widespread changes affecting both body and mind(4). the menstrual cycle is the term for the physiological changes that can occur in fertile women for the purposes of sexual reproduction and fertilization. the menstrual cycle is under the control of the endocrine system, is necessary for reproduction. the menstrual cycle is a complex interaction between the reproductive system and the endocrine system. this interaction is dedicated to the maintenance of the productive function and an appropriate hormonal balance in women. it is documented that gustatory and food habits change during menstrual cycle (5-6). variation in preference for sucrose during different phases of menstrual cycle has been very well documented (7). increase in salt appetite or intake during pregnancy and lactation in animal and in human is also very well documented (8), but there is scarce data related to sour and bitter preference during different phases of menstrual cycle. also, less data is available on taste recognition threshold during menstrual cycle for indian population. so we formulated the present study to compare the variations in taste recognizing threshold during different phases of menstrual cycle for all four basic taste modalities. material and methods: the present study was conducted in the department of physiology, government medical college & hospital, nagpur after taking approval from institutional ethics committee. subjects included were 50 female volunteers of 18 to 20 years of age. inclusion criteria are: 1) all non-obese females having regular menses (28–30 days) for 3 previous cycles without history of any significant illnesswere selected for the study (9). exclusion criteria are: 1) pregnant and lactating women (9, 10). 2) those who are on oral contraceptive and any prescribed medicine (9). 3) mental, gynaecological disorders and disorder related to eating (9). 4) smoking and alcoholics (11). taste recognition threshold done was done during three phases of menstrual cycle i.emenstrual phase (day 1–6), follicular phase (day 7–14) and luteal phases (day 15–28 to 30) in this study. all the taste parameters were recorded during these 3 phases (8). precautions: following precautions were taken before starting the experiment (12). 1) the subjects were asked not to eat or drink anything except water at least for one hour before the threshold measurements. 2) at the time of testing the entire procedure was explained to each subject. 3) tests were carried out in the morning time between 8 to 11 am. taste stimuli: stimulus representing the four classical basic pjmsvolume 4 number 1: jan june 2014 original article tastes was included for tasting the recognition taste threshold for particular taste. seven serial half dilutions of the stock concentration were made for each taste solution, by using deionised distilled water and used for experiment (13). the starting concentrations were glucose (2.00 m), sodium chloride (1.00 m), citric acid (0.05 m), and quinine sulphate (0.001 m). the taste threshold for each solution was investigated as per harris and kalmus method assisted by forced choice and up down tracking procedure for better output and result (14). subjects were given two or three drop of the solution of lowest concentration on the dorsum of tongue to taste first and then tasted successive higher solution until a definite taste was identified. distilled water was used in between two solutions for rinsing. rinsing of mouth was repeated till the subject volunteer said that no taste of the previously tasted concentration lingers on. accordingly the actual threshold concentration was determined and the bottle number noted. standard sequence was followed for taste recognition threshold i.e. sweet first followed by salt, sour and bitter taste solution (15).the statistical analysis was done by using kruskal-wallis test. results: taste recognition threshold for sweet taste : figure 1: sweet taste response in different phases of menstrual cycle it was observed that at 0.125 molar and lower concentrations in follicular phase seventeen subjects were able to recognize sweet taste properly while in menstrual phase fifteen subjectandin luteal phaseeight subjects were able to recognize sweet taste properly. for higher concentration that is 0.25 molar and above, thirty three subjects in follicular phase while thirty five subjects in menstrual phase and forty two subjects in luteal phase were able to recognize sweet taste properly. in general luteal phasesubjects show statistically significant raised threshold than follicular phase subjects (p<0.01), while no statistically significant difference is seen between menstrual and follicular phase and also in between menstrual and luteal phase (p>0.05).(figure 1) taste recognition threshold for salt taste : figure 2:salt taste response in different phases of menstrual cycle it was observed that at 0.0312 molar and lower concentrations, in menstrual phase twenty five subjects were able to recognize salt taste properly while follicular phase andluteal phasefifteen and elevensubjects were able to recognize salt taste properly. for higher concentration that is 0.625 molar and above, menstrual phasetwenty five subjects were able to recognize salt taste properly while follicular phase and luteal phase thirty five and thirty nine subjects were able to recognize salt taste properly. in general follicular phase (p < 0.05) and luteal phase (p < 0.01) subjects show statistically significant raised threshold than menstrual phase subjects.(figure 2) taste recognition threshold for sour taste (figure 3): figure 3: sour taste response in different phases of menstrual cycle it was observed that at 0.003125 molar and lower concentrations in menstrual phase thirty one subjects were able to recognize sour taste properly while follicular phase and luteal phasetwenty nine and twenty five subjects were able to recognize sour taste properly. for higher concentration that is 0.00625 molar and above, menstrual phasenineteen subjects were able to recognize sour taste pjmsvolume 4 number 1: jan june 2014 original article 46 properly while follicular phase and luteal phasetwenty one and twenty five subjects were able to recognize sour taste properly. in general sour taste threshold do not show statistically significant alteration in different phases of menstrual cycle (p > 0.05). however, sour taste threshold is seen to beincreasein luteal phase. (figure 3) taste recognition threshold for bitter taste (figure 4): figure 4: bitter taste response in different phases of menstrual cycle it was observed that at 0.000031 molar and lower concentrations, in luteal phase twenty nine subjects were able to recognize bitter taste properly while menstrual phaseand follicular phase seventeen subjects were able to recognize bitter taste properly. for higher concentration that is 0.000062 molar and above, luteal phase twenty one subjects were able to recognize bitter taste properly while menstrual phase and follicular phase thirty three subjects were able to recognize bitter taste properly. in general luteal phase subjects shows statistically significant decrease taste threshold than mens trualandfollicular phase subjects (p < 0.05). (figure 4) discussion: it is well known that taste threshold alters in different phases of menstrual cycle (5,6), however, the result of previous studies often presented with varying conclusion (16). the result of the present study revealed statistically significant variations for four basic taste modalities during different phases of menstrual cycle. in general follicular phase shows raised salt threshold, luteal phase shows raised salt and sweet threshold, but decreased bitter taste threshold. in agreement with previous studies (7,17), the increased sweet taste threshold may be one of the reasons for increased sweet (carbohydrate) consumption during luteal phase. dalvit-mcphillips (18) have found significant and consistent variation during the menstrual cycle only in carbohydrate consumption, not in fat or protein. the data showed that women consumed more carbohydrate per day in the luteal phase than in the follicular phase. it was postulated that this increased carbohydrate intake may be an attempt to compensate for the change in basal metabolic rate. she also noted the well described anorectic effect of oestrogen levels in other mammalian species. thus the decrease in taste threshold for sweet taste during follicular phase may be related to high level of oestrogen and that increase taste threshold for sweet taste during luteal phase may be due to interaction between oestrogen and increased progesterone. the present study shows taste recognition threshold for salt is increased during follicular and luteal phase as compared to menstrual phase. this is similar to the findings of with verma etal (8) and frye etal (19). females in their follicular and luteal phase of their menstrual cycle have high levels of circulating oestrogen and progesterone and these hormones appear to be related to salt intake. thus the female salt preference increases when levels of endogenous hormones are high and decline when level of these hormones are lower. this view is supported by the studies which reported that salt appetite or intake increase when animal's oestrogen and progesterone levels are exogenously or endogenously increased (20-21). besides the direct effect of hormones on salt appetite there could be indirect effects of oestrogen on salt appetite through opioid receptor (22) while that of progesterone is by affecting the membrane fluidity and flux of ions (23) that may cause increased sodium requirement and its appetite. our data also revealed that during luteal phase bitter taste recognition threshold decreased, these findings are consistent with the observations made by alberti-fidanza etal(5) and reason for this may be increased progesterone level in luteal phase. present study does not reveal significant alteration for sour taste recognition.alberti et al (5) and sueda k et al (16)have come out with the similar observation. however, mild rise in sour taste threshold is seen in our study during luteal phase. this may indicate reduction in unpleasantness for sour taste, which may further continue for more preference for sour food in first trimester of pregnancy (10). in present study cyclical changes in taste recognition threshold are seen predominantly for sweet and salt taste during different phases of menstrual cycle. however, the causes of these variations are still unclear and it may be attributed to cyclical physiological variation of oestrogen and progesterone. decrease threshold for bitter taste during luteal phase as seen from our study may explain the aversion for bitter taste, and which may secondarily lead to preference for salt and sweet. further, the highest preference for sweet and salt during luteal phase might be associated particularly with raised progesterone level and could be correlated to increased weight gain and other premenstrual symptoms. we conclude that taste threshold changes during menstrual cycle. this altered taste threshold can modify food preference and diet of individual. a cyclical hormonal change during menstrual cycle is one of the factors responsible for it. however, further studies involving hormonal assays along with taste recognition threshold during different phases of menstrual cycle are needed. pjmsvolume 4 number 1: jan june 2014 original article 47 references: 1) danker hh, roczen k, lowenstein wu. regulation of food intake during menstrual cycle. anthropol anz 1995; 53: 231–238. 2) ganong wf. smell and taste. in review of medical st physiology, 21 edasia: mcgraw-hills companies 2003: 188-194. 3) zverevyuriy p. effects of caloric deprivation and satiety on sensitivity of the gustatory system. bmc neuroscience 2004; 51471: 2202-5. 4) kaur sandeep, manchanda kc, garg a, maheshwari a. effect of female sex hormones on central auditory conductivity in young rural females in bhatinda district of punjab. national j of physiol, pharmacy and pharmacology 2013; 3(2): 124-128. 5) alberti-fidanza a, fruttini d, servili m. gustatory and food habit changes during the menstrual cycle. int j vitam nutr res 1998; 68(2): 149-153. 6) kuga m, ikeda m, suzuki k. gustatory changes associated with the menstrual cycle. physiol behav 1999; 66(2): 317322. 7) than tt, delay er, maier me. sucrose threshold variation during the menstrual cycle. physiolo behav 1994 aug; 56(2):237-239. 8) verma p, mahajan kk, mittal s, ghildival a. salt preference across different phases of menstrual cycle. indian j physiolo pharmacol 2005 jan; 49(1):99-102. 9) masayo m, kazuyuki s, toshiya f, fukuko k. positive relationship between menstrual synchrony and ability to smell 5 androst-16-en-3-ol. chem senses 2000; 25: 407411. 10) nicole ochsenbein-kolble, ruth von mering, roland zimmermann, thomas hummel. changes in gustatory function during the course of pregnancy and postpartum. 11) mojet j, heidema j, elly c. taste perception with age; generic or specific losses in suprathreshold intensity of five basic taste qualities?chem senses 2003; 28: 397-413. bjog 2005; 112: 1636–1640. 12) loretta mm, nielsen cr. sucrose taste threshold: age related differences. j of gerontology 1982; 37(1): 64-69. 13) bhatia s, sircar ss, ghorai bk. taste disorder in hypo and hyperthyroidism. ind j physiol pharmacol 1991; 35(3): 152158. 14) harris h, kalmus h, trotter wr. taste sensitivity to phenylthiourea in goitre and diabetes. lancet 1949; 2(6588): 1038-1039. 15) schroeder ja, schroeder e. use of the herb gymnema sylvestre to illustrate the principles of gustatory sensation: an undergraduate neuroscience laboratory exercise. the j of undergraduate neurosci edu 2005; 3(2): a59-a62. 16) sueda k, atsumi k, inayoshi t, okad e. gustatory changes associated with menstrual cycle-threshold for sweet, sour and bitter taste. natural science 2004; 50: 29-34. 17) pliner p, fleming a. food intake, body weight and sweetness preferences over menstrual cycle in humans. physiol behav 1983; 30: 663–666. 18) davit-mcphillips sp. the effect of the human menstrual cycle on nutrient intake. physiol and behav 1983; 31: 209212. 19) frye ca, demolar gl. menstrual cycle and sex differences influence salt preference. physiol and behav 1994; 55: 193197. 20) denton da, nelson jf. the control of salt appetite in wild rabbits during lactation. endocrinology 1978; 103: 1880–1887. 21) fregly mj, newsome dg. spontaneous nacl appetite by administration of an oral contraceptive and its components to rats. in: kare m, fregly mj, bernard ra, eds. biological and behavioural aspects of salt intake. new york: academic press: 1980: 248–272. 22) gosnell ba, majchrzak mj, krahn dd. effect of preferential delta and kappa opioid receptor agonists on the intake of hypotonic saline. physiol behav 1990; 47: 601–603. 23) carlson jc, gurber my, thompson je. a study of the interaction between progesterone and membrane lipids. endocrinology 1983; 117: 190–194. pjmsvolume 4 number 1: jan june 2014 original article 48 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 panacea journal of medical sciences 2021;11(3):448–451 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article diagnosis and modalities of treatment of fracture penis in a single center: an observational study ashok kumar nayak1, sanjay kumar mahapatra2,*, rohit kumar gohil1, harish chandra dhamudia1, kranti guru1 1dept. of general surgery, veer surendra sai institute of medical sciences and research, burla, odisha, india 2dept. of urology, veer surendra sai institute of medical sciences and research, burla, odisha, india a r t i c l e i n f o article history: received 03-02-2021 accepted 03-03-2021 available online 24-11-2021 keywords: eggplant deformity a b s t r a c t introduction: penile fracture has very low incidence. sexual intercourse, masturbation, or forceful penile manipulation are the common causes of penile fracture. surgery is the primary treatment but in certain cases conservative treatment is also beneficial but usually has poor outcome. the aim of this study was to review the pattern of penile fracture occurrence, its clinical presentation, diagnosis, management, and outcome at our center. materials and methods: between 2012 to 2018 and, 30 patients with penile blunt trauma on an erect penis were admitted to our center. we analyzed the following variables: age, etiology, symptoms and signs, diagnosis, treatment, complications and erectile dysfunction during the follow-up. 29 patients underwent surgical repair and 1 patients were submitted to conservative management. results: follow-up was in every three months for one year. trauma during sexual relationship was the main cause of penile fracture. the most common site of tear was the proximal shaft of penis. urethral injury was not present in any patient. during follow-up, 27 cases (93.10%) of the surgical group and one of the conservative group reported sufficient erections for intercourse, with no voiding dysfunction. however, the remaining 2 patients (6.89%) from the surgical group developed erectile dysfunction and penile deviation.one patient managed conservatively developed chordee. conclusion: early surgical intervention is the primary modality of treatment for fracture penis and give better outcome with less complications. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction penile fracture is one of the uncommon urological emergencies. the first documented report of this fracture is credited to an arab physician, abul kasem, in cordoba over 1000 years ago. 1 penile fracture is defined as a rupture of the tunica albuginea of the corpus. the urethra and corpus spongiosum may also be affected. in an erect penis, this fascia is much stretched and taut, thus prone for fracture if subjected to undue sudden flexion forces. common causes * corresponding author. e-mail address: snjmahapatra@gmail.com (s. k. mahapatra). include coitus, sudden forced flexion in the erection state, rolling over in bed, and masturbation. penile fracture has a typical clinical presentation that includes the report of a cracking sound, followed by penile detumescence and pain. physical examination usually includes oedema, hematoma, and “eggplant deformity”. 2,3 presence of haematoma, rolling sign and a palpable tunical defect are usually considered pathognomonic features of penile fracture. 4 the incidence of urethral injury is significantly higher in the usa and europe (20%) than in asia, the middle east, and the mediterranean region (3%), probably due to the different aetiology-intercourse trauma https://doi.org/10.18231/j.pjms.2021.088 2249-8176/© 2021 innovative publication, all rights reserved. 448 nayak et al. / panacea journal of medical sciences 2021;11(3):448–451 449 instead of self-inflicted injury. 3,5–8 proper history taking and thorough skilful clinical examination is adequate to establish diagnosis of fracture penis, however in case of diagnosis dilemma one can take the help of ultrasonograpy and mri. 9 in case of voiding dysfunction or blood at the meatus, a preoperative retrograde urethrography or urethroscopy during surgical exploration should be considered. immediate surgical exploration, evacuation of hematoma, control of bleeders, and repair of the tunica tear is the present trend in management. 10 conservative therapy restricted to uncomplicated cases is also useful in selected cases. an analysis of the clinical presentation, diagnosis, management, and outcome of 45 cases that presented to our centre over the last 6 years is the purpose of this study. 2. material and methods study locationveer surendra sai institute of medical science and research, burla, odisha. study populationhospital based study. it consists of all the patients admitted in the department of urology or general surgery, vimsar, burla with the clinical features of penile fracture. those patients with previous history of erectile dysfunction, impotence, psychiatric illness or old history of injury to penis are excluded from the study. 2.1. operational definitions outcome, exposure. 2.2. study type descriptive study. 2.3. study design prospective observational study. 2.4. study period from 1st february 2012 to 28th february 2018. 2.5. data collection tools data collected by taking history of the patient in the form of in-depth interview by the investigators face to face at the time of admission are as follows; age distribution, marital status, nationality, initiating cause of fracture(sexual intercourse, masturbation, rolling over, blunt trauma), time interval between the event and presentation to our hospital (within 6 hours, vs after 6 hours), presence of characteristic cracking sound, previous history of erectile dysfunction, impotence, psychiatric illness or injury to penis. the clinical findings are recorded under following headings: swelling, discoloration, detumesence, pain, noise, hematoma, curvature, presence of bleeding per urethra. the treatment provided is recorded as either surgical or conservative treatment. operative findings were recorded as size of tear, site of tear, whether associated with urethral injury or not. duration of hospital stay is recorded. the complications recorded as follows: pain, edema, infection, plaque, curvature, erectile dysfunction, cordee, urinary symptoms, resurgery and aneurysm formation. for proper analysis, complications were grouped as early and delayed. complications that occurred within 2 weeks postoperatively were grouped as early (wound infections and skin necrosis) and later than 1 month were grouped as delayed (erectile dysfunction, painful erection, and penile deviations). erectile dysfunction was crudely assessed on follow-up by a questionnaire as to be good, mild to moderate and poor erection (insufficient for intercourse). 2.6. sample size -30 measuresthe purpose of the study was informed to each participant and they were also informed of the fact that each of them was free to withdraw any time. assurance was given to them concerning confidentiality. a written informed consent was obtained from each participant and their mailid obtained from them. all patients underwent thorough clinical examination on admission. presence of urethral bleeding and other associated injuries were investigated. apart from routine blood tests, a coagulation profile was done for all patients. ultrasound examination and doppler study were done in selective cases only. most of the time, clinical diagnosis was enough to decide on the management option. every patient underwent surgery under spinal anaesthesia apart from two apprehensive patients who required general anaesthesia; exploration of the fracture site was carried out by a degloving subcoronal incision. the hematoma was evacuated and any bleeding vessels were ligated and the site of tunica defect located, measured, and then repaired by using synthetic, absorbable, inverted knot sutures. we routinely used 3-0 pds sutures for all our cases. after repair, artificial erection was induced to make sure there was no leakage. a foleys catheter 16f was inserted and retained for 2 days postoperatively. all cases received antibiotics for 5 days postoperatively with sedation for 24–48 h. none of the patients received any anti erectile medication. conservative treatment was in the form of cold compress with anti-inflammatory drugs along with antibiotic coverage. all patients were followed up a week after discharge and then every 3 months up to 1 year. four patients can be followed up to 6 months only, sexual function of each patient were evaluated a 3 month follow up. evaluation was done by using international index of erectile function-5 (iief-5) as all of our paint gave history of having partner. the iief-5 instrument classifies the severity of erectile dysfunction (ed) into five categories: severe (5-7), moderate (8-11), mild to moderate (12-16), mild (17-21), and none (22-25). 11 the penile doppler study was performed in selected cases to measures peak systolic 450 nayak et al. / panacea journal of medical sciences 2021;11(3):448–451 velocity(psv), end diastolic velocity (edv) and resistive index (r,i). ri values >0.9 have been associated with normal penile vascular function, while ri values <0.75 are consistent with veno-occlusive dysfunction. 12 2.7. statistical analysis spss 9.0 software for windows was used for analysis of the data. 3. results table 1: causes of penile fracture cause number percentage sexual intercourse 22 73.33 masturbation 5 16.66 rolling over 2 6.66 blunt trauma 1 3.33 table 2: presentation of penile fracture presentation number percentage swelling 29 96.66 discolouration 25 83.33 noise 10 33.33 detumescence 14 46.66 hematoma 12 40 pain 29 96.66 curvature 8 26.66 urethral bleed 1 10 time from trauma to intervention (0-24hours)-23 (>24 hours))-7 76.66(<24 hours) 23.33( > 24 hours) table 3: operative finding size of tear range mean 5mm 2-8mm 6 site of tear number percentage left corpora cavernosa 12 26.66 proximal 6 25 mid 4 25 distal 2 50 right corpora cavernosa 16 40 proximal 7 33.33 mid 7 16.66 distal 2 50 both corpora 1 3.33 unknown (conservative treatment without imaging) 1 3.33 4. discussion as mentioned earlier fracture penis is an uncommon urological condition. although it has varied aetiologies, its clinical manifestations are relatively uniform among table 4: hospital stay and complications in patients managed operatively duration of hospital stay 2-5 days mean-3.5 days pain 5 20.83 wound oedema 5 20.83 infection 5 20.83 plaque nil curvature 1 4 erectile dysfunction 2 8.33 mild chordee 2 8.33 urinary disorder 3 12.5 reoperation nil aneurysm 1 4.16 table 5: evaluation of sexual function at 3 month intervaliief-5 severity number of patients no ed (22-25) 28 mild ed (17-21) 1 mild to moderate ed (12-16) 1 moderate ed (8-11) 0 severe ed (5-7) 0 different cases. between these 6 years of study duration 30 patients of penile fracture were studied and followed up. the usual cause of penile fracture is abrupt bending of the erect penis by blunt trauma, which may occur during sexual intercourse, masturbation, rolling over in the bed, or during the practice known as ’taghaandan,’ in which the erect penis is pushed down to achieve detumescence, resulting in a click. 2 out of 30 patients 22(73.33%) had sustained injury during sexual intercourse followed by 5(16.66%) patients where masturbation was the cause, 2(6.66%) patient had rolling over erect penis, and one (3.33%) had blunt trauma over erect penis. our finding is similar to many published literatures with sexual intercourse being the most common cause of penile fracture. 11,13,14 one of our objectives was to analyse the various clinical manifestation of fracture penis. swelling over the penis and pain were the most common clinical features, seen in 29(96.66%) patients, erythematous discolouration was present in 25(83.33%), 10(3.33%) patients had history of characteristic cracking noise, detumescence, haematoma, curvature and bleeding per urethra were found in 14(46.66%), 12(40%), 8(26.66%) and 1(3.33%) cases respectively. however rs mohapatra et al in there study have found rapid detumescence (95%) as most common presentation followed by swelling (90%), characteristic popping sound in 85% cases and pain was present only among 50% cases. 14 b patil et al in their study found penile oedema as most common presentation and typical click were present only in 22.1% cases. 11 23 (76.66%) patients presented to the hospital within 24 hours of injury, 23.33% presented after 24 hour of nayak et al. / panacea journal of medical sciences 2021;11(3):448–451 451 surgery. in a study by b. patil et al, only 38.88% (7/18) patients present within a day. el-assmy et al. in their study found 81% patients presented within 24 hr. the delay in presentation may be due to feeling of shame or hesitancy out of embarrassment. 29(96.66%) patients were subjected to surgical intervention. the per-operative findings were as follows: the mean size of tear was 6mm with a range of 2 to 8 mm. right side corpora cavernosa tear (n=12, 40%) were more frequent than the left side (n=8, 26.66%). the site of injury were as follows; most common being proximal shaft (48.2%), mid shaft (34.48%) and distal shaft (13.79%). many previous study in literature have shown proximal shaft as the most common site of tear. 11,14 the incidence of urethral injury varied from 0% to 3% in reports from iran, persian gulf countries, and japan to 20%–38% in reports from european countries. 12,15 some of the literatures describe it in up to 10-33% of cases of penile fracture. 12 however in our study none of the patient had associated urethral injury. the mean duration of hospital stay was 3.5 days with a range of 2-5 days. in post-operative period 5(20.83%) patients had pain and surgical site infection along with partial skin necrosis. 28 patient came for follow up at 3 month period. 26 patient had iief-5 score between 22-25;i.e. no erectile dysfunction. one patient had mild erectile dysfunction with iief-5 score of 19, and one had mild to moderate ed with score of 14. delayed complications e.g. erectile dysfunction, curvature and chordee were observed in 2(6.66%), 1(3.33%) and 2(6.66%) cases. one patient which was managed conservatively had chordee and no other early or delayed complication. the number of complication in our study is less as compared to many previous studies. b. patil et al in their study found that 44.4% had post-operative wound infection and erectile dysfunction. 11.11% had chordee. 11 early presentation to the hospital may be the reason for fewer complications in the patients in our study. 5. conclusion history and physical examination is the most important diagnostic tool for penile fracture. early surgical repair achieves significantly better outcomes compared to conservative management or delayed surgery. 6. conflict of interest the authors declare that there are no conflicts of interest in this paper. 7. source of funding none. references 1. eke n. fracture of the penis. br j surg. 2002;89(5):555–65. 2. zargooshi j. penile fracture in kermanshah, iran: report of 172 cases. j urol. 2000;164(2):364–6. 3. morey af, dugi dd. genital and lower urinary tract trauma. in: wein a, kavoussi l, partin a, novick a, editors. campbell-walsh urology. 10th edn. elsevier-saunders, co; 2012. p. 2520–20. 4. walton jk. fracture of the penis with laceration of the urethra. br j urol. 1979;51(4):308–9. doi:10.1111/j.1464-410x.1979.tb04715.x. 5. eke n. fracture of the penis. br j surg. 2002;89(5):555–65. doi:10.1046/j.1365-2168.2002.02075.x. 6. zargooshi j. penile fracture in kermanshah, iran: the long-term results of surgical treatment. bju int. 2002;89(9):890–4. doi:10.1046/j.1464410x.2002.02745.x. 7. jack gs, garraway i, reznichek r, rajfer j. current treatment options for penile fractures. rev urol. 2004;6(3):114–20. 8. derouiche a, belhaj k, hentati h, hafsia g, slama mr, chebil m, et al. management of penile fractures complicated by urethral rupture. int j impot res. 2008;20:111–4. doi:10.1038/sj.ijir.3901599. 9. saglam e, tarhan f, hamarat mb, can u, coskun a. efficacy of magnetic resonance imaging for diagnosis of penile fracture: a controlled study. investig clin urol. 2017;58(4):255–60. doi:10.4111/icu.2017.58.4.255. 10. jack gs, garraway i, reznichek r, rajfer j. current treatment options for penile fractures. rev urol. 2004;6:114–120. 11. patil b, kamath su, patwardhan sk, savalia a. importance of time in management of fracture penis: a prospective study. urol ann. 2019;11(4):405–9. doi:10.4103/ua.ua_80_18. 12. gedik a, kayan d, yamiş s, yılmaz y, bircan k. the diagnosis and treatment of penile fracture: our 19-year experience. ulus travma acil cerrahi derg. 2011;17(1):57–60. 13. reis lo, cartapatti m, marmiroli r, júnior edo, saade rd, fregonesi a, et al. mechanisms predisposing penile fracture and long-term outcomes on erectile and voiding functions. adv urol. 2014;doi:10.1155/2014/768158. 14. mahapatra rs, kundu ak, pal dk. penile fracture: our experience in a tertiary care hospital. world j mens health. 2015;33(2):95–102. doi:10.5534/wjmh.2015.33.2.95. 15. karadeniz t, topsakal m, ariman a, erton h, basak d. penile fracture: differential diagnosis, management and outcome. br j urol. 1996;77(2):279–81. author biography ashok kumar nayak, associate professor sanjay kumar mahapatra, assistant professor rohit kumar gohil, assistant professor harish chandra dhamudia, assistant professor kranti guru, junior resident cite this article: nayak ak, mahapatra sk, gohil rk, dhamudia hc, guru k. diagnosis and modalities of treatment of fracture penis in a single center: an observational study. panacea j med sci 2021;11(3):448-451. http://dx.doi.org/10.1111/j.1464-410x.1979.tb04715.x http://dx.doi.org/10.1046/j.1365-2168.2002.02075.x http://dx.doi.org/10.1046/j.1464-410x.2002.02745.x http://dx.doi.org/10.1046/j.1464-410x.2002.02745.x http://dx.doi.org/10.1038/sj.ijir.3901599 http://dx.doi.org/10.4111/icu.2017.58.4.255 http://dx.doi.org/10.4103/ua.ua_80_18 http://dx.doi.org/10.1155/2014/768158 http://dx.doi.org/10.5534/wjmh.2015.33.2.95 editorial panacea journal of medical science, may – august 2015:5(2);59-60 59 should patients have the right to record consultations? bardale r professor and head dept. of forensic medicine govt. medical college and hospital, miraj dist. sangli bardaleru@yahoo.in since ages, trust is the fundamental basis of doctorpatient relationship. however, in recent time the stable relationship is receiving blows. moreover, after enactment of consumer protection act the threads between the doctor-patient relationships are breaking slowly. now doctors become service provider and patients become consumers. concurrently adverse publicity in print and electronic media is adding fuel and causing uneasiness in doctor-patient relationship. with each passing day the relationship is becoming uncomfortable and at times bitter enough to manhandle a doctor or suing in the court of law. advances made in communication technology have changed the common-day situation and now every individual have cell phones or smartphone with 3g or 4 g connectivity. technology makes it easy for individuals to have audio or video recording of anything they come in contact and such information is shared over social media. there is no surprise if the smartphones have made inroads in consultation chambers with patient recording the conversation. some patient may ask permission to record and someone may do it covertly1,2. in some countries patients are increasingly asking their doctors to allow them to record the conversation during the consultation. about two to three months back news appeared in the times of india that at bangalore one female had requested her paediatrician to allow her to record the consultation. in coming days it will be common for doctors to receive such requests and/or demands from patients. now the question is where we stand? what will be doctor’s concerns? what will be the possible social and legal implications? doctor’s concern: certainly doctors will have apprehension and will take back seat if some patient requests to allow recording of the consultation. such request may impair the doctor-patient relationship. from doctor’s point of view such request raises question over their honesty and integrity. in other way patient is not having faith on his or her doctor. such recording will destroy the professional autonomy and privacy3. the other concern will be related with safeguarding own image and information contained in such recording. now a day various types of software are available in the market. a clever piece of editing in the original recording can change the entire scenario. at times such editing may tarnish the image of a doctor or such edited words may be used against other doctor in law suits. sometimes such wrong and edited information would be uploaded on you tube or other social medias and misquote the doctor. social issues: for a patient his or her health is paramount and in today’s world everybody wants the best. in this attempt patient gathers various information from internet. sometimes such information is helpful and at other times not relevant. with increasing awareness, more patients will demand such recording and other people in society may endorse their view. in fact the society may uphold the entire issue stating that it will bring more transparency in doctor-patient relationship. from the limited published papers, the reason given by patient for recording is to review the consultation for their personal use or many times it will be helpful for them while having second opinion (1-3). sometime such recordings can be used against the doctors; may be for court procedures or to have ransom by way of blackmailing. this will have greatest implications on medical practice. never the less such increasing demands may shift the medical practice into defensive medicine. legal issues: many possible legal issues will surface if such phones are allowed to record the consultation. firstly can a patient use smart phone to record consultation? the answer is yes. as per section 2 (1 ha) of the information technology act 2008 “communication device means cell phones, personal digital assistance or combination of both or any other device used to communicate, send or transmit any text, video, audio or image”. once a doctor accepts a patient then doctor-patient relationship exists and legally it becomes contract. once contract is established, a doctor is legally duty bound to treat the patient with rajesh bardale should patients have the right to record consultations? panacea journal of medical science, may – august 2015:5(2);59-60 60 reasonable degree of knowledge, care and skill. as per section 10 a of the information technology act 2008 “where in a contract formation, the communication of proposals, the acceptance of proposals, the revocation of proposals and acceptances, as the case may be, are expressed in electronic form or by means of an electronic record, such contract shall not be deemed to be unenforceable solely on the ground that such electronic form or means was used for that purpose”. therefore once contract is established, a doctor cannot revoke the said contract stating that smart phone is being used to record the conversation while consultation. secondly, whether such information recorded will be used against doctors in court proceedings especially in cases with alleged medical negligence? again the answer is yes and such recording can be considered as evidence in the court of law. of course one has to establish authenticity of such digital material but such evidences can be permissible. conclusion: the current cultural and societal norms of recording and clicking images or videos relating to their private lives and publishing on social media or internet is becoming commonplace practice. in coming days recording of consultation request will be reality rather than a perception. even if doctor doesn’t consents for such recording what is surety that patient or his relative will not record the consultation on another devise? most of the smartphones have record functions which can be easily activated without a doctor or nurse’s knowledge. such covert recording is potential threat for medical profession. every technology brings its ill effect along with its benefit. such technological advances are blessings in disguise. the major question is how different organizations and doctors will react to the concept of recording becoming normalised? do recordings of the clinical consultation become part of the clinical record? and, if so, what are the ramifications of how such data could be used and accessed (2)? is it not unethical to denying care to patients who want digital record? whether such record keeping would be an invaluable tool in protecting against unsubstantiated complaints or legal actions? technological advances will undoubtedly bring further changes. at present the concept of consultation recording is limited to educated people but possibility of wide range spreading of such information cannot be ignored or underestimated. now time has come to have a meaningful deliberations and a conclusion on the entire issue so that it will benefit the patient and at the same time it will safeguard the dignity and professional autonomy of doctors. references: 1. elwyn g. should doctors encourage patients to record consultations? bmj 2015;350:g7645. 2. elwyn g, barr pj, grande sw. patient’s recording clinical encounters: a path to empowerment? assessment by mixed methods. bmj open 2015;5:e008566. 3. tsulukidze m, grande sw, thompson r, rudd k, elwyn g. patients covertly recording clinical encounters: threat or opportunity? a qualitative analysis of online text. plos one 2015;10:e0125824. 2 introduction: stanford type b acute aortic dissection represents a tear in the intima that originates beyond the origin of the subclavian artery. the current treatment of uncomplicated acute cases remains medical although the morbidity and mortality rates remain significant with an early mortality of 10% to 12% (13). for this reason, the optimal initial management, especially in complicated cases of acute type b aortic dissection, has become debatable.this veto allowed endovascular treatment to increasingly gain interest as an initial treatment strategy.however, there still remain many uncertaintiesof clinical profiles and outcomes of acute type b aortic dissection. similarly, acute type b intramural hematoma presentsan unpredictable if at all clouds the simplistic understanding of the natural history of this moribund and lethal condition. this article outlines the overall understanding acute type b dissection and discussesthe challenges of the optimal strategy to manage acute type b dissection and the best treatment for uncomplicated cases. historical perspective: in 1960s, debakey reported the results in 179 patients who had sustained acute aortic dissection and were treated surgically with an early mortality of 21% and a 5-year survival rate of 50% (1). among the patient population reported 38% of the patients had an acute type a dissection and the majority had a debakey type iii (stanford type b) dissection. debakey reports the message of his report indicating that all type of acute dissection should have surgical intervention. wheat and palmer and colleagues (2-3)proposed a rather selective less invasive approach arguing that medical treatment with a correct combination of antihypertensive and maintaining the rate of rise of aortic pressure (aortic dp/dt) will suffice. in 1970, daily and colleagues (4)introduced the stanford type a/b dissection classification system and reported that no major difference in early outcome in patients with type b dissections treated medically or surgically were observed. in a 1979, stanford compiled the early results from 11 studies published in the 1970s were analyzed. the overall mortality rate in this era was 33% in medically treated patients (range, 21% to 67%); the average operative mortality rate for patients with acute type b dissections treated surgically was 36% (5). thereafter, the consensus opinion has been that most patients with acute type b dissections should be treated medically, unless lifethreatening dissection-related complications are present(612). a perspective on etiology, pathophysiologyand risks of acute type b dissection: aortic dissection is more common in males with a peak incidence at 50–70 year of age. aortic dissection can result either from a tear in the intima and propagation of blood into the media or from intramural hematoma formation in the media followed by perforation of intima. an intimal tear can occur in the regions of the aorta that are subjected to the greatest stress and pressure fluctuations. because mechanical stress in the aortic wall is proportional to intramural pressure and vessel diameter, hypertension and aortic aneurysm are known risk factors for dissections.most aortic dissections occur with an initial transverse tear along the greater curvature of the aorta, usually within 10 cm of the aortic valve. the aortic root motion has a direct impact on the mechanical stresses acting on the aorta(13). while hourly mortality data for type b dissection are not available, the overall in-hospital mortality is reported to be 11%. for those patients in the highest risk group, type b mortality can be as high as 71%.data from the international registry of aortic dissection (irad)(14) showed the following risk factors in acute aortic dissections: male sex, age, a history of hypertension or atherosclerosis, prior cardiac surgery including aortic valve surgery, a history of bicuspid aortic valve, or a history of marfan syndrome. the younger patients were more likely to have marfan syndrome, bicuspid aortic valve, ehlers-danlos syndrome, loeys-dietz syndrome and a pjmsvolume 4 : number 2 : july dec. 2014 review article abstract: acute type b dissection carries a high risk of mortality and morbidity. this risk can be reduced with appropriate, quick and correct diagnosis. approaches to its optimal management is still vigorously debated and requires a detailed knowledge of the known natural history of this disease. however, there is much unknown knowledge surrounding this disease, particularly toward the timing of any surgical intervention. this article outlines the overall understanding acute type b dissection and discusses the challenges of the optimal strategy to manage acute type b dissection and the current recommended treatment for uncomplicated cases. keywords: acute type b aortic dissection, optimal initial management, treatment for uncomplicated cases. 1 thoracic aortic aneurysm service, liverpool heart & chest hospital, thomas drive, l14 3pe, uk drmbashir@mail.com acute type b dissection: a leap between the known and the unknown 1 1 1 1 1 bashir mohamad , fok matthew , bilal haris , oo aung , kuduvalli manoj 3 tachycardia and hypotension result from aortic rupture, pericardial tamponade, acute aortic valve regurgitation, or even acute myocardial ischemia with involvement of the coronary ostia. differential or absent pulses in the extremities and a diastolic murmur of aortic regurgitation may also be present. syncope, stroke, and other neurological manifestations secondary to malperfusion syndrome may develop. a complete neurological examination is essential and findings should be documented (10,13,17-18). diagnosis: accurate diagnosis of aortic dissection and ahigh index of suspicion are imperativeespecially in patients with predisposing risk factors such as hypertension, known and documented aneurysmal disease of the aorta, or a familial connective tissue disorders. however, not always we are presented with a full history and an all knowing patients of their medical status. this present a further challenge especially when patients are very moribund and their state of consciousness might not be pristine. what compounds the aforementioned is the delay in diagnosis. approximately 4.4 million patients who present annually to the us emergency departments for chest pain, only about 2,000 have acute aortic dissection and as a result correctly diagnosed aortic dissection is only in 15%–43% of patients in the initial presentation (21-23). biochemical markers: the quest for the ideal biomarker to the detection and screening of aortic aneurysm and dissection continues. the standard blood-based test, or tests, capable of detecting individuals at risk for aortic aneurysm and dissection disease is still not available. currently, several biomarkers are being investigated as suitors for prediction, risk stratification and prognostic evaluation in taa patients which include; d-dimer, plasmin, fibrinogen, matrix metalloproteinases, cytokines, cd4 + cd28cells, c-reactive protein, elastin peptide, endothelin, hepatocyte growth factor, homocysteine, ribonucleic acid signature. d-dimer has previously been identified as a potential biomarker in aortic dissection proving itself to have a sensitivity of 99% . its downfall though is that elevated ddimers are highly non-specific, particularly in diseases of the chest. this critical point negates its usefulness as a sole biomarker. the development of rna signatures is yielding significant interest. these biomarkers measure rna regulation related to aortic aneurysms and potentially could be useful in dissection and rupture prediction. so far, this rna signature test, it has shown to be 80% accurate in determining whether a patient has an aneurysm, and potentially this may prove to be useful as a screening tool. smooth muscle myosin heavy chain, a major component of the smooth muscle in the aortic medial layer, is released to the circulation shortly after the onset of dissection. in a pilot pjmsvolume 4 : number 2 : july dec. 2014 review article history prior cardiac surgery.the average age for aortic dissection was 63.1 years, with type b slightly older (66.3 vs 61.2 years). 65.3% of patients were male. 62.3% of the patients had type a dissection, 72.1% had a history of hypertension, and 4.9% had marfan syndrome. trimarchi et al used the irad database to look at 613 patients with acute type b aortic dissections between 1996 and 2009 (15). in this study the mean aortic size at time of dissection was 4.1 cm and furthermore, only 18.4% of patients in this cohort had an aortic diameter equal to or greater than 5.5cm, the current recommended surgical intervention size. however, the study reports a mortality rate of 6.6% and 23% in aortic diameters less than 5.5cm and greater than 5.5cm respectively (p < 0.001). this study further demonstrates that risk of dissection is not entirely dependent on aneurysm size. however, the irad study had no information regarding the denominator of patients at risk with small aneurysm. because of the bell-curve distribution of aortic size, many millions of patients have aortas in the 4 to 5 cm range, so that the actual likelihood of dissection is indeed small. so, the irad study recommended no change from current intervention criteria (16). clinical presentation: the clinical presentation of dissection patients may be diverse. it has been described that the pain is as stabbing, tearing, or ripping in nature. however,the most common characteristic of acute type b dissection presentation is acute pain localized to the chest, abdomen, and back and sudden collapse. analysis of the international registry of acute dissection (irad), noted that severe chest pain is more common with type a dissections, whereas back pain and abdominal pain are more common in type b dissection (14). the irad reported that 95.5% of all aad patients presented with pain. however, in previous reports it was revealed that between 5 and 17% of all dissection patients present with painless acute aortic dissections. it should be noted that painless type b acute aortic dissection does not infer that these patients have uncomplicated dissections, as they still can develop malperfusion and aortic rupture. (14,17-18). as expected, atypical presentation can lead to a delay in diagnosis, which is associated with higher mortality (19). immediate adequate medical treatment is essential and has to include optimal blood pressure control in order to reduce shear stress and limit the propagation of the dissection. therefore, it is important to recognize these patients at the earliest possible stage (17-18). the true incidence in the population is probably even higher, as an atypical presentation will likely result in a higher risk of death prior to the diagnosis. however, as expected, painless type b dissection patients did not show this clinical pattern since involvement of the head and neck vessels did not occur (20). physical examination may reveal tachycardia accompanied by hypertension from anxiety and pain. 4 pjmsvolume 4 : number 2 : july dec. 2014 review article study, the assay (>2.5 microgram/l) had a sensitivity of 90.9% and specificity of 98% in detecting acute aortic dissection as compared to healthy volunteers(24). elastin is another major structural component of the medial layer of aortic wall. shinohara and colleagues demonstrated that an elisa measuring soluble elastin fragments (selaf)in the serum with the cutoff set at + 3 sd (standard deviation) above the mean of age-adjusted healthy subjects had a sensitivity of 88.9% and specificity of 99.8% (25). however, the elisa for selaf takes 3 hours to perform, a major drawback for a time sensitive condition such as acute aortic dissection. imaging: the choice for the diagnostic imaging depends on patient's stability, local expertise, and availability. its use should be to expedite the assertion of aortic dissection, identify the type/extentand locate the intimal tears. it should confirm the presence of true/false lumen and whether a thrombus is present, assess any aortic side branch involvement, detect any aortic regurgitation or coronary artery dissection to certain extent, and aid in the identification of the dissection aftermath i.e. any extravasationswithin the pericardium, mediastinum or hemothorax (26). aortography has lost its place as the gold standard test due to a number of serious disadvantages, including the use of a heavy dose of iv contrast (1 mg/kg), the risks of an invasive procedure, and the extended time it takes to complete the procedure (up to 2+ hours). on the contrary, in 2002 irad reported (27) that computed tomography angiography (cta) is used in 63% of cases of suspected a o r t i c d i s s e c t i o n , f o l l o w e d t r a n s e s o p h a g e a l echocardiography (tee) in 32%, aortography 4%, and magnetic resonance angiography (mra) in 1%. computed tomography angiography, tee and mra have similar pooled sensitivity (98%–100%) and specificity (95%–98%) although the pooled positive likelihood ratio appeared to be higher for mra (positive likelihood ratio, 25.3; 95% confidence interval, 11.1–57.1) than for tee (14.1; 6.0–33.2) or cta (13.9; 4.2–46.0). cta is widely available and relatively rapid, provides visualization of the entire aorta down to iliac arteries, and delineates the involvement of aortic side branches (2728). the use of ecg-gated ct offered the option instead of selecting scan data acquired in exactly the same phase of the cardiac cycle for each image as in standard ecg-gated reconstruction techniques, the patient's ecg signal is used to omit scan data acquired during the systolic phase of highest cardiac motion. with this approach cardiac pulsation artifacts in ct studies of the aorta, of paracardiac lung segments, and of coronary bypass grafts can be effectively reduced.again the culprit of cta being the first definitive choice include the requirement that patients be transported to the cta suite, the use of potentially nephrotoxic contrast, and the inability to assess aortic insufficiency. mra is highly accurate and does not require the use of a contrast dye. it is, however, usually not available on an emergency basis and requires patients to be in mra suite for an extended period of time. other issues such as claustrophobia, the use of ventilator, and patient's use of metal devices (pacemakers, aneurysmal clips) may further complicate its routine use (27). tee is a viable alternative in patients who are critically ill and/or hemodynamically unstable. the main advantages of a tee include speed, good sensitivity and specificity, and the fact that it can be performed at the patient's bedside in the ed. its main limitations are lack of widespread expertise and subjective reporting which necessitates high level of expertise to avoid false positive reports. optimal strategy for the management of acute type b dissection: managing acute type a aortic dissection, entails an immediate surgical repair of the ascending aorta. although this is debatable whether this should be open repair or endovascular intervention, the approach is unified as a surgical intervention. however, when it comes for patients with acute type b aortic dissection this presents a dilemma and different groups advocates different approaches albeit surgical, medical or endovascular. there is a trend in the literature that the best way in the middle and would be to adopt the “complication-specific approach”, reserving surgical replacement of the descending aorta for patients with rupture, organ ischemia, refractory pain, uncontrollable hypertension, sizable dilatation of the false lumen, or other life-threatening conditions. approximately 25% of patients presenting with acute type b aortic dissection are complicated at admission by malperfusion syndrome or hemodynamic instability, resulting in a high risk of early death if untreated(29-32). furthermore, the endovascular techniques has shifted the paradigm and indeed the traditional open surgical repair, with more patients now being treated medically despite the presence of complications that in the past would have prompted operative treatment. the medical management of acute type b dissection began to gain credence with the concept of anti-impulsive therapy as described by wheat et al. he demonstratedthat the force of contraction (dp/dtmax) and blood pressure in the propagation of acute dissection in a dog model (33). starting in the early 70's, medical management of uncomplicated type b dissection was increasingly gaining the position as the standard of care due to availability of antihypertensive and the lower mortality compared to surgical approach. up to current date this still follow pursuit and the combination therapy of anti-impulsive and antihypertensive remains the cornerstone of modern medical management of type b aortic dissections.yet, the concept of medical management was challenged again by different authorities worldwide. the questions were raised to delineate the patients with 5 grafts in aortic dissection (instead) trial, was performed to evaluate its benefit (48).this trial randomised 140 patients to optimal medical therapy only or to receive tevar plus optimal medical therapy. the trial ran for two years and its primary end points were mortality with secondary end points of aortic remodelling, dissection progression and aorta related death. there was no statistical difference between survival in either groups, with cumulative survival in the optimal medical therapy group and in the tevar groups as 95.6% vs. 88.9% respectively (p=0.15). interestingly, the survival in the medical therapy group was surprisingly high, with the researchers basing their sample size calculations on the assumption of a mortality rate up to 30% in the medical group. hence this led to underpowering of the study. moreover, there was no statistical difference in aorta-related death rate between the two groups (p=0.44) or between aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgery). three neurological adverse events occurred in the tevar group (1 paraplegia, 1 stroke, and 1 transient paraparesis), versus 1 case of paraparesis with medical treatment. finally, aortic remodelling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% of patients with tevar versus 19.4% of those who received medical treatment (p>0.001), which suggests on-going aortic remodelling(48). although hard to draw conclusion from this trial it represents that medical therapy exceeds expectations. the investigators do pertain to the point that later evidence may divulge in the future differences in the two groups as further adverse events in each group will reveal themselves. of major concern in this trail is the fact that the study was underpowered to evaluate the mortality end point, as was pointed out by the authors in their article. for the study to have adequate power, 28 events needed to be observed, but only 11 events were observed. thus, the significance of the negative results of this study must be called into question. extending the follow-up of these patients would potentially provide further time points to allow for a more meaningful analysis of the data (49). conclusion: although the unknown is known regarding attributable aetiology, pathophysiology, risk factors, clinical presentation and diagnostic tools required for pinpointing acute type b dissection, the ambiguity regarding the optimal management is on-going. the timing of intervention after dissection onset and complications are not uniformly understood. patients assigned to medical treatment, tevar, or open surgery often significantly differ in baseline co-morbidity illnesses and severity of the disease, making direct comparisons among treatment strategies difficult.for complicated type b dissection, endovascular therapies are becoming the standard of care in many centres as they have shown to have a better outcome compared to the open repair approach(47, 50-52). pjmsvolume 4 : number 2 : july dec. 2014 review article hypertensive crises or refractory hypertension, malperfusion and patients who are hemodynamically stable with impending risk of rupture. in addition, thoughts were also given to patients with intramural hematoma and questionswere raised as to what is best and how it's purposeful to manage this entity. international registry of acute aortic dissection (irad) trial data showed that inhospital mortality after medical management was significantly increased in average-risk patients with type b aortic dissection under medical therapy with refractory hypertension/pain compared with those without these features (35.6% vs. 1.5%; p = 0.0003) (34). the same applies to malperfusion that has been demonstrated to be too subtle to be detected early. in the majority of cases, patients who underwent medical therapy presented with uncomplicated dissection, although a percentage required early interventions for complications that developed during hospital stay. a minority of patients with complications was treated with medical therapy only, either due to the lack of appropriate facilities or due to the presence of co-morbidities or morphology that made open surgery or endovascular intervention not feasible. for acute aortic dissections treated medically, the pooled early mortality rate was 6.4% (95% ci: 5.1% to 7.9%). the pooled rates of stroke and spinal cord ischemia developing early during medical management alone were 4.2% (95% ci: 2.3% to 7.4%) and 5.3% (95% ci: 3.4% to 8.4%), respectively, with a combined early neurological complication event rate of 10.1% (95% ci: 7.5% to 13.5%). long-term survival ranged from approximately 70.2% to 89% at 5 years(35-46). the recent interdisciplinary expert consensus document on management of type b aortic dissection, which included a systematic review and consensus from 7 leaders from the multidisciplinary fields of cardiology, cardiothoracic surgery, vascular surgery, and interventional radiology, published pooled data on 1,529 patients with acute complicated type b aortic dissection who underwent open surgical repair from high quality studies reported in the literature(47).within this cohort of patients, the recorded combined perioperative mortality was reported at 17.5% (95% ci: 15.6% to 19.6%) with mean rates of stroke and spinal cord ischemia after treatment of 5.9% (95% ci: 4.8% to 7.3%) and 3.3% (95% ci: 2.4% to 4.5%) respectively.the consensus included long term follow up of up to 5 years, which range was reported from 44% to 64.8% on the contrary, the expert consensus further reported a summary of pertinent results for endovascular intervention of acute type b aortic dissection on available data from 2,359 patients(29, 30, 48-52). the early pooled mortality rate was 10.2% (95% ci: 9.0% to 11.6%). pooled rates of early stroke and spinal cord ischemia after treatment were 4.9% (95% ci: 4.0% to 6.0%) and 4.2% (95% ci: 3.3% to 5.2%), respectively. survival rates ranged from 56.3% to 87% at 5 years. freedom from aortic events ranged from 45% to 77% at 5 years. in 2009 the first prospective randomized study for elective stent graft placement in survivors of uncomplicated chronic type b aortic dissection, the investigation of stent references: 1. debakey me, henly ws, cooley da, morris gc jr, crawford es, beall ac jr. surgical management of dissecting aneurysms of the aorta. j thorac cardiovasc surg 1965;49:130-49. 2. wheat mw jr, palmer rf, bartley td, seelmanrc. treatment of dissecting aneurysms of the aorta without surgery. j thorac cardiovasc surg1965;50:364-73. 3. wheat mw jr, harris pd, malm jr, kaiser g, bowman fo jr, palmer rf. acute dissecting aneurysms of the aorta: treatment of results in 64 patients. j thorac cardiovasc surg 1969;58:344-51. 4. daily po, trueblood hw, stinson eb, wuerflein rd, shumway ne. management of acute aortic dissections. ann thorac surg 1970;10:237-47. 5. miller dc, stinson eb, oyer pe, rossiter sj, reitz ba, griepp rb, et al. operative treatment of aortic dissections. experience with 125 patients over a sixteen-year period. j thorac cardiovasc surg 1979;78:365-82. 6. crawford es. the diagnosis and management of aortic dissection. jama 1990;264:2537-41. 7. desanctis rw, doroghazi rm, austen wg, buckley mj. aortic dissection. n engl j med 1987;317:1060-67. 8. miller dc. surgical management of acute aortic dissection: new data. semin thorac cardiovasc surg 1991;3:225-237. 9. miller dc. surgical management of aortic dissections: indications, perioperative management, and long-term results. r.m. doroghazi, e.e. slater aortic dissection. 1983 mcgraw-hill new york: 193-243. 10. reul gj, cooley da, hallman gl, reddy sb, kyger er 3rd, wukasch dc. dissecting aneurysm of the descending aorta: improved surgical results in 91 patients. arch surg 1975;110:632-40. 11. svensson lg, crawford es, hess kr, coselli js, safi hj. dissection of the aorta and dissecting aortic aneurysms: improving early and long-term surgical results. circulation 1990;82(5):iv24-38. 12. safi hj, estrera al. aortic dissection. br j surg 2004;91:523525. 13. hebballi r, swanevelder j. diagnosis and management of aortic dissection. contin educ anaesthcrit care pain 2009; 9: 14-18. 14. hagan pg, nienaber ca, isselbacher em, bruckman d, karavite dj, russman pl. the international registry of acute aortic dissection (irad): new insights into an old disease. jama 2000;283:897-903. 15. trimarchi s, jonker fhw, hutchison s, isselbacher em, pape l a, patel hj, et al. descending aortic diameter of 5.5 cm or greater is not an accurate predictor of acute type b aortic dissection. j thoraccardiovasc surg. 2001;142:e101–7. 16. mohamad b,fok m, hammoud i, rimmer l, shaw m, field m, et al.a perspective on natural history and survival in nonoperated thoracic aortic aneurysm patients. aorta 2013;1:182-189. 17. imamura h, sekiguchi y, iwashita t, dohgomori h, mochizuki k, aizawa k, et al.. painless acute aortic dissection: diagnostic, prognostic and clinical implications. circ j 2011; 75:59–66. 18. park sw, hutchison s, mehta rh, isselbacher em, cooper jv, fang j, et al. association of painless acute aortic dissection with increased mortality. mayo clinproc 2004; 79:1252–1257. 19. mészáros i, mórocz j, szlávi j, schmidt j, tornóci l, nagy l, et al. epidemiology and clinicopathology of aortic dissection. chest 2000; 117:1271–78. 20. tolenaar jl, hutchison sj, montgomery dan, o'gara patrick, fattori rosella, et al. painless type b aortic dissection: insights from the international registry of acute aortic dissection. aorta 2013;1:96-101. 21. klompas m. does this patient have an acute thoracic aortic dissection. jama. 2002;287:2262–72. 22. mccaig lf, nawar ew. national hospital ambulatory medical care survey: 2004 emergency department summary. adv data 2006; 372:1–29. 23. sullivan pr, wolfson ab, leckey rd, burke jl. diagnosis of acute thoracic aortic dissection in the emergency department. am j emerg med 2000;18:46–50. 24. suzuki t, katoh h, tsuchio y, hasegawa a,kurabayashi m,ohira a. diagnostic implications of elevated levels of smooth-muscle myosin heavy-chain protein in acute aortic dissection. the smooth muscle myosin heavy chain study. ann intern med 2000;133:537–41. 25. shinohara t, suzuki k, okada m, shiigai m, shimizu m, maehara t, et al. soluble elastin fragments in serum are elevated in acute aortic dissection. arteriosclerthrombvascbiol 2003;23:1839-44. 26. lindsay j jr. aortic dissection. heart dis stroke 1992; 1:69–76. 27. moore ag, eagle ka, bruckman d,moon bs,malouf jf,fattori r, et al. choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: international registry of acute aortic dissection (irad). am j cardiol 2002;89:1235–8. 28. shiga t, wajima z, apfel cc, inoue t, ohe y. diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. arch intern med 2006;166:1350–6. 29. fattori r, tsai tt, myrmel t, evangelista a, cooper jv, trimarchi s, et al. complicated acute type b dissection: is surgery still the best option?: a report from the international registry of acute aortic dissection. j am coll cardiol intv 2008;1:395– 402. 30. tsai tt, fattori r, trimarchi s, isselbacher e, myrmel t, evangelista a, et al. long-term survival in patients presenting with type b acute aortic dissection: insights from the international registry of acute aortic dissection. circulation 2006;114:2226 –31. pjmsvolume 4 : number 2 : july dec. 2014 review article 6 7 pjmsvolume 4 : number 2 : july dec. 2014 review article 31. trimarchi s, eagle ka, nienaber ca, pyeritz re, jonker fh, suzuki t, et al. international registry of acute aortic dissection (irad) investigators. importance of refractory pain and hypertension in acute type b aortic dissection: insights from the international registry of acute aortic dissection (irad). circulation 2010;122:1283–9. 32. nienaber ca, eagle ka. aortic dissection: new frontiers in diagnosis and management: part i: from etiology to diagnostic strategies. circulation2003;108:628–635. 33. prokop ek, palmer rf, wheat mw. hydrodynamic forces in dissecting aneurysms. in-vitro studies in a tygon model and in dog aortas. circ res 1970;27:121–7. 34. winnerkvist a, lockowandt u, rasmussen e, rådegran k. a prospective study of medically treated acute type b aortic dissection. eur j vascendovascsurg 2006;32:349-55. 35. hata m, sezai a, niino t, yoda m, wakui s, unosawa s, et al. prognosis for patients with type b acute aortic dissection: risk analysis of early death and requirement for elective surgery. circ j. 2007;71:1279-82. 36. niino t, hata m, sezai a, yoshitake i, unosawa s, shimura k, et al. optimal clinical pathway for the patient with type b acute aortic dissection. circ j 2009;73:264-8. 37. estrera al, miller cc 3rd, safi hj, goodrick j, keyhani a, porat e, et al. outcomes of medical management of acute type b aortic dissection. circulation 2006;114;1 suppl:i384 –9. 38. estrera al, miller cc, goodrick j, porat ee, achouh pe, dhareshwar j, et al. update on outcomes of acute type b aortic dissection. ann thorac surg 2007;83:s842-5. 39. kitada s, akutsu k, tamori y, yoshimuta t, hashimoto h, takeshita s. usefulness of fibrinogen/fibrin degradation product to predict poor one-year outcome of medically treated patients with acute type b aortic dissection. am j cardiol 2008;101:1341– 4. 40. sakakura k, kubo n, ako j, fujiwara nn, funayama h, ikeda n, et al. determinants of long-term mortality in patients with type b acute aortic dissection. am j hypertens 2009;22:371–7. 41. chemelli-steingruber i, chemelli a, strasak a, hugl b, hiemetzberger r, czermak bv. evaluation of volumetric measurements in patients with acute type b aortic dissection–thoracic endovascular aortic repair (tevar) vs conservative. j vasc surg 2009;49:20–8. 42. chemelli-steingruber i, chemelli a, strasak a, hugl b,hiemetzberger r,jaschke w, et al. endovascular repair or medical treatment of acute type b aortic dissection? a comparison. eur j radiol 2010;73:175– 80. 43. dick f, hirzel c, immer ff, hinder d, dai-do d, carrel tp, schmidli j. quality of life after acute type b dissection in the era of thoracic endovascular aortic repair. vasa 2010;39:219-28. 44. garbade j, jenniches m, borger ma, barten mj, scheinert d, gutberlet m, et al. outcome of patients suffering from acute type b aortic dissection: a retrospective single-centre analysis of 135 patients. eur j cardiothorac surg 2010;38:285–92. 45. miyahara s, mukohara n, fukuzumi m, morimoto n, murakami h, nakagiri k, et al. long-term follow-up of acute type b aortic dissection: ulcer-like projections in thrombosed false lumen play a role in late aortic events. j thorac cardiovasc surg 2011; 142:e25–31. 46. irad investigators. role and results of surgery in acute type b aortic dissection: insights from the international registry of acute aortic dissection (irad). circulation 2006;114;suppl:i357– 64. 47. fattorirossella, caopiergiorgio, rango paola de, czerny martin, evangelista arturo, et al. interdisciplinary expert consensus document on management of type b aortic dissection, j am coll cardiol 2013;61:1661-1678. 48. nienaber ca, rousseau h, eggebrecht h, kische s, fattori r, rehders tc, et al. randomized comparison of strategies for type b aortic dissection: the investigation of stent grafts in aortic dissection (instead) trial; instead trial. circulation. 2009;120:2519-28. 49. kwolek christopher j, watkins michael t. the investigation of stent grafts in aortic dissection (instead) trial, the need for ongoing analysis. circulation 2009;120:25132514. 50. khoynezhad a, donayre ce, omari bo, kopchok ge, walot i, white ra. midterm results of endovascular treatment of complicated acute type b aortic dissection. j thorac cardiovasc surg 2009; 138:625-31. 51. bozinovski j, coselli js. outcomes and survival in surgical treatment of descending thoracic aorta with acute dissection. ann thorac surg 2008;85:965–70. 52. eggebrecht h, lönn l, herold u, breuckmann f, leyh r, jakob hg, et al. endovascular stent-graft placement for complications of acute type b aortic dissection. curr opin cardiol 2005;20:477-83. panacea journal of medical sciences 2021;11(3):395–400 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article alterations in pulmonary function following laparoscopic cholecystectomy malaya kumar patel1, sheela ekka1, mahendra ekka1,*, pujarini beuria2, sapan kumar jena1 1dept. of anaesthesiology, veer surendra sai institute of medical sciences and research, burla, odisha, india 2dept. of anaesthesiology, s.c.b. medical college and hospital, cuttack, odisha, india a r t i c l e i n f o article history: received 12-01-2021 accepted 13-03-2021 available online 24-11-2021 keywords: lungphysiology pulmonary function tests laparoscopic cholecystectomy a b s t r a c t background: in laparoscopic cholecystectomy, inflammation of the punctured abdominal wall or gall bladder bed, carbon dioxide pneumo-peritoneum and intraoperative patient position has significant effect in the pathogenesis of pulmonary dysfunction. the objective of this study is to detect any changes in pulmonary functions following laparoscopic cholecystectomy using bedside spirometry and to detect degree of impairment of pulmonary function, their complications and the time taken for recovery of postoperative spirometry measurements to the preoperative (baseline) values. materials and methods: this was a prospective observational study in which the preoperative and postoperative spirometry of 70 patients undergoing laparoscopic cholecystectomy under general anaesthesia was compared. pre-operative spirometry was performed to record the baseline values. patients who had normal fvc, fev1, pefr values were included in the study. those who were not able to perform acceptable maneuver were excluded from the study. pulmonary function testing was done twice following surgery on postoperative day one and on postoperative day three. adequate pain relief was given to attain a vas score of less than 40. spirometry values were compared using paired t-test. p-value of <0.05 was considered statistically significant. results: significant differences were found for the forced vital capacity variable (p=0.001), forced expiratory volume in the first second (p=0.020) and peak expiratory flow rate (p=0.000) between the preand immediate postoperative periods, indicating restrictive ventilator dysfunction. conclusion: light restrictive respiratory disturbances were observed after laparoscopic cholecystectomy, wih rapid recovery of pulmonary function, which may lower postoperative pulmonary morbidity and mortality. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction changes in pulmonary function account for significant morbidity andmortality following surgery. 1 abdominal surgery results in the greatest depression in pulmonary function which has been reported to be as high as 70% 2 and micro atelectasis is regarded as a uniform occurrence. the most common post-operative complicationsare * corresponding author. e-mail address: mekka15071976@gmail.com (m. ekka). atelectasis, pulmonary edema, pneumonia, pulmonary thromboembolism and acute exacerbation of copd. they increase mortality, morbidity, length of hospital stay& overall medical cost. although laparoscopic cholecystectomy results in postoperative pulmonary complication, but there is faster recovery of postoperative pulmonary function and less atelectasis and hypoxemia than open cholecystectomy. inflammation of the punctured abdominal wall or gall bladder bed, or both, carbon dioxide pneumo-peritoneum https://doi.org/10.18231/j.pjms.2021.079 2249-8176/© 2021 innovative publication, all rights reserved. 395 396 patel et al. / panacea journal of medical sciences 2021;11(3):395–400 or intraoperative patient position has significant effect in the pathogenesis of this pulmonary dysfunction. 3 the impact of upper abdominal surgery on respiratory function parameters, including lung volumes, flow rates, arterial blood gases and diaphragmatic function, was investigated in several studies. 4,5 the aim of my study is to detect degree of impairment of pulmonary functions and complications after laparoscopic cholecystectomy using bedside spirometry, so that early diagnosis and interventions may decrease post-operative morbidity and mortality. 2. materials and methods 1. spirometer for pulmonary function testing (easy one) 2. pulse oximeter for measuring spo2 2.1. spirometry specifications 1. easy one(t m ) diagnostic 6.5(c) ndd 2000-2010 2. product of ndd medical technologies 2.2. test specifications 1. value selectionbest trial 2. system interpretationgold 2008 / hardie 3. predictedknudson 83 4. paediatric predictedpolgar 2.3. methodology after obtaining institutional ethical approval, this prospective observational study was carried out on a total of 70 patients of either sex between 20-60 years of age, bmi between 18.5-29.9 kg/m2, belonging to asa physical status i and ii, scheduled for elective laparoscopic cholecystectomy under general anaesthesia. written informed consent was obtained from all the patients before the surgery. the patients were subjected to detailed clinical examination and routine investigations to exclude any systemic disorder. emergency surgery, patients with cardio-respiratory diseases, pregnant women, patients with smoking history, duration of surgery exceeding 60 minutes were the exclusions. based on previous studies, 6 a sample size of 53 was required considering an error margin of 5% and a power of 80%. considering a dropout rate of more than 10%, a total of 70 patients were enrolled in the study. patients have been explained about the study procedure, benefits, importance of post-op lung function and the need to do spirometry in the immediate postoperative period. then the pre-op spirometry was performed to record the baseline values. patients who had normal fvc, fev1, pefr values only were included in the study. patients who were unable to perform acceptable maneuver excluded from the study. following a standardized anesthetic protocol, all the cases were done under general anaesthesia with inj. glycopyrrolate 0.04mg/kg, inj. midazolam 0.05mg/kg and inj. nalbuphine 0.1mg/kg as premedication. inj. diclofenac 1.5mg/kg was given as additional intra-op analgesia. induction was done with inj. propofol 2mg/kg and inj. succinylcholine 1.5mg/kg. endotracheal intubation was done with appropriate size cuffed endotracheal tube. adequate plane of anaesthesia was maintained with sevoflurane (1%-2%) and n2o in a 50% mixture with o2. adequate muscle relaxation attained by using inj. vecuronium in standard prescribed dosage. etco2 monitoring was done for all patients to ensure adequate ventilation and co2 elimination. the beginning of surgery corresponded to the moment of the skin incision and the end, the last stitch of the skin suture. the patients were all operated on by the same surgeon using the similar surgical technique. incision was given at the upper edge of the umbilical scar in supine position. intra-abdominal pressure was maintained at a pressure ≤ 12 mmhg throughout the laparoscopic procedure. at the end of procedure, abdomen was compressed to release the residual gas from peritoneum. the patients underwent serial spiro metric measurements. the first test was carried out pre-operatively. the second test was within the first 24 post-operative hours. and third test was undertaken on post-operative day3. most patients were discharged from hospital on postoperative day 3, so we could not perform spirometry after day 3. the spirometry was always conducted by the same professional – a respiratory function technician – with the same equipment: easy onetm diagnostic 6.5 software pc based portable spirometer, which can measure pulmonary flow and volume parameters and is validated by the american thoracic society (ats). the device, in addition to generating flow-volume and volume-time curves, discriminated 12 spirometric variables and the results were printed out automatically. the parameters were analyzed based on knudson’s regression equation. preparation for each spirometry session included calibrating the spirometer through an appropriate calibration syringe, adjusted to ambient temperature (25ºc to 40ºc) and atmospheric pressure. the individual variables height (in cm), weight (in kg), gender and date of birth were recorded and stored in the spirometer. after 10 minutes of rest in a calm environment, each patient underwent three valid and reproducible tests. the spirometry reports were always provided and interpreted by the same person, a specialist in lung function tests, blinded to the patients’ clinical history. the variables fvc, fev1 and pefr were analyzed individually, preand postoperatively, up to the point when their values normalized (80 % of the pre-calculated theoretical value for fvc, fev1 and pefr). the hypothesis that means between patel et al. / panacea journal of medical sciences 2021;11(3):395–400 397 groups were equal before and after surgery was tested through paired t-test. the value of p<0.05 was considered statistically significant. inj. tramadol at a dose of 1mg/kg intramuscular was given for postoperative analgesia. patients were followed up to post-op ward where first post-op spirometry was done within first 24hrs after assessing the pain scale. vas (visual analogue scale from 0-100) was used to assess the pain score. vas score less than 40 was taken as acceptable score since it indicates minimal pain which won’t affect the performance of spirometry. when pain scores were more than 40, intravenous paracetamol was given at a dose of 15 mg/kg body weight over 20 min as infusion. once pain score is within acceptable limits post-op spirometry was performed at the bedside. those patients whose pain score was more than 40 excluded from the study. 3. results fig. 1: consort diagram a total of 60 patients were analyzed after exclusion due to various reasons. data were collected in a prescribed format and tabulated in microsoft excel 2016 and analyzed using spss version 23. normality assumption was examined by the shapiro-wilk w test. according to normality testing, the variables used in analysis were expressed in mean ± sd. descriptive statistics were presented in the form of frequency, percentages, mean ± sd, minimum maximum, the difference between mean of three pft parameters (fev1, fvc, pefr) of the same study group at different time (i.e. pre operatively, on postoperative day1 and on postoperative day3) were evaluated using one way repeated measure anova after fulfilling the parametric tests prerequisites. statistical significance was set at p< 0.05. the percentage of participants in 20-30yrs, 30-40yrs, 4050 years, 50-60 years age group are 31.7%,35.0%, 26.7%, 6.7% respectively with a mean age of 36.3 years and the range was 21-58yrs. majority of the patients in this study group belonged to the female gender group (n=38, 63.3%). male gender was only 36.7%. majority of the patients in this study group belonged to the 51-60kgs weight, class interval (n=21, 35%) with a mean weight of 57.6kgs.minimum weight of the patient was 42kg and maximum was 85kg. height of the patients in this study group was between 142 to 170 cm with maximum percentage in 151-160cms height (n=24, 40%) & mean height of157.1cms. bmi range of the patients was 19-29 kg/m2 with a mean of 23.3 ± 2.9 kg/m2. fig. 2: comparison of mean of fev1 in preop. and post op. period mean fev1 values preoperatively, post operatively on day 1 and post operatively on day 3 are 2.63 l, 2.16l & 2.54l respectively. the results of anova indicated a significant effect of time on fev1 values, f value=79.271, p value<0.05. it means that there is significant change in fev1 value of patient before and after operation. follow up comparisons indicated that each pair wise difference was significant, i.e. p< 0.05. there is a significant decrease in fev1 value on day 1 following lap cholecystectomy as well as on day 3 following operation. but fev1 on day 3 post op is significantly higher compared to day 1 post op. preoperative fev1.>post op day 3 fev1 (96.4%)> post op day 1 fev1 (81.9%). 3.1. distributionof fvc values during pre op, one way repeated measure anova test was used to compare the mean fvc values of total 60 patients before operation, on day 1 and day 3 following operation. the test shows a statistically significant difference in mean fvc 398 patel et al. / panacea journal of medical sciences 2021;11(3):395–400 table 1: mean value preoperative post-operative day 1 post-operative day 3 fev1 2.635 2.160(81.9%) 2.541(96.4%) fvc 3.029 2.487(75.6%) 2.885(95.2%) pefr 6.509 5.393 (82.8%) 6.159 (92.6%) fig. 3: comparison of mean of fvc values during pre op, post op day 1 and post op day 3 values when compared at three different time periods with f value= 74.05, p value < 0.05 and eta2= 0.719. further pair wise comparison was done between each possible pair. it is clearly evident from the above table that mean fvc value in preoperative period is more than mean fvc in postoperative day 1 and day 3 and the difference in the mean values are significant. however, the mean fvc value during post op day 1 is lower as compared to post op day 3 and the difference in is also significant.(p value<0.05) so, the conclusion is there is a significant change in fvc values after lap cholecystectomy. however, fvc parameter gradually improves on day 3 following operation. pre-op fvc> post op day 3(75.6%)> post op day 1(95.2%) one way repeated measure anova test was used to compare the mean pefr values of total 60 patients before operation, on day 1 and day 3 following operation. the test shows a statistically significant difference in mean pefr values when compared at three different time periods with f value=118.14, p value < 0.05. here difference of mean of pefr between each group was compared, where 1=preoperative, 2= postoperative day 1, 3= postoperative day 3 and i time is the reference group to which other group (j time) are compared based on estimated marginal means 1. the mean difference is significant at the 0.05 level. 2. adjustment for multiple comparisons: bonferroni. further pair wise comparison was done between each possible pair. it is clear from the above table that mean fig. 4: comparison of mean of pefr values during preop, post op day 1 and post op day 3 pefr value in preoperative period is more than mean pefr in postoperative day 1 and day 3 and the difference in the mean values are significant. however, the mean pefr value during post op day 1 is lower as compared to post op day 3 and the difference in is also significant.(p value<0.05). so, the conclusion is there is a significant change in pefr values after lap cholecystectomy. however, fvc parameter gradually improves on day 3 following operation. pre-op pefr> post op day 3 pefr (94.6%)> post op day 1 pefr (82.8%). statistically significant differences occurred in all the three variables when preoperative and postoperative values were compared (p=0.001for fvc, p=0.020 for fev1, p=0.000 for pefr). follow up comparisons indicated that each pair wise difference was significant, i.e. p< 0.05. there is a significant decrease in fev1 and fvc value on day 1 following lap cholecystectomy. but fev1 on day 3 post op is significantly higher compared to day 1 post op. (pre.>post day3> post day 1). 4. discussion laparoscopic surgery has been a revolutionary alternative to many open surgical procedures. for the anaesthetists, “minimally invasive” surgery requires maximally attentive anaesthesia. pneumoperitoneum in conjunction with extreme patient positioning induces transient, but significant, multiorgan derangements that require short-term manipulation of physiology to minimize patel et al. / panacea journal of medical sciences 2021;11(3):395–400 399 table 2: pairwise comparisons of mean fev1, vc & pefr values during pre-operative, postop day1 and post op day 3 (i) time (j) time mean difference fev1 (i-j) fev1 sig. mean difference fvc(i-j) fvc sig. mean difference pefr (i-j) pefr sig. 1 2 .475* .000 .542* .000 1.116* .000 3 .093* .020 .144* .000 .350* .000 2 1 -.475* .000 -.542* .000 -1.116* .000 3 -.381* .000 -.398* .000 -.766* .000 3 1 -.093* .020 -.144* .000 -.350* .000 2 .381* .000 .398* .000 .766* .000 complications. subjectively there is no doubt that patients recover more quickly from laparoscopic procedure, and one of the reasons for this smoother recovery may be this procedure’s diminished effect on postoperative pulmonary function compared with previously standard open procedure. laparoscopic cholecystectomy does not damage the abdominal muscles and diaphragmatic function is significantly less affected compared to the open method. this procedure is accompanied by a lower impact on respiratory function and better oxygenation. post operatively all the patients had a significant fall in fvc values measured on postoperative day 1. the reduction was significantly more, from mean pre-op fvc 3.029 l to post-op fvc 2.487 with a reduction of 24.4 %. the second post-op fvc done on postoperative day3 revealed improvement in capacities. the fvc recovered to 2.885 l which is just 4.8% less compared to pre-op values. hence fvc measurements after lap-cholecystectomy were found to be significantly low both during first and third postoperative day, this is similar to the findings published by hasukic s et al, s.m.ravimohan et al. 7,8 post operatively all the patients had a significant fall in fev1 values. the pre-op mean fev1 value of 2.635 l was reduced to 2.160 l on postoperative day1, with a reduction of 18.1% which later improved significantly to 2.541 l on postoperative day3,is again a reduction of 3.6 % compared with the pre-op value. the mean fev1 values after laparoscopic cholecystectomy were significantly reduced both on first and third postoperative day, this is like the findings reported by hasukic s et al. and suter m. et al. 7 pefr value in mean was of 6.5 l/min in preop which decreased to 5.39 l/min with a reduction of 17.2% on postoperative day1. it later recovered well at 6.16 l/min measured on postoperative day 3 which was still 5.4% less compared with pre-op values. the pefr values were significantly reduced in laparoscopic cholecystectomy both during first and third postoperative day. this is like the findings reported by hasukic s et al. 7 in the present study, mild restrictive ventilatory defects were observed, with fvc, fev1 and pefr reduction, when these three variables were compared preand postoperatively, and the decrease in fvc is more than that of fev1. therefore, it can be concluded that laparoscopic cholecystectomy also results in postoperative spirometric changes, an observation that agrees with several other scientific journals. however, in the present study, the more pronounced decreases in fvc, fev1 and pefr were 24.4%, 18.4% and 17.2% respectively on postoperative day 1, in relation to the baseline values. but on postoperative day 3, the more pronounced decrease in fvc, fev1 and pefr are 4.8%, 3.6% and 5.4% respectively. this implies that postoperative day3 spirometric values are comparable to normal tests when compared with the predicted values. reports were found of scientific observations like those made in the present study. more marked alterations are usually found, even in laparoscopies, with decreases between 20% and 30% 9 in all the variables or even more expressive reductions, greater than 40%. several studies 10,11 showed that for patients who underwent upper abdominal surgery, compared with the abdominal cavity, the thoracic wall provided major postoperative contributions in respiratory movement. showing that after upper abdominal surgery, (1) the artificial stimulation of phrenic nerves produced normal trans-diaphragmatic pressure; and (2) diaphragmatic pressures developed during inspiration were shown to be decreased. as for why general anaesthesia and analgesia had no effects, the diaphragmatic activity is not affected by perceptible postoperative pain. however, a reflex inhibition regarding diaphragmatic motility seems to occur with the aid of the abdominal region nerves being activated during the operation. thus, in the present study, reduced diaphragm dysfunction a characteristic of laparoscopic procedures, along with shorter anaesthetic and surgical time, were the main determinants for minimally altered postoperative spirometric values in relation to the preoperative values. thus, the spirometric variables decreased in the immediate postoperative period when compared with the preoperative values, and in the following measurement (third postoperative day), values were already equivalent to those of the preoperative period. several studies pointed to the recovery of pulmonary function after laparoscopic cholecystectomy between 8 to 10 days 12,13 which finds no support in the present study. the difference is likely 400 patel et al. / panacea journal of medical sciences 2021;11(3):395–400 explained by the reduced operative time involving less tissue injury and diaphragm dysfunction. 5. conclusion from the above study, we concluded that there is mild restrictive pulmonary dysfunction after laparoscopic cholecystectomy, which manifested as significant decrease in fvc, fev1 and pefr in postoperative day1 and day3 in comparison with preoperative (baseline) values. but there was a faster recovery of pulmonary functions, which was evident by the rapid improvement of fvc, fev1 and pefr as seen in postoperative day 3. 6. conflict of interest the authors declare that there are no conflicts of interest in this paper. 7. source of funding none. references 1. ali j, weisel rd, layug ab, kripke bj, hechtman hb. consequences of postoperative alterations in respiratory mechanics. am j surg. 1974;128(3):376–46. 2. churchill ed, mcneil d. the reduction in vital capacity following operation. surg gynecol obstet. 1927;44(6):483–8. 3. beecher hk. the measured effect of laparotomy on the respiration. j clin investig. 1933;12(4):639–50. 4. wightman ja. a prospective survey of the incidence of postoperative pulmonary complications. br j surg. 1968;55(2):85–91. 5. latimer rg, dickman m, day wc, gunn ml, schmidt cd. ventilatory patterns and pulmonary complications after upper abdominal surgery determined by preoperative and postoperative computerized spirometry and blood gas analysis. am j surg. 1971;122(5):622–32. 6. ramos gc, pereira e, neto sg, and eco. pulmonary function after laparoscopic cholecystectomy and abbreviated anesthetic-surgical time. revista do colegio bras cirurgioes. 2009;36(4):307–11. 7. hasukic s, mesic d, dizdarevic e, keser d, hadiselimovic s, bazardanovic m. pulmonary function after laparoscopic and open cholecystectomy. surg endosc ultrasound interv techn. 2002;16(1):163–9. 8. ravimohan sm, kaman l, jindal r, singh r, jindal sk. postoperative pulmonary function in laparoscopic versus open cholecystectomy: prospective, comparative study. indian j gastroenterol: official j indian soc gastroenterol. 2005;24(1):6–8. 9. erice f, fox gs, salib ym, romano e, meakins jl, magder sa, et al. diaphragmatic function before and after laparoscopic cholecystectomy. anesth: j am soc anesthesiologists. 1993;79(5):966–75. 10. osman y, fusun a, serpil a, umit t, ebru m, bulent u, et al. the comparison of pulmonary functions in open versus laparoscopic cholecystectomy. j pak med assoc. 2009;59(4):201–4. 11. tiefenthaler w, pehboeck d, hammerle e, kavakebi p, benzer a. lung function after total intravenous anaesthesia or balanced anaesthesia with sevoflurane. br j anaesth. 2011;106(2):272–6. 12. trianthiroussou md, vassiliou mp, behrakis pk. postoperative changes on pulmonary function after laparoscopic and open cholecystectomy. hepatogastroenterology. 2003;50(53):1193–200. 13. wong dh, weber ec, schell mj, wong ab, anderson ct, barker sj, et al. factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. anesth analgesia. 1995;80(2):276–84. author biography malaya kumar patel, associate professor sheela ekka, assistant professor mahendra ekka, assistant professor pujarini beuria, senior resident sapan kumar jena, senior resident cite this article: patel mk, ekka s, ekka m, beuria p, jena sk. alterations in pulmonary function following laparoscopic cholecystectomy. panacea j med sci 2021;11(3):395-400. panacea journal of medical sciences 2021;11(2):321–325 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article prospective study on prevalence of aeroallergens in allergic rhinitis in a teaching hospital, telangana g shyam1, g rachana1,*, mohammed yawar1 1dept. of ent, maheshwara medical college, patancheru, hyderabad, telangana, india a r t i c l e i n f o article history: received 06-12-2020 accepted 13-01-2021 available online 25-08-2021 keywords: allergic rhinitis aeroallergens ige antibody eosinophilia a b s t r a c t background: allergic rhinitis is an ige antibody mediated, inflammatory disease. the most commonly encountered risk factors for allergic rhinitis are presence of atopy, asthma, eczema, and other allergic illnesses. identification of aeroallergens helps in patient counseling to modify life style and prevent exposure to triggering factors. aim of the study: to determine the prevalence of aeroallergens in allergic rhinitis. materials and methods: this was a prospective study done in cases of allergic rhinitis over a duration of one year from january 2019 to december 2019. complete history taking was followed by ent examination including rhinoscopy and endoscopy, peripheral smear examination for eosinophils, absolute eosinophil count testing and skin prick testing with known allergens and serum ige level testing. results: a total of 145 cases of allergic rhinitis were studied. the patient age ranged from 11 years to 50 years. the male to female ratio was 0.5:1. most common allergen causing allergic rhinitis was dust mite which constituted about 44.1% cases. the next common allergen was mold which accounted for 20.6% cases. conclusion: we conclude that there are numerous aeroallergens that can cause allergic rhinitis and the most common ones are dust mites, molds, house dust, animal dander, pollen and others. correct identification of the aeroallergen helps in the proper counseling of the patients so as to prevent exposure to those aeroallergens thereby reducing the episodes and severity of allergic rhinitis. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction allergic rhinitis is an ige antibody mediated, inflammatory disease that is characterized by one or more of the following symptoms: nasal congestion, rhinorrhea (anterior and posterior), sneezing, and itching. 1,2 allergic rhinitis may be classified by 3 temporal pattern and context of exposure to a triggering allergen, 4 frequency and duration of symptoms, and/ or 1 severity. temporal patterns may be 3 seasonal (eg, pollens), 4 perennial (year-round exposures, eg, house dust mites), or 3 episodic environmental (from allergen exposures not * corresponding author. e-mail address: drrachana1234@gmail.com (g. rachana). normally encountered in the patient’s home or occupational environment, eg, visiting a home with pets not present in an individual’s home. 1,2 allergic rhinitis severity can be classified as being mild (when symptoms are present but are not interfering with quality of life) or more severe (when symptoms are severe enough to interfere with quality of life. 1,2 factors that may lead to a more severe problem include sleep disturbance; impairment of daily, sport, or leisure activities; and impairment of school or work performance. 5 the most common encountered risk factors for allergic rhinitis are presence of atopy, asthma, eczema, and other allergic illnesses. 6 https://doi.org/10.18231/j.pjms.2021.065 2249-8176/© 2021 innovative publication, all rights reserved. 321 322 shyam, rachana and yawar / panacea journal of medical sciences 2021;11(2):321–325 parental history of allergic illness is also a well-known risk factor. the risk of allergic rhinitis (ar) rises in children of parents with ar, asthma, hay fever and pollen allergies. 7–9 factors such as, vitamin d, obesity, exposure to cigarette smoke, amplify overall serum ige, elevate blood eosinophils and other environmental exposures of urban settings can also contribute to ar. 10,11 2. aim of the study to determine the prevalence of aeroallergens in allergic rhinitis. 3. materials and methods this was a prospective study done in cases of allergic rhinitis atttending the ent opd at maheshwara medical college, patancheru, hyderabad, telangana. the study period was for one year from beginning of january 2019 to end of december 2020. there were no ethical issues involved. informed consent was obtained from all the patients included in the study. 3.1. inclusion criteria 1. age range from 11 years to 50 years. 2. both genders. 3. rhinorrhea. 4. sneezing. 5. symptoms of nasal obstruction. 3.2. exclusion criteria 1. age less than 11 years and more than 50 years. 2. pregnant women. 3. patients with chronic respiratory tract infections. 3.3. methodology a thorough history was taken including age, gender, occupation, history of atopy, etc. symtoms such as sneezing, rhinorrhoea, nasal itching and nasal congestion were asked and noted thoroughly. personal history such as any food allergy or drug allergy was noted. complete local and general examination was done. ent examination was done including anterior rhinoscopy, and diagnostic nasal endoscopy. peripheral blood smear examination was done in all cases and eosinophil count was noted. absolute eosinophil count was noted and up to 440 cells/mm3 was taken as normal. total serum ige level was measured: it was measured by elisa and chemiluminescent assay. the upper limit of normal was taken as 150 iu/ml. skin prick test (spt): the patients were tested for few aeroallergens. the tests were performed according to standard methods with allergens. glycerinated buffered saline was used as a negative control and histamine diphosphate or dichloride was used as a positive control. the skin prick reaction was read after 15-20 minutes and considered positive if the reaction wheal diameter was at least 3 mm larger than negative control. data was entered into excel sheets for statistical analysis. 4. observations and results total of 145 cases of allergic rhinitis were studied table 1: age and gender distribution age distribution females males no. of cases 11 – 20 years 20 15 35 (24.1%) 21-30 years 26 19 45 (31% ) 31 40 years 45 10 55 (37.9%) 41 – 50 years 40 60 100 (6.8%) total 95(65.5%) 50(34.4%) 145 (100%) in the present study, age distribution ranged from 11 years to 50 years. majority of the cases were reported among 31-40 years.table 1 4.1. gender distribution there were 95 (65.5%) female patients and 50(34.4%) male patients in the study and the male to female ratio was 0.5:1. table 2: distribution based on symptoms symptoms no. of cases percent (%) only rhinnorhea 30 20.6% nasal obstruction + sneezing 22 15.1% nasal obstruction + rhinnorhea 35 24.1% ictching in nose + rhinnorhea 20 13.7% nasal congestion 18 12.4% nasal obstruction + rhinnorhea +pruritis of eyes 20 13.7% total 145 100% in the present study most of the cases presented with rhinorrhea and/or nasal obstruction. rhinnorhea. out of 145 patients with allergic rhinitis, 55% had history of episodic symptoms, 23% had complaints of aggravation of symptoms due to change of season and 12% had symptoms throughout the year.table 2 4.2. distribution based on past history history of atopy was seen in 120(82.7%) and history of food allergy was present in 25(17.2%) cases. shyam, rachana and yawar / panacea journal of medical sciences 2021;11(2):321–325 323 table 3: distribution based on type of allergen allergens no. of cases percent (%) house dust 20 13.7% dust mite 64 44.1% animal dander 10 6.8% grass pollen 11 7.5% trees pollen 4 2.7% insects 5 3.4% mold 30 20.6% fungal spores 10 0.6% total 145 100% in the present study, most common allergen causing allergic rhinitis was dust mite which constituted about 44.1% cases followed by molds and house dust.table 3 4.3. distribution of cases based on seasonal variation dust mites and dusts were more common during winter season, 74(51%) cases, pollens were more common during summer season 35(24.1%) cases and fungi and insects were common during rainy season 36 (24.8%) cases. 4.4. distribution based on eosinophil count on peripheral blood smear in the present study, 32(22%) cases showed eosinophil count <6% and 113(77.9%) cases showed >6% eosinophil count. 4.5. distribution based on absolute eosinophil count (aec) there were 30(20.6%) cases that had aec <440/cumm and 115(79.3%) cases that had aec > 440/cumm. 4.6. distribution based on serum ige levels there were 30(20.6%) cases with serum ige level of <150 iu/l and 115(79.3%) cases with >150 iu/l serum ige level. 5. discussion this was a prospective study to determine the prevalence of allergic rhinitis in hospital visiting patients in telangana. a total of 145 cases were studied. 5.1. comparative studies related to age distribution in the present study, most of the cases (37.9%) of allergic rhinitis were observed among 31-40 years followed by 31% in the 21-30 years age group. kammili j et al 12 in their study observed that the most common age-group affected was 21-30 years, i.e., 66.66% while only 15% of the patients belonged to the age-group of 31–40 years. aggarwal d et al 13 observed majority of their patients were in the age group of 31-40 years (31%) with male to female ratio of 1.5: 1. wang w et al 14 reported the median age as 19.0 years. bellamkonda m et al 15 in a similar study observed the youngest patient to be 16 years and the oldest as 45 years. the mean age of their study group was 27 years. our observations compare well with the above studies. 5.2. comparative studies related to gender distribution in the present study, females were predominant ie. 65.5% (95/145) when compared to males ie, 34.4 % (50/145). bellamkonda m et al 15 in their study observed that female patients were slightly more than the male patients with a male to female ratio of 0.935:1 ie they had 31 females and 29 males in their study. kammili j et al 12 observed allergic rhinitis more in males than in females, with 66.66% in males and 33.33% in females. wang w et al 14 in their study had 2269 males (55.5%) and 1816 (44.5%) females. 5.3. comparative studies related to prevalence of sensitisation to aeroallergens in the present study, most common allergen causing allergic rhinitis was dust mite which constituted about 44.1%. the next common allergen was mold which occupied 20.6%, followed by house dust 13.7%, animal dander (6.8%), grass pollen 7.5% trees pollen 2.7%, insects 3.4% and fungal spores 0.6%. in wang w et al 14 study, among the 4085 patients with allergic rhinits, the prevalence rates of sensitization to aeroallergens were as follows: 84.4% for house dust mites, 23.4% for pet allergens (combination of dog hair and cat dander), 21.1% for cockroaches, 9.1% for mould allergens, 7.7% for mixed tree pollens and 6.0% for mixed weed pollen. in kammili j et al 12 study, dust mites (20.82%) and dusts (12.49%) were more common during winter season, pollens (17.49%) were more common during summer season, and fungi (4.9%) and insects (5.83%) during rainy season. most common allergen in their study was dust mite (32.48%) followed by pollens (27.48%), dusts (18.32%), fungi (10.82%), and insect (9.16%). in the study by aggarwal d et al 13 the most common allergen/ irritant causing aggravation of symptoms was dust, which was responsible for 97% of cases, followed by smoke (22%) and the least was pollen (5%). in the study by nagare p et al 16 dust was the most common risk factor for allergic rhinitis accounting for 82% followed by weather changes in 46% cases. 5.4. comparative studies related to symptoms in the present study, majority of the cases presented with nasal obstruction and rhinnorhea ie, 24.1% cases. next common symptom was only rhinorhea and was seen in 20.6% cases whereas, in the study by bellamkonda m et al 15 the most common nasal symptom was nasal discharge (80%) followed by sneezing (78.34%) and nasal obstruction 324 shyam, rachana and yawar / panacea journal of medical sciences 2021;11(2):321–325 (70%). seven patients (11.67%) had altered sense of smell and headache. the most common ophthalmological symptom associated with allergic rhinitis was congestion in eyes in about 40% of patients followed by itching. photophobia and foreign body sensation were seen in 1.67% patients, respectively in their study. our findings correlate well with the above authors. 5.5. comparative studies related to history of comorbidities in the present study history of atopy was seen in 82.7% cases, and 17.2% had history of food allergy. bellamkonda m et al 15 observed in a similar study that a total of 19(31.67%) patients had a positive family history of allergy. two had history of food allergy; one patient to milk and other to peanuts. one patient had drug hypersensitivity to aspirin. nagare p et al 16 observed dust allergy among 50 patients, 5 had family history of allergic rhinitis and 10% had atopy. 5.6. comparative studies related to peripheral blood smear eosinophilia in the present study, 77.9% cases showed eosinophil count > 6% whereas, in the study by nagare p et al 16 they observed that eosinophil count in 66% patients was < 5% and in 34% patients it was >= 5%. aggarwal d et al 13 observed 49% of patients had raised eosinophils in their peripheral blood smear. 5.7. comparative studies related to aec in the present study 79.3% cases showed aec > 440 cells/cumm. in the study by bellamkonda m et al 15 the majority of patients (26.6%) had aec ranging between 301 and 400 cells/cumm followed by 25% patients in range of 400-500 cells/cumm. aggarwal d et al 13 observed an absolute eosinophil count (aec) of >440 cells/mm3 in 50% of patients. 5.8. comparative studies related to skin prick test in the present study, the skin prick test was strongly positive for dust mite in 44.1% cases. the next common allergen was molds which accounted for 20.6% cases, followed by house dust in 13.7% cases, animal dander in 6.8% cases, grass pollen in 7.5% cases, trees pollen in 2.7% cases, insects in 3.4% cases and fungal spores in 0.6% cases. aggarwal d et al 13 in their study observed the prevalence of skin prick test was strongly positive for pollens (46.19%), followed by dust (16.4%), dust mites (15.7%), fungus (9.7%), insects (9.24%) and to epithelia (2.77%). among 68 aeroallergens, most common offending allergen was d-farinae (30%) in their study. 6. conclusion we conclude that there are numerous aeroallergens that can cause allergic rhinitis and the most common ones are dust mites, molds, house dust, animal dander, pollen and others. correct identification of the aeroallergen helps in the proper counseling of the patients so as to prevent exposure to those aeroallergens thereby reducing the episodes and severity of allergic rhinitis. 7. conflict of interest the authors declare that there are no conflicts of interest in this paper. 8. source of funding none. references 1. benincasa c, lloyd rs. evaluation of fluticasone propionate aqueous nasal spray taken alone and in combination with cetirizine in the prophylactic treatment of seasonal allergic rhinitis. drug investig. 1994;8(4):225–33. 2. lorenzo gd, pacor ml, pellitteri me, morici g, gregoli ad, bianco c, et al. randomized placebo-controlled trial comparing fluticasone aqueous nasal spray in mono-therapy, fluticasone plus cetirizine, fluticasone plus montelukast and cetirizine plus montelukast for seasonal allergic rhinitis. clin exp allergy. 2004;34(2):259–67. 3. anolik r. clinical benefits of combination treatment with mometasone furoate nasal spray and loratadine vs monotherapy with mometasone furoate in the treatment of seasonal allergic rhinitis. ann allergy asthma immunol. 2008;100(3):264–71. 4. barnes ml, ward jh, fardon tc, lipworth bj. effects of levocetirizine as addon therapy to fluticasone in seasonal allergic rhinitis. clin exp allergy. 2006;36(5):676–84. 5. martin bg, andrews cp, bavel jv. comparison of fluticasone propionate aqueous nasal spray and oral montelukast for the treatment of seasonal allergic rhinitis symptoms. ann allergy asthma immunol. 2006;96(6):851–7. 6. sultész m, gabor k, hirschberg a, galffy g. prevalence and risk factors for allergic rhinitis in primary schoolchildren in budapest. int j pediatr otorhinolaryngol. 2010;74(5):503–9. 7. wang qp, wu km, li zq, xue f, chen w, ji h, et al. association between maternal allergic rhinitis and asthma on the prevalence of atopic disease in offspring. int arch allergy immunol. 2012;157(4):379–86. 8. westman m, kull i, lind t, melen e, stjarne p, toskala e, et al. the link between parental allergy and offspring allergic and nonallergic rhinitis. allergy. 2013;68(12):1571–8. 9. dold s, wjst m, mutius ev, reitmeir p, stiepel p. genetic risk for asthma, allergic rhinitis, and atopic dermatitis. arch dis childhood. 1992;67(8):18–22. 10. wright al, holberg cj, halonene m, martinez fd, morgan w, taussig lm, et al. epidemiology of physician-diagnosed allergic rhinitis in childhood. pediatrics. 1994;94(6):895–901. 11. musaad s, patterson t, ericksen m, lindsey m, dietrich k, succop p, et al. comparison of anthropometric measures of obesity in childhood allergic asthma: central obesity is most relevant. j allergy clin immunol. 2009;123(6):1321–7. 12. kammili j, praveenkumar. analysis of distribution of allergens and its seasonal variation in allergic rhinitis. j med sci. 2019;5(3):59– 62. doi:10.5005/jp-journals-10045-00129. 13. aggarwal d, abhhilash s, kapur s, gupta d. study of causal aeroallergens in allergic rhinitis. int j otorhinolaryngol head neck http://dx.doi.org/10.5005/jp-journals-10045-00129 shyam, rachana and yawar / panacea journal of medical sciences 2021;11(2):321–325 325 surg. 2019;5(4):916–21. 14. wang w, huang x, chen z, zheng r, chen y, zhang g, et al. prevalence and trends of sensitisation to aeroallergens in patients with allergic rhinitis in guangzhou, china: a 10-year retrospective study. bmj open. 2016;6(5):11085. doi:10.1136/bmjopen-2016-011085. 15. bellamkonda m, vinodkumar g. clinicopathological study of allergic rhinitis. asian j pharm clin res. 2017;10(1):186–91. 16. nagare p, chavan s, jain p, burgute s. study of clinicopathological profile in patients of allergic rhinitis. indian j basic appl med res. 2019;8(2):374–80. author biography g shyam, associate professor g rachana, senior resident mohammed yawar, senior resident cite this article: shyam g, rachana g, yawar m. prospective study on prevalence of aeroallergens in allergic rhinitis in a teaching hospital, telangana. panacea j med sci 2021;11(2):321-325. http://dx.doi.org/10.1136/bmjopen-2016-011085 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2021;11(2):274–279 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article comparative study of efficacy of platelet rich plasma injection versus corticosteroid injection in conservative management of periarthritis shoulder surai soren1, ashok kumar nayak1, rabindra nayak1, sambit kumar panda2,*, sabyasachi swain1 1dept. of orthopaedics surgery, m.k.c.g medical college, berhampur, odisha, india 2dept. of orthopaedics, bb medical college, bolangir, odisha, india a r t i c l e i n f o article history: received 03-12-2020 accepted 02-01-2021 available online 25-08-2021 keywords: platelet rich plasma injection corticosteroid injection efficacy periarthritis shoulder a b s t r a c t materials and methods: analysis of eighty patients with periarthritis shoulder was done. patients were thoroughly evaluated and were divided into two groups in a randomized trial. forty patients were in groupa who received 3doses of injection of prp (4ml) 2 weeks apart within a duration of 6weeks. equal number of patients were in group-b. they received 2ml of injection corticosteroid 2weeks apart within a duration of 6 weeks. all participants were advised to perform a home-based hot fomentation and 15min exercise therapy. one participant from group a and 2 from group b were lost to follow up. there were 35 male and 42 female who completed the study. analysis of 77 subjects who completed the study was done. participant were evaluated for range of motion of shoulder as main outcome measure. visual analogue scale (vas) and (quick dash) was used to measure pain and functions of the shoulder. the evaluation of participants was done at 0,3,6 and 12 weeks. anova test and chi-square test, was repeatedly used to measure the differences. results: participants who were given prp injections showed significant improvements in active and passive range of shoulder motion as measured by vas and quick dash over corticosteroid injection. this was also reflected statistically. no major adverse reactions were observed during 12 weeks of intervention. conclusion: in our study, the injection of prp showed marked improvement in the range of motion of shoulder over corticosteroid injection but it needs other study to be treatment of choice. it emerged as an option for treatment in diabetes patient and condition where steroid is contraindicated. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction periarthritis (pa) shoulder is characterised by pain, stiffness of shoulder joint. 1–3 it limits the movement of shoulder joint. periarthritis shoulder affects around 2-5% of general population. it goes up to about 20% with diabetes mellitus. as our country is a diabetic capital of the world the incidence may be much higher. 4,5 there are various methods of treatment for periarthritis like intra-articular injection of hyalauronic acid and * corresponding author. e-mail address: drsambitpanda@gmail.com (s. k. panda). corticosteroid, physiotherapy which includes mobilization exercise, ultrasonic therapy, manipulation under general anaesthesia, arthroscopic release of fibrous tissue. 6–8 the ultrasonic therapy produces in consistent results. 9,10 thus none of the treatment provide complete relief from periarthritis. 11,12 the search for a better treatment is continuing. in that respect prp is a promising treatment. 1,4 prp is extracted from patients own blood. it contains higher concentration of platelets above the baseline. 13,14 along with higher platelet concentration it has higher growth factors and anti-inflammatory agents which promotes to reduce healing time and inflammation. thus, the time for https://doi.org/10.18231/j.pjms.2021.056 2249-8176/© 2021 innovative publication, all rights reserved. 274 soren et al. / panacea journal of medical sciences 2021;11(2):274–279 275 recovery from periarthritis is reduced. with this background we tried to examine the efficacy of prp injection with corticosteroid injection in periarthritis. 6 2. materials and methods randomised comparative study was conducted at mkcgmch berhampur in an opd set up from january 2019 to december 2019. the study was approved by the institutional ethical committee. the present study excluded patients with local abscesses, diabetes mellitus, malignancy, pregnancy, and blood disorders (coagulopathy and thrombocytopenia); patients on nsaids or systemic steroids within one week before injection; those who received previous local injection of steroid within past 3 weeks or previous injection of prp within past 6 months; and patients with painful active, cervical spine conditions. all patients were subjected to history taking, demographic data recording and clinical examination which includes general examination and local examination of shoulder joint. all patients underwent blood examination which includes complete blood count, fasting blood sugar, erythrocyte sedimentation rate, serum uric acid, rheumatoid factor, c-reactive protein, hepatitis a,b and c virus antibody, tridot testand also radiological examination such as plain radiography shoulder joint, where two projections were formed: antero-posterior view with the patient standing, the arm in the hanging position first with maximal external and then with maximal internal rotation of the shoulder. 2.1. inclusion criteria 1. age over 25 years 2. shoulder pain for at more than one month with loss of active shoulder movements (flexion, abduction and external rotation). 15,16 3. antero-posterior radiographs of the shoulder joint in neutral rotation should be normal. 4. willingness to be part of the study and refuse other modality of treatment. 2.2. exclusion criteria 1. unwillingness to participate in the study 2. intrinsic shoulder joint pathology 3. any history of shoulder trauma/surgery 4. presence of complex regional pain syndrome 5. history of intra-articular injection in the involved shoulder joint in last six months 6. patients with haematological disorders 7. patients with chronic diseases and pregnancy or breastfeeding. eighty participants fulfilled the inclusion/exclusion criteria. they were divided into two groups a and b equally. this was done in a randomized manner. the participants were provided with all the information regarding the study. they were apprised with withdrawal rights. after thorough counselling, informed consent was taken. group a participants received 3 doses of intra-articular injection (4ml of prp). group b participants received 2ml of methyl prednisolone acetate by posterior approach. the sulcus between the head of the humerus and acromion was identified. the needle was inserted 2-3cm inferior and medial to the postero-lateral corner of the acromion and directed anteriorly towards the coracoid process. 17,18 throughout the whole procedure aseptic measured and precautions were taken. after the injection patient were observed for any adverse reactions. then they are sent to home. they were instructed to limit shoulder movement for 48 hours and to use cold compression and paracetamol in case of unbearable pain. after a week exercise was started. prp was prepared by taking 10ml of venous blood from every patient. blood was collected in a sterile tube. the sterility of the tubes was verified by culture in the department of microbiology. the sterile tubes were filled with sodium citrate to prevent coagulation. the sterile tube with citrated blood was centrifuged at 3500 rpm for 10 minutes to separate the blood component. then 4ml of prp was taken out. all the participants of group a and b were taught shoulder exercise which included active range of shoulder movement like abduction, flexion, external rotation and internal rotation. pendulum exercise was also taught. all the participants were instructed to perform the exercise twice daily at home. they were advised to perform the exercises in gentle manner. ointment or painrelieving oil can be used by the participants in case of increased pain. after baseline evaluation and intervention all the participants were assessed at 3,6 and 12 weeks. the assessment was done by physiatrist. physiatrist was unaware of the intervention received by participants. the participant had been instructed not to reveal about the treatment. improvement in active and passive range of motion of shoulder was assessed by goniometer. the data generated were expressed as standard deviation and mean. the change in the mean values of continuous variables with time was compared by using anova test. one-way anova test was applied to compare mean values between groups for each domain of continuous variable. 19 to determine difference between the groups post-hoc tests (bonferroni correction) was used. result of p value > 0.05 was considered to be significant. 276 soren et al. / panacea journal of medical sciences 2021;11(2):274–279 3. observation & results a total of 97 subjects with complaints of shoulder pain associated with restriction of motion were assessed for eligibility. a total of 80 subjects were found eligible and randomised to two groups of 40 each. 3 participants (1 in group a; 2 in group b) were lost to follow up. analysis of 77 subjects (35 males; 42 females) who completed the study was done. data of age, sex, involvement of dominant or nondominant side and other clinical features of each group are given in [table 1 (a), (b), (c) and (d)]. the data given is a baseline feature. mean of age, sex distribution, duration of symptom, range of motion of shoulder, involvement of shoulder was almost the same in both the group. 1 participant in prp group reported pain and pricking sensation which was relieved by ice compression. no major side effects were observed during period of study. age group involved in both the group was between 29-75yrs. no significant difference was observed in age group. similarly, the sex distribution was almost the same in both the groups. there was predominance of dominant side as compared to non-dominant side in both the group. duration of symptoms was almost the same in both the group. at follow up, after the initial intervention there was improvement in active range of shoulder movement. abduction, flexion, internal rotation, external rotation in both the group. at 12 week of assessment prp treatment showed marked improvement in mean active range of shoulder movement abduction, flexion, external rotation and internal rotation over steroid injection. there was improvement with steroid injection at 12 weeks in mean active range shoulder movement but the improvement was far more less than prp treatment [table 3]. analysis of passive range of shoulder motion showed improvements similar to active motion, with significant improvement seen at 12 weeks [table 4]. active range of motion in shoulder in degrees [mean] in baseline, 3 week, 6 weeks, 12 weeks in table 3. {statistical test: anova with bonferroni correction between groups and repeat anova within group}. passive range of motion of shoulder in degree in baseline, 3 week, 6 weeks,12 weeks in table 4. [statistical test: anova with bonferroni correction between groups and repeat anova with in group] at 6weeks, more significant improvement was seen only in prp as shown by post-hoc test with bonferroni correction. 4. discussion age of participants was in range of 29-75yrs with mean of 53.5±12.5years. this is in line with the data reported in literature. 12 female are more affected than male in periarthritis. and our study is similar to the other studies. 20 in this study the dominant side was affected more than nondominant side contrary to the other studies, 12 which shows non-dominant side to be involved more. treatment with prp resulted in better vas score for pain and quick dash score for function after 6weeks. treatment with prp resulted in marked improvement in pain, active and passive range of motion of shoulder after 12 weeks. this was also reflected statistically. treatment with steroid injection also showed improvement in pain and functional movement of shoulder but it was not up to the level of prp. the improvement was in line with that of other previous studies. 11,14,19 systematic review of steroid use in pa by griesser mj et al. showed significant but transient improvement in abduction and forward elevation and significant short as well as long term diminution of pain measured by vas and shoulder pain and disability index (spadi). 6 in our study it was found that prp was better than steroid. there is increasing evidence to support the use of prp in pa. advantagerandomization of the participant to eliminate the selection bias was done in our study. assessment by a blinded investigator to minimize the bias was incorporated in the study. use of goniometer to measure the range of motion of shoulder. 5 simple method of preparation of prp. drawbacksduration of the study was only 1 year and the intervention was only for 12 weeks. since the duration of periarthritis shoulder is between 1-2 years. there is the need for a longer study beyond 12weeksand similar trend soren et al. / panacea journal of medical sciences 2021;11(2):274–279 277 table 1: (a) prp mean (sd) (n=39) corticosteroid mean (sd) (n=38) sex, no. (%) male 22 (56.4) 18(47.4) female 17 (43.6) 20 (52.6) (b) prp mean (sd) (n=39) corticosteroid mean (sd) (n=38) age (years) mean 52.5(12.8) 54(12.2) range (29-75) (30-72) (c) side involved, n(%) prp (39) corticosteroid (38) dominant 22(56.4) 20(52.6) non-dominant 17(43.5) 18(47.3) (d) prp (n=39) corticosteroid (n=38) duration of symptoms, in months mean 4.4 5.1 table 2: patient demographic and baseline features range of motion (in shoulder) prp (n=39) corticosteroid (n=38) mean standard deviation mean standard deviation abduction active 105.8397 10.37876 97.0592 11.37512 passive 115.2051 9.78635 106.8158 10.49673 flexion active 107.0385 15.18163 93.6974 14.78028 passive 115.2244 12.14439 103.5526 13.58148 external rotation active 53.4615 8.54488 40.7566 7.14651 passive 61.2564 8.41785 49.6250 7.06456 internal rotation active 43.5192 5.69579 34.7171 4.42283 passive 49.8269 5.56426 43.1908 4.29937 statistical test: [-chi-square test for sex & involved side was done. anova with bonferroni test for duration of symptom and range of motion of shoulder-] table 3: prp mean (sd) (n=39) corticosteroid mean (sd) (n=38) pvalue abduction baseline 82(8.3) 80.5(11.2) 0.11 3 weeks 96.1(9.8) 90.4(11.4) 0.48 6 weeks 112.5(12.6) 102.1(12.0) 0.12 12 weeks 132.6(12.6) 115.0(11.7) 0.023 flexion baseline 84.6(13.4) 76.9(16.5) 0.18 3 weeks 98.9(14.8) 87.3(14.9) 0.07 6 weeks 114.4(16.6) 99.2(14.6) 0.24 12 weeks 132(14.0) 115(11.7) 0.023 external rotation baseline 32.4(6.1) 27.5(5.8) 0.039 3 weeks 45.3(7.8) 35.0(6.6) 0.005 6 weeks 59.6(9.1) 45.4(8.6) 0.036 12 weeks 76.7(13.4) 55.5(9.0) 0.036 internal rotation baseline 25.6(3.7) 21.6(3.2) 0.041 3 weeks 37.2(5.4) 29.0(3.8) 0.0 6 weeks 49.3(6.8) 38.8(5.1) 0.002 12 weeks 60.6(6.5) 49.0(6.3) 0.001 278 soren et al. / panacea journal of medical sciences 2021;11(2):274–279 table 4: prp mean (sd) (n=39) corticosteroid mean(sd) (n=38) p-value abduction baseline 88.6(8.1) 86.7(10.8) 0.25 3 weeks 105.0(9.5) 99.7(11.5) 0.38 6 weeks 148.9(16.0) 113.8(10.6) 0.021 12 weeks 153.0(12.0) 126.8(10.1) 0.003 flexion baseline 90.5(11.2) 83.5(14.6) 0.04 3 weeks 106.7(12.0) 96.6(14.5) 0.14 6 weeks 123.5(14.1) 110.8(13.8) 0.094 12 weeks 140.5(13.9) 123.3(12.3) 0.045 external rotation baseline 38.0(6.2) 33.3(5.9) 0.16 3 weeks 52.5(6.7) 44.0(7.3) 0.018 6 weeks 66.8(7.6) 55.0(8.3) 0.004 12 weeks 85.3(11.0) 65.5(7.9) 0.001 internal rotation baseline 30.4(6.0) 27.4(3.2) 0.008 3 weeks 43.1(5.9) 37.0(4.0) 0.08 6 weeks 57.2(6.2) 49.0(5.7) 0.003 12 weeks 69.2(7.2) 59.4(5.7) 0.008 has been reported in literature. 12 5. conclusion in our study, the injection of prp showed marked improvement in the range of motion of shoulder over corticosteroid injection but it needs other study to be treatment of choice. it emerged as an option for treatment in diabetes patient and condition where steroid is contraindicated. 6. conflict of interest the authors declare that there are no conflicts of interest in this paper. 7. source of funding none. references 1. hsu wk, mishra a, rodeo sr, fu f, terry ma, randelli p, et al. platelet-rich plasma in orthopaedicapplications:evidencebased recommendations for treatment. j am acad orthop surg. 2013;21(12):739–48. 2. hand gcr, athanasou na, matthews t, carr aj. the pathology of frozen shoulder. j bone joint surg br. 2007;89(7):928–32. 3. zuckerman jd, rokito a. frozen shoulder:a consensus definition. j shoulder elbow surg. 2011;20(2):322–25. 4. harmon kg, rao al. the use of platelet-rich plasma in the nonsurgical management of sports injuries:hype or hope? haematology am soc haematol educ program. 2013;2013:620–6. doi:10.1182/asheducation-2013.1.620. 5. pal b, anderson j, dick wc, griffiths id. limitation of joint mobility and shoulder capsulitis in insulinand non-insulin-dependent diabetes mellitus. br j rheumatol. 1986;25(2):147–51. 6. griesser mj, harris jd, campbell je, jones gl. adhesive capsulitis of the shoulder:a systematic review of the effectiveness of intra-articular corticosteroid injections. j bone joint surg am. 2011;93(18):1727–33. 7. jacobs lg, smith mg, khan sa, smith k, joshi m. manipulation or intra-articular steroids in the management of adhesive capsulitis of the shoulder?a prospective randomized trial. j shoulder elbow surg. 2009;18(3):348–53. 8. carette s, moffet h, tardif j, bessette l, morin f, frémont p, et al. intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder:a placebo-controlled trial. arthritis rheum. 2003;48(3):829– 38. 9. chauhan s, kothari sy, laisram n. comparison of ultrasonic therapy, sodium hyaluronate injection and steroid injection in the treatment of periarthritis shoulder. ijpmr. 2012;23(3):105–10. 10. dogru h, basaran s, sarpel t. effectiveness of therapeutic ultrasound in adhesive capsulitis. joint bone spine. 2008;75(4):445–50. 11. lloyd-roberts gc, french pr. periarthritis of the shoulder:a study of the disease and its treatment. br med j. 1959;1(5137):1569–71. 12. neviaser as, neviaser rj. adhesive capsulitis of the shoulder. j am acad orthop surg. 2011;19(9):536–42. 13. blanchard v, barr s, cerisola fl. the effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis:a systematic review. physiotherapy. 2010;96(2):95–107. 14. eppley bl, woodell je, higgins j. platelet quantification and growth factor analysis from platelet-rich plasma:implications for wound healing. plast reconstr surg. 2004;114(6):1502–8. 15. mcfarland eg. examination of the shoulder:the complete guide. new york: thieme; 2006. 16. schellingerhout jm, verhagen ap, thomas s, koes bw. lack of uniformity in diagnostic labeling of shoulder pain:time for a different approach. man ther. 2008;13(6):478–83. 17. rizk te, pinals rs, talaiver as. corticosteroid injections in adhesive capsulitis:investigation of their value and site. arch phys med rehabil. 1991;72(1):20–2. 18. page mj, green s, kramer s, johnston rv, mcbain b, buchbinder r, et al. electrotherapy modalities for adhesive capsulitis (frozen shoulder) cochrane. database syst rev. 2014;(10):11324. 19. kennedy ca, beaton de, smith p, eerd dv, tang k, inrig t, et al. measurement properties of the quickdash (disabilities of the arm, shoulder and hand) outcome measure and cross-cultural adaptations of the quickdash:a systematic review. qual life res. 2013;22(9):2509–47. 20. dias r, cutts s, massoud s. frozen shoulder. bmj. 2005;331(7530):1453–6. http://dx.doi.org/10.1182/asheducation-2013.1.620 soren et al. / panacea journal of medical sciences 2021;11(2):274–279 279 author biography surai soren, assistant professor ashok kumar nayak, associate professor rabindra nayak, assistant professor sambit kumar panda, associate professor sabyasachi swain, senior resident cite this article: soren s, nayak ak, nayak r, panda sk, swain s. comparative study of efficacy of platelet rich plasma injection versus corticosteroid injection in conservative management of periarthritis shoulder. panacea j med sci 2021;11(2):274-279. panacea journal of medical sciences 2022;12(1):86–90 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article elevated high sensitivity c-reactive protein in patients with subclinical hypothyroidism: a case control study anuradha panda1, deepak kumar dasmohapatra2,*, aditya narayan dash3, babita ekka4 1dept. of pathology, maharaja krishna chandra gajapati medical college and hospital, brahmapur, odisha, india 2dept. of transfusion medicine, veer surendra sai institute of medical science and research, burla, odisha, india 3dept. of cardiology, mkcg medical college and hospital, brahmapur, odisha, india 4medical officer, odisha mining corporation, india a r t i c l e i n f o article history: received 10-07-2021 accepted 22-09-2021 available online 30-04-2022 keywords: subclinical hypothyroidism high sensitivity creactive protein thyroid stimulating hormone hyperlipidemia cardiovascular disease a b s t r a c t background: inflammation in subclinical hypothyroidism (sch) imposes a significant cardiovascular risk. the aim of the present study was to assess the elevated levels of high sensitivity c-reactive protein (hs-crp) in sch patients. materials and methods: in this study, 50 cases of sch and 50 cases of euthyroid were selected. the complete history of the subjects were taken and demographic , biochemical parameters like age, bmi, thyroid profiles, lipid profiles and hscrp were estimated. results: the mean tsh levels were significantly (p<0.05) elevated in sch cases as that of the controls (8.56± 1.76 vs 2.28± 0.65 µu/ml). further, hs-crp level was significantly (p<0.05) higher in sch cases as that of the controls (2.93 ±0.87 vs 1.16 ±0.45 mg/l). meanwhile, lipid profiles were also elevated in sch cases as that of the controls. coefficient correlation analysis showed significant association between tsh and hs-crp. conclusion: thus, increased level of hs-crp in sch highlights the inflammatory status and thus associated with the development of cardiovascular diseases in sch. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction clinically, subclinical hypothyroidism (sch), is defined as an elevated level of serum thyroid-stimulating hormone (tsh) with a parallel normal serum free thyroxine levels (ft4) and triiodothyronine (ft3). 1 global prevalence of sch is reported to be around 3% to 12%. 2 in india, the estimated prevalence of sch is 9.4%. 3 mounting studies have shown a significant association between sch and metabolic disorders, hypertension and cardiovascular disorders. 4,5 a recent meta-analysis displayed significant association between sch and coronary heart disease with * corresponding author. e-mail address: dkdm@rediffmail.com (d. k. dasmohapatra). an increased risk of cardiovascular mortality in patients with tsh level above 10 ml u/l. 6 wide array of inflammatory markers has been identified as independent risk factors for cvd. high-sensitivity c-reactive protein (hscrp), is touted to be a reliable predictor of cvd as compared to the lipid profile markers. array of observational studies displayed a strong association between hs-crp and morbidity and mortality associated with coronary heart disease, 7,8 and also increased the prediction of cardiovascular risk by adding hscrp to the framingham risk score. 9 various clinical studies elicited marked association between hs-crp and index of subclinical atherosclerosis, like coronary artery calcification and intima-media thickness. 10 the crp is an acute phase https://doi.org/10.18231/j.pjms.2022.017 2249-8176/© 2022 innovative publication, all rights reserved. 86 panda et al. / panacea journal of medical sciences 2022;12(1):86–90 87 reactant, produced in the liver. the mechanism of crp induced inflammatory condition is due to the upregulated expression adhesion molecules in vascular endothelial cells triggered by crp. 11 conflicting scenario exists in the role of hscrp for analysing the cvd risk in sch. wide range of studies showed the elevated hscrp level in sch. 12–15 in this backdrop, the present study was undertaken to evaluate the incidence of elevated levels of hscrp in individuals with sch and also to delineate the risk of developing coronary vascular events. 2. materials and methods this was a cross-sectional case control study conducted in veer surendra sai institute of medical science and research, burla, odisha. the study group included patients attending the department of pathology. 50 patients with subclinical hypothyroidism (sch) based on thyroid status (increased level of tsh, ft3 and ft4) were designated as cases based on the exclusion criteria. further, 50 patients who were euthyroid based on serum tsh, ft3 and ft4 levels were designated as controls based on the exclusion criteria. patients encountered with diabetes, hypertension, renal and liver disorders, coronary heart disease, undergoing thyroxine replacement therapy, affected with systemic infections were excluded from the study. further, patients on nsaids, antibiotics, hrt and statins (which can increase hscrp were also excluded from the study). further the from the selected sch cases the complete history was collected thorough general and systemic examination was done as per proforma. under strict aseptic techniques, blood samples were collected after overnight fast, and analysed for the following required parameters. the above mentioned procedure was repeated for controls. the collected blood samples were centrifuged at 10,000 rpm for 10 minutes and the serum was collected in vials and stored at −80◦c until the analysis. samples were analysed for thyroid hormones, hscrp, and haematological parameters, fasting blood sugar, renal function tests, liver function tests and lipid profiles. the reference range for the above mentioned parameters were as follows, thyroid profile: tsh: 0.34–4.25 miu/l, free t4: 0.7–1.24 ng/dl and free t3: 2.4–4.2 pg/ml; fasting plasma glucose: 75-100 mg/dl; lipid profiles: total cholesterol: less than 200 mg/dl; triglycerides: 30-200 mg/dl; hdl cholesterol: 40-60 mg/dl. high sensitivity c-reactive protein (based on the risk for atherosclerosis): low risk: less than 1 mg/l; intermediate risk: 1-2.9 mg/l; high risk: more than or equal to 3 mg/l. 2.1. data analysis the data were expressed as mean ± sd. statistical analysis was done using unpaired students-t-test. a p value <0.05 was considered as statistically significant. the correlation between the parameters was carried out using pearson’s correlation. 3. results in the present study, among the sch cases most of them were between the age group of 21-30 years (34%), followed by 31-40 years (5.5%), 41-50 years (28%). thus majority of the cases constitute between 21-50 years. in the control subjects maximum numbers were in the age between 31-40 years (36%). further the mean age among the sch cases and control was found to be 39.44±5.5 and 39.76± 6.5 and it was statistically non-significant (p>0.05). in the present study, the female preponderance was higher constituting around 90% in both the sch cases and controls. in the present the mean height of sch cases and control was found to be 1.59 m ± 0.07 and 1.64± 0.09 respectively (p> 0.05) and it was not significant. the mean weight was found to be (62.76± 7.65 vs 65.87 ± 8.32; p> 0.05) among the sch cases and controls. further, the bmi was found to be (26.76 ± 3.76 vs 27.87±3.56 p> 0.05; non-significant) among the sch cases and controls. the biochemical profiles of sch cases and controls were displayed in table 1. in the present study tsh levels were significantly (p<0.05) elevated in sch cases as that of the control (8.56± 1.76 vs 2.28± 0.65 µu/ml). however, no significant differences (p>0.05) were seen in the levels of free t4 and t3 between the sch cases and controls. in addition to the tsh levels, significantly higher levels of the hscrp were observed in sch cases when compared with controls (2.93 ±0.87 vs 1.16 ±0.45 mg/l; p < 0.05) respectively. furthermore, the lipid profiles total cholesterol and triglycerides were significantly (p < 0.05) higher in sch cases as that of the controls (176.65± 41.25 vs 135.87 ±51.24 mg/dl; 154.72 ±49.25 vs 125.65 ±24.8 mg/dl) respectively. meanwhile, hdl cholesterol was significantly (p < 0.05) lower in sch cases as that of the control (35.76± 7.2 vs 46.96 ±8.52 mg/dl). as per american diabetes association (ada)/centers for disease control and prevention (cdc) and national academy of clinical biochemistry (nacb) experts the risk stratification of cvd for hscrp is <1, 1 to 3, >3 mg/l for low, moderate, and high risk respectively. in this study, most of the sch cases (50%) were at moderate risk of developing cvd with hscrp level between 1-3mg/dl. meanwhile 14% of the sch cases were at high risk of developing cvd with hscrp level between > 3 mg/dl. the coefficient correlation analysis of hs-crp with age, bmi, thyroid profiles and lipid profiles were shown in table 2. in the present study, coefficient correlation analysis 88 panda et al. / panacea journal of medical sciences 2022;12(1):86–90 table 1: biochemical parameters of controls and sch cases in the present study parameters control (n=50) (mean±s.d) sch cases (n=50) (mean±s.d) p -value tsh (µu/ml) 2.28± 0.65 8.56± 1.76 <0.05* free t4 (ng/dl) 1.24±0.87 1.14±0.45 0.07n s free t3 (pg/dl) 3.25± 0.76 3.12±0.84 0.06 n s hs-crp (mg/ml) 1.16 ±0.45 2.93 ±0.87 <0.05* total cholesterol (mg/dl) 135.87 ±51.24 176.65± 41.25 <0.05* hdl cholesterol (mg/dl) 46.96 ±8.52 35.76± 7.2 <0.05* triglycerides (mg/dl) 125.65 ±24.8 154.72 ±49.25 <0.05* *p-value<0.05 significant; sd: standard deviation table 2: coefficient correlation analysis for the effect of age bmi, thyroid profiles and lipid profiles onhscrp in sch variables f-value p-value age 0.94 0.67 n s bmi 0.67 0.77n s tsh 55.46 <0.05* free t3 1.12 0.54n s freet4 1.34 0.48n s total cholesterol 0.72 0.76n s triglycerides 1.43 0.45n s hdl cholesterol 0.82 0.82n s *p<0.05 significant; ns-non significant displayed significant and positive association between hscrp and tsh (p< 0.005; f-value: 55.46). however, the other variables like age, bmi, free t3 and t4, lipid profiles had not shown any significant correlation with hs-crp (p>0.05) furthermore, pearson coefficient analysis revealed the significant (p<0.05) association between tsh and hs-crp with a pearson coefficient of 1 for tsh and 0.876 for hscrp respectively. 4. discussion subclinical hypothyroidism (sch) is clinical condition in which the thyroid functions have been altered. sch is of high clinical important since it has a high prevalence which inturn may overture to cause hypothyroidism and associated cvd risks. mounting studies indicate that high-sensitivity c-reactive protein (hs-crp) is a reliable marker of primary proinflammatory conditions and effective cvd. 16,17 in the present study, there exists an elevated level of hs-crp in sch as that of normal subjects (euthyroid). the results of our study is in corroboration with other studies done by similar results were observed in the studies done by gupta et al. 18 and vaya et al 19 in their study concluded that the hs-crp is significantly elevated in sch patients along with the other inflammatory markers like interleukin-6 and esr. thus in our study, sch cases has no earlier history of systemic inflammation and the elevation in hs-crp is not due to prevailing inflammatory condition other than sch. 20 it has been noted that tsh level >10 µu/ml has been significantly associated with higher cardiovascular risk. in our study, out of 50 sch cases, 40 patients has the tsh value >10 µu/ml. further added, in our study as per ada, cdc and nacb criteria 14% of sch cases were at high risk for the progression of cvd. our results are in line with the study done by vyakaranam et al. 21 where 23.3% of sch cases were at high risk for cvd development. mounting studies displayed contrasting results regarding the sch and this association is still under obscure. 22,23 in this study, elevated levels of total cholesterol, triglycerides were observed in sch cases as that of the control. our observation is in consistent with the previous studies were sch subjects displayed higher cholesterol and triglycerides level sch patients in this study were also observed by various studies. 24,25 further, decreased hdl cholesterol level was observed in sch cases in the present study, which is in line with the previous reports. 26 in our study, coefficient correlation and pearson coefficient analysis had confirmed a significant positive association between tsh and hscrp in sch. however, in our study other variables like age, bmi and lipid profiles were not significantly correlated with hs-crp. previous research done by yu et al. 14 showed confirmed significant positive correlation between hs-crp and tsh after adjusting for potential confounder. panda et al. / panacea journal of medical sciences 2022;12(1):86–90 89 5. conclusion on the basis of data evaluated in this study, it has been revealed that the sch patients are associated with increased tsh, hs-crp levels and dyslipidemia. further, coefficient correlation showed significant association between tsh and hs-crp. thus the elevated hscrp levels in sch showcases the cvs risk and useful for the potential early diagnosis and treatment. further, large cohort studies are highly warranted to elucidate the hs-crp involvement in sch. apart from hs-crp it is highly vital to find out role of various inflammatory mediators status in sch. 6. acknowledgment none. 7. conflict of interest none. 8. funding of sources no financial support was received for the work within this manuscript references 1. fatourechi v. subclinical hypothyroidism: an update for primary care physicians. mayo clin proc. 2009;84(1):65–71. doi:10.1016/s00256196(11)60809-4. 2. iervasi g, molinaro s, landi p, taddei mc, galli e, mariani f. association between increased mortality and mild thyroid dysfunction in cardiac patients. arch intern med. 2007;167:1526–1558. 3. unnikrishnan ag, menon uv. thyroid disorders in india: an epidemiological perspective. indian j endocrinol metab. 2011;15(2):s78–81. doi:10.4103/2230-8210.83329. 4. biondi b, galderisi m, pagano l, sidiropulos m, pulcrano m, d’errico a, et al. endothelial-mediated coronary flow reserve in patients with mild thyroid hormone deficiency. eur j endocrinol. 2009;161(2):323–9. doi:10.1530/eje-09-0196. 5. jiskra j, limanova z, antosova m. thyroid diseases, dyslipidemia and cardiovascular risk. vnitr lek. 2007;53(4):382–5. 6. rodondi n, elzen wd, bauer dc, cappola ar, razvi s, walsh jp, et al. subclinical hypothyroidism and the risk of coronary heart disease and mortality. jama. 2010;304(12):1365–74. doi:10.1001/jama.2010.1361. 7. ridker pm, rifai n, rose l, buring je, cook nr. comparison of crp and ldl cholesterol in prediction of first cardiovascular event. n engl j med. 2002;347(20):1557–65. doi:10.1056/nejmoa021993. 8. ridker pm, cook n. clinical usefulness of very high and very low levels of c-reactive protein across the full range of framingham risk scores. circulation. 2004;109(16):1955–9. doi:10.1161/01.cir.0000125690.80303.a8. 9. cushman m, arnold am, psaty bm, manolio ta, kuller lh, burke gl, et al. c reactive protein and the 10-year incidence of coronary heart disease in older men and women: the cardiovascular health study. circulation. 2005;112(1):25–31. doi:10.1161/circulationaha.104.504159. 10. park r, detrano r, xiang m, fu p, ibrahim y, labree l, et al. combined use of computed tomography coronary calcium scores and c-reactive protein levels in predicting cardiovascular events in nondiabetic individuals. circulation. 2002;106(16):2073–7. doi:10.1161/01.cir.0000033819.29662.09. 11. pasceri v, willseron jt, yeh et. direct proinflammatory effect of crp on human endothelial cells. circulation. 2002;102(18):2165–8. doi:10.1161/01.cir.102.18.2165. 12. roy s, banerjee u, dasgupta a. interrelationship of the proinflammatory marker hscrp with dyslipidemic changes: a comparative study between subclinical and overt hypothyroidism. j evol med dent sci. 2016;5(16):806–12. doi:10.14260/jemds/2016/186. 13. syamsunder an, pal p, kamalanathan cs, parija sc, pal gk, jayakrishnan g, et al. dyslipidemia and low-grade inflammation are associated with sympathovagal imbalance and cardiovascular risks in subclinical and overt hypothyroidism. int j clin exp physiol. 2014;1(1):26–33. doi:10.4103/2348-8093.129726. 14. yu yt, ho ct, li ci, davidson le, liu cs, li tc, et al. subclinical hypothyroidism is associated with elevated high-sensitive c-reactive protein among adult taiwanese. endocrine. 2013;44(3):716–22. doi:10.1007/s12020-013-9915-0. 15. mahto m, chakraborthy b, gowda sh, kaur h, vishnoi g, lali p, et al. are hscrp levels and ldl/hdl ratio better and early markers to unmask onset of dyslipidemia and inflammation in asymptomatic subclinical hypothyroidism? indian j clin biochem. 2012;27(3):284– 9. doi:10.1007/s12291-012-0206-y. 16. goswami b, tayal d, tyagi s, mallika v. assessment of insulin resistance, dyslipidemia and inflammatory response in north indian male patients with angiographically proven coronary artery disease. minerva cardioangiol. 2011;59(2):139–47. 17. guruprasad s, rajasekhar d, subramanyam g, rao ps, vanajakshamma v, latheef k, et al. high sensitivity c-reactive protein levels across spectrum and severity of coronary artery disease. j clin sci res. 2012;1(3):126–30. 18. gupta g, sharma p, kumar p, itagappa m. study on subclinical hypothyroidism and its association with various inflammatory markers. j clin diagn res. 2015;9(11):4–6. doi:10.7860/jcdr/2015/14640.6806. 19. vayá a, giménez c, sarnago a, alba a, rubio o, hernández-mijares a, et al. subclinical hypothyroidism and cardiovascular risk. clin hemorheol microcirc. 2014;58(1):1–7. doi:10.3233/ch-141871. 20. ridker pm, hennekens ch, burning je, rifai n. c reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. new engl j med. 2000;342(12):836–43. doi:10.1056/nejm200003233421202. 21. vyakaranam s, kondaveedu s, nori s, dandge s, bhongir av. study of serum high-sensitivity c-reactive protein in subclinical hypothyroidism. indian j med biochem. 2018;22(1):66–70. doi:10.5005/jp-journals-10054-0057. 22. arikan s, bahceci m, tuzcu a, celik f, gokalp d. postprandial hyperlipidemia in overt and subclinical hypothyroidism. eur j intern med. 2012;23(6):141–5. doi:10.1016/j.ejim.2012.05.007. 23. upadya bu, suma mn, srinath km, prashant a, doddamani p, sv s, et al. effect of insulin resistance in assessing the clinical outcome of clinical and subclinical hypothyroid patients. j clin diagn res. 2015;9(2):1–4. doi:10.7860/jcdr/2015/9754.5513. 24. sridevi a, vivekanand b, giridhar g, mythili a, subrahmanyan ka. insulin resistance and lipid alterations in subclinical hypothyroidism. indian j endocrinol metab. 2012;16(2):345–6. doi:10.4103/22308210.104085. 25. kvetny j, heldgaard pe, bladbjerg em, gram j. subclinical hypothyroidism is associated with a lowgrade inflammation, increased triglyceride levels and predicts cardiovascular disease in males below 50 years. clin endocrinol (oxf). 2004;61(2):232–8. doi:10.1111/j.1365-2265.2004.02088.x. 26. erdem ty, ercan m, ugurlu s, balci h, acbay o, gundogdu s, et al. plasma viscosity, an early cardiovascular risk factor in women with subclinical hypothyroidism. clin hemorheol microcirc. 2008;38(4):219–25. http://dx.doi.org/10.1016/s0025-6196(11)60809-4 http://dx.doi.org/10.1016/s0025-6196(11)60809-4 http://dx.doi.org/10.4103/2230-8210.83329 http://dx.doi.org/10.1530/eje-09-0196 http://dx.doi.org/10.1001/jama.2010.1361 http://dx.doi.org/10.1056/nejmoa021993 http://dx.doi.org/10.1161/01.cir.0000125690.80303.a8 http://dx.doi.org/10.1161/circulationaha.104.504159 http://dx.doi.org/10.1161/01.cir.0000033819.29662.09 http://dx.doi.org/10.1161/01.cir.102.18.2165 http://dx.doi.org/10.14260/jemds/2016/186 http://dx.doi.org/10.4103/2348-8093.129726 http://dx.doi.org/10.1007/s12020-013-9915-0 http://dx.doi.org/10.1007/s12291-012-0206-y http://dx.doi.org/10.7860/jcdr/2015/14640.6806 http://dx.doi.org/10.3233/ch-141871 http://dx.doi.org/10.1056/nejm200003233421202 http://dx.doi.org/10.5005/jp-journals-10054-0057 http://dx.doi.org/10.1016/j.ejim.2012.05.007 http://dx.doi.org/10.7860/jcdr/2015/9754.5513 http://dx.doi.org/10.4103/2230-8210.104085 http://dx.doi.org/10.4103/2230-8210.104085 http://dx.doi.org/10.1111/j.1365-2265.2004.02088.x 90 panda et al. / panacea journal of medical sciences 2022;12(1):86–90 author biography anuradha panda, senior resident deepak kumar dasmohapatra, senior resident aditya narayan dash, senior resident babita ekka, medical officer cite this article: panda a, dasmohapatra dk, dash an, ekka b. elevated high sensitivity c-reactive protein in patients with subclinical hypothyroidism: a case control study. panacea j med sci 2022;12(1):86-90. panacea journal of medical sciences 2022;12(2):387–392 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article medical student’s attitude towards serving rural areas: a cross sectional study in maharashtra, india priyanka chintaram sahu1,*, inamdar i f2, ajaykumar chintaram sahu3 1dept. of community medicine, shri balaji institute of medical science, raipur, chhattisgarh, india 2dept. of community medicine, dr. shankarrao chavan govt medical college, nanded, maharashtra, india 3dept. of community medicine, raipur institute of medical sciences, raipur, chhattisgarh, india a r t i c l e i n f o article history: received 16-10-2021 accepted 18-01-2022 available online 17-08-2022 keywords: doctors medical students rural practice a b s t r a c t context: rural population of india is grossly underserved by healthcare professionals. gap exits between health services for urban and rural communities. aims: 1) to determine the attitude of medical students towards serving rural areas and factors affecting it. 2) to explore reasons behind willingness and unwillingness to work in rural areas. study setting and design: it was a cross-sectional study conducted in medical colleges. materials and methods: among three medical colleges in city, two medical colleges were selected by simple random sampling using lottery method. all 450 undergraduate medical students in both selected medical colleges were included into the study. statistical analysis used: binary logistic regression analysis, odds ratio, chi-square test and percentages were used to analyse the data. results: 35.82% medical students were interested in working at rural areas. age, parental education, place of residence, type of college and year of undergraduation of medical students had significant association with their preference towards rural practice. social service was commonest reason students being interested in working rural area while scarcity of health facilities was major cause for negative attitude towards rural practice. conclusions: majority of medical students were not in favour of working in rural areas. urban rural disparity was more obvious among allopathy students. there is need to focus on working environment at rural areas as lack of amenities in the rural areas was a common reason behind unwillingness of students towards rural practice. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction access to health is a basic human right but there are widened health gaps between different countries, within country and among social groups. 1 health status of rural people are poor, and they do not have access to the same range of healthcare services as urban communities. 2 74% of graduate doctors living in urban areas serve only 28% of * corresponding author. e-mail address: piyusahu13@gmail.com (p. c. sahu). national population while rural population remains largely underserved. this disparity of health care in rural areas is only going to increase in future. 3 across the country, rural public health facilities failing to attract, retain, and ensure regular presence of highly trained medical professionals. 4 thus this study was carried out to determine the attitude of medical students towards serving rural areas and to explore reasons behind willingness and unwillingness to work in rural areas. https://doi.org/10.18231/j.pjms.2022.073 2249-8176/© 2022 innovative publication, all rights reserved. 387 388 sahu, inamdar i f and sahu / panacea journal of medical sciences 2022;12(2):387–392 2. materials and methods it was a cross-sectional study conducted over the period of 6 months from june to december 2012 at nanded city, maharashtra. nanded is the second largest urban center in the marathwada region, after aurangabad in maharashtra. there are three medical colleges in the nanded city (one allopathic, one ayurvedic and one homeopathic). among these, two medical colleges (one allopathic and one ayurvedic) were selected by simple random sampling using lottery method. all 450 undergraduate medical students from first year to final year and interns in both selected medical colleges were included into the study. in the case of the students who were absent at the time of first session, mop up round was undertaken to cover the remaining subjects. all medical students from first year to final year and internees were included in the study. medical students not giving voluntary consent to participate in the study were excluded from study. the subjects were clearly told about the aims and objectives of the study. they were requested to fill the proforma with full assurance about the confidentiality and anonymity of their information. the subjects were assured that the data would be used only for scientific purpose of the study. informed consent was obtained from the study subjects. the students were asked to complete the questionnaire in a class at the end of lecture and returned them to author in the same session. information regarding socio demographic characteristics, preference of medical students regarding place of practice, factors associated with their preference of place of practice and reasons behind willingness and unwillingness to practice in rural areas were collected using self-administrated questionnaire to the medical students. data was entered into spss 16 software and analyzed. association was tested between preference of place of practice and socio-demographic and other associated factors using chi square test. p value < 0.05 was considers as statistically significant. 3. results among 450 medical students only 416 completely answered the questionnaire. thus, response rate was (92.44%). 183(44%) students were from ayurvedic college and 233(56%) students were from allopathic college. 3.1. socio-demographic profile of medical students majority 225(54.1%) students were from 20 – 24 years age group including student’s 101(55.2%) from ayurveda and 124(53.2%) from allopathy. females constituted 219(52.6%) of all students. 993(50.8%) females were studying in ayurvedic college while 126(54.1%) were from allopathic college. only 18(4.3%) students were married and 398(95.7%) were unmarried. 306(73.6%) student were hindu, 65(15.6%) were muslim and 34(8.2%) were buddha by religion. 314(75.5%) students belong to nuclear family and 102(24.5%) from joint family. majority students were from well-educated family. 275(66.1%) had father’s education while 97(23.3%) had maternal education above graduation level. (table 1) 3.2. preference of place of practice and factors associated with it majority 267 (64.18%) medical students wish to practice at urban areas while 149 (35.82%) students were interested in working at rural areas. among ayurveda around 45% students were interested in working rural areas as compared to only 27% students from allopathy. (figure 1) fig. 1: preference of place of medical practice by study subject among medical students, significantly higher numbers of students of ayurveda were interested in working at rural areas as compared to students from allopathy, while preference towards rural practice significantly decreases from first to final year of undergraduation. age, father’s education, mother’s education, place of residence and place of primary education of medical students had association with their preference towards rural practice. (table 2) 3.3. binary logistic regression analysis between sociodemographic characteristic and preference of place of practice reported by medical students the above associations concluded by chi square and chi square trend test were further examined through binary logistic regressions by taking rural or urban areas as preference of place of practice as a dependent variable and medical student’s sociodemographic characteristic as a covariate (independent variables). odds ratio along with levels of significance of regression models for preference of place of practice were shown sahu, inamdar i f and sahu / panacea journal of medical sciences 2022;12(2):387–392 389 table 1: socio-demographic profile of medical students socio-demographic variables ayurveda (%) 183(44) allopathy (%) 233(56) total (%) 416(100) yearof undergraduation 1st year 42 (23.0) 49 (21.0) 91(21.88) 2nd year 47 (25.7) 49 (21.0) 96(23.08) final year 46(33.8) 90(66.2) 36(32.7) intern 48 (26.2) 45 (19.3) 93(22.36) age ≤ 19 years 68 (37.2) 87 (37.3) 155(37.3) 20 – 24 years 101 (55.2) 124 (53.2) 225(54.1) ≥ 25 years 14 (7.7) 22 (9.4) 036(8.7) fathers education illiterate 7(3.8) 3(1.3) 010(2.4) upto primary 3(1.6) 2(0.9) 005(1.2) secondary 22(12) 22(9.4) 044(10.6) hsc/ intermediate 39(21.3) 43(18.5) 082(19.7) graduate and above 112(61.2) 163(70.0) 275(66.1) mothers education illiterate 27(14.8) 15(6.4) 042(10.1) upto primary 6(3.3) 8(3.4) 014(3.4) secondary 71(38.8) 98(42.1) 169(40.6) hsc/ intermediate 46(25.1) 48(20.6) 094(22.6) graduate and above 33(18) 64(27.5) 097(23.3) place of primary education rural 66 (36.1%) 54 (23.2%) 120(28.85) urban 117 (63.9%) 179 (76.8%) 296(71.15) table 2: factors associated with preference of place of practice by medical students socio-demographic variable place of practice (n – 416) p value (1) p value (2) rural (%) urban (%) speciality ayurveda 84(45.9%) 99(54.1%) <0.0001 allopathy 65(27.9%) 168(72.1%) year of under-graduation i year 43(47.3%) 48(52.7%) <0.0001 <0.0001 ii year 46(47.9%) 50(52.1%) final year 43(31.6%) 93(68.4%) interns 17(18.3%) 76(81.7%) age ≤ 19 years 70(45.2%) 85(54.8%) 0.002 0.000420 – 24 years 73(32.4%) 152(67.6%) ≥ 25 years 06(16.7%) 30(83.3%) fathers education illiterate 08(80.0%) 02(20.0%) 0.0004 < 0.0001 upto primary 02(40%) 03(60%) secondary 25(56.82%) 19(43.18%) hsc/intermediate 30(36.6%) 52(63.4%) graduate and above 84(30.55%) 191(69.45%) mothers education illiterate 20(47.6%) 22(52.4%) < 0.0001 <0.001 upto primary 11(78.6%) 03(21.4%) secondary 58(34.32%) 111(65.68%) hsc/intermediate 39(41.5%) 55(58.5%) graduate and above 21(21.65%) 76(78.35%) place of pri.edu. rural 70 (58.3%) 50 (41.7%) <0.0001 urban 79 (26.7%) 217 (73.3%) residence rural 69(57.5%) 51(42.5%) <0.0001 urban 80(27%) 216(73%) 1 (χ2 test), 2 (χ2 test for trend) 390 sahu, inamdar i f and sahu / panacea journal of medical sciences 2022;12(2):387–392 table 3: binary logistic regression analysis between sociodemographic characteristic and preference of place of practice reported by medical students characteristics b s.e. wald df sig. exp(b) 95.0% c.i.for exp(b) lower upper speciality .795 .245 10.558 1 .001 2.214 1.371 3.576 year of undergraduation .016 .161 .009 1 .923 1.016 .741 1.392 age -.212 .104 4.117 1 .042 .809 .659 .993 sex -.056 .249 .050 1 .822 .946 .580 1.542 type of family .681 .269 6.389 1 .011 1.976 1.165 3.349 marital status .785 .592 1.756 1 .185 2.192 .687 6.999 religion .280 .128 4.816 1 .028 1.324 1.030 1.700 residence .036 .355 .010 1 .919 1.037 .517 2.080 fathers education -.135 .109 1.558 1 .212 .873 .706 1.080 mothers education -.013 .093 .019 1 .890 .987 .823 1.184 medical professional relative .131 .240 .300 1 .584 1.140 .712 1.826 place of primary education 1.067 .342 9.769 1 .002 2.908 1.489 5.680 socioeconomic status -.121 .147 .677 1 .411 .886 .664 1.182 table 4: reasons behind willingness to practice in rural area reasons behind willingness in practicing at rural area no. of medical students (%) (n-149) social service 70(47.0%) to gain experience 18(12.1%) near to home 15(10.1%) easy to settle 14(9.4%) less competition in practice 10(6.7%) get time to study for pg entrance 09(6.0%) less workload in rural areas 07(4.7%) less stressful work 06(4.0%) total 149(100%) table 5: reasons behind unwillingness to practice in rural area reasons behind unwillingness to practice in rural area no. of medical students (%) (n-267) scarcity of health facilities 89(33.3%) less money 49(18.4%) bad living conditions 41(15.4%) no scope to learn advance technique 19(7.1%) non cooperative people 17(6.4%) less safety 17(6.4%) less experience 15(5.6%) away from friends, family and relatives 11(4.1%) communication problem 09(3.4%) in table 3. a significant association was found between preference of place of practice and medical students characteristics namely, type of medical speciality, age, religion, type of family, and place of primary education. (table 3) 3.4. reasons behind willingness to practice in rural area social service 70(47.0%) and to gain experience 18(12.1%) were commonest reasons students being interested in working rural area. easy to settle 14(9.4%), get time to study for pg 09(6.0%), less workload 07(4.7%) and less stress 06(4.0%) were other common reason behind willingness of medical students towards rural practice. (table 4) 3.5. reasons behind unwillingness to practice in rural area scarcity of health facilities 89(33.3%), less money 49(18.4%) and bad living conditions 41(15.4%) were recognised as major reasons for negative attitude of medical students towards rural practice. no scope to learn advance technique 19(7.1%), noncooperative people 17(6.4%), less sahu, inamdar i f and sahu / panacea journal of medical sciences 2022;12(2):387–392 391 safety 17(6.4%) and less experience 15(5.6%) were other factors due to which medical students not favour to work at rural areas. (table 5) 4. discussion around the world, the health status of people in rural areas is generally worse than in urban areas. even in countries where the majority of the population lives in rural areas, the resources are concentrated on the cities. 5 in present study, medical students revealed a slightly negative attitude toward working in rural areas. only one third (35.82%) students were in favor of working in rural areas. wide variation was noted among choice of medical students regarding place of practice in different countries. preference of indian medical students towards rural practice ranges from 29% in goa, 6 33.8% in delhi, 7 44% in karnataka 8 to 55.95% at haryana. 9 in contrast to indian studies, majority of medical students from nigeria, 10 uganda 11 and nepal 12 prefer to serve rural areas as compared to urban one. thus, it is needed to understand differences in rural health care policies in these countries and india from doctor’s point of view. rural background and primary education at rural areas were identified as the strong variable associated with the retention of health professionals in rural communities by various literatures. 7,10,13,14 this can be explained by the familiarity of medical students with rural setting and cultural norms. we observed that medical students with well-educated parents had less favourable attitude towards working at rural areas similar to study conducted by saini et al. 7 and singh et al. 14 medical students from ist and iind years of undergraduation showed more willingness to work in rural area may be because of poor knowledge regarding working conditions in rural area. 14 for the medical students who were interested to work in rural area, the major reason for that decision was to provide service to the poor/underprivileged (social service) as there is scarcity of health care facilities in rural area. similar finding was reported from various literatures in india 6,7 and other countries like nigeria 15 and uganda 16 where the major reasons were to provide medical services to the poor and the vulnerable respectively. in study by dutt et al. 8 medical students wish to work in rural area to gain experience, to get postgraduate seat and for monitory benefits. the reasons for not willing to work in a rural area included scarcity of health facilities, less money and bad living conditions. many studies had mentioned a similar list of common factors which revealed the role of government in improving working conditions in rural areas. 7,8,16,17 this to an extent paints the same picture of other rural and underserved areas of the world with regards to health service delivery and the need for concerted action in-order to improve delivery of services and patient care in these areas. 5. conclusion majority of the medical students participated in this study were unwilling to practice in rural area after their qualification. interest towards rural practice is significantly higher among ayurveda students and students from rural background. lack of social amenities, scarcity of health facilities, bad living conditions and inadequate remuneration emerged as potential barriers to students opting for a career in rural health. these findings suggest us about the attitude of medical students to rural health care and explore various factors such as rural residence which have influencing role for intending medical students towards rural practice. 6. conflicts of interest no potential conflict of interest relevant to this article was reported. 7. source of funding none. references 1. thayyil j, jeeja mc. issues of creating a new cadre of doctors for rural india. int j med public health. 2013;3(1):8–11. 2. chillimuntha ak, thakor kr, mulpuri js. disadvantaged rural health issues and challenges: a review. national j med res. 2013;3(1):80–2. 3. yadav k, jarhyan p, gupta v, pandav cs. revitalizing rural health care delivery: can rural health practitioners be the answer? indian j community med. 2009;34(1):3–5. 4. bhandari l, dutta s. health infrastructure in rural india. [cited on 12 april 2016]. available from: http://www.iitk.ac.in/3inetwork/html/ reports/iir2007/11-health.pdf. 5. strasser r. rural health around the world: challenges and solutions. fam pract. 2003;20(4):457–63. doi:10.1093/fampra/cmg422. 6. jagadish ac, sissy c, annet o. a cross sectional study of attitudes among goan doctors towards rural service. j evol med dent sci. 2015;4(66):11468–73. 7. saini nk, sharma r, roy r, verma r. what impedes working in rural areas? a study of aspiring doctors in the national capital region, india. rural and remote health. 2012;12:1967. 8. dutt ra, shivalli s, bhat mb, padubidri jr. attitudes and perceptions toward rural health care service among medical students. med j dy patil univ. 2014;7(6):703–8. 9. sharma v, gupta n, rao nc. perception towards serving rural population amongst interns from dental colleges of haryana. j clin diagn res. 2014;8(9):31–32. 10. brieger wr. attitude of nigerian medical students towards rural practice. j med educ. 1979;54(5):427–9. 11. kaye dk, mwanika a, sekimpi p, tugumisirize j, sewankambo n. perceptions of newly admitted undergraduate medical students on experiential training on community placements and working in rural areas of uganda. bmc med educ. 2010;10:47. doi:10.1186/14726920-10-47. 12. shankar pr, thapa tp. student perception about working in rural nepal after graduation: a study among firstand second-year medical students. hum resour health. 2012;10:27. doi:10.1186/1478-449110-27. 13. silvestri dm, blevins m, afzal ar, andrews b, derbew m, kaur s, et al. medical and nursing students’ intentions to work abroad or in http://www.iitk.ac.in/3inetwork/html/reports/iir2007/11-health.pdf http://www.iitk.ac.in/3inetwork/html/reports/iir2007/11-health.pdf http://dx.doi.org/10.1093/fampra/cmg422 http://dx.doi.org/10.1186/1472-6920-10-47 http://dx.doi.org/10.1186/1472-6920-10-47 http://dx.doi.org/10.1186/1478-4491-10-27 http://dx.doi.org/10.1186/1478-4491-10-27 392 sahu, inamdar i f and sahu / panacea journal of medical sciences 2022;12(2):387–392 rural areas: a cross-sectional survey in asia and africa. bull world health organ. 2014;92(10):750–9. doi:10.2471/blt.14.136051. 14. singh rk, rawat c, pandey s. attitude of medical students toward serving in rural areas and its determinants: a cross-sectional study from uttarakhand. int j med sci public health. 2015;4(6):814–7. 15. ossai en, anyanwagu uc, azuogu bn, uwakwe ka, ekeke n, ibiok n, et al. perception about working in rural area after graduation and associated factors: a study among final year medical students in medical schools of southeast nigeria. br j med med res. 2015;8(2):192–205. 16. wandira g, maniple e. do ugandan medical students intend to work in rural health facilities after training? health policy and development. health policy devt . 2009;7(3):203–14. 17. gaikwad v, sudeepa, madhukumar s. a study on career preferences and attitude towards the rural health services among the graduating interns of a medical college in bangalore rural. int j biol med res. 2012;3(2):1577–80. author biography priyanka chintaram sahu, associate professor inamdar i f, associate professor ajaykumar chintaram sahu, assistant professor cite this article: sahu pc, inamdar i f, sahu ac. medical student’s attitude towards serving rural areas: a cross sectional study in maharashtra, india. panacea j med sci 2022;12(2):387-392. http://dx.doi.org/10.2471/blt.14.136051 editorial panacea journal of medical sciences, may-august,2016;6(2): 52-53 52 mind maps and medical education nilofer mujawar guest editor, panacea journal of medical sciences, professor, dept. of pediatrics, nkp salve institute of medical sciences & research centre email: nilofer.mujawar@gmail.com access this article online website: www.innovativepublication.com doi: 10.5958/2348-7682.2016.00001.4 a good teacher, naturally, wants his/her students to do well. in teaching, a good teacher would always strive to turn the lesson into an engaging experience for students that would at once be stress-free and memorable. medical students, especially, are at the receiving end of a system that compels them to absorb loads of knowledge in a short span of time. for the medical teacher too, it is a race against time to complete the syllabus in a specified time period. the syllabus is not only vast but also difficult. so, there is a constant search for a magical process that would suit both; the students as well as the teachers. one of the most popular ways recommended worldwide for medical teaching and learning is mind mapping. so what exactly is mind mapping? wikipedia defines it thus: “a mind map is a powerful graphic technique which provides a universal key to unlock the potential of the brain. it harnesses the full range of cortical skills – word, image, number, logic, rhythm, colour and spatial awareness – in a single, uniquely powerful manner. in so doing, it gives you the freedom to roam the infinite expanses of your brain. the mind map can be applied to every aspect of life where improved learning and clearer thinking will enhance human performance.” if the older generation of doctors looks back, they would realize that they assimilated knowledge mainly from reading print and they would also recall that the colourful diagrams in the books not only piqued their interest but also helped them understand the topic well, leaving a permanent imprint on their minds that made it easier to remember it later in words. so, the underlying fact remains that any visual or graphical support facilitates recall. visual images enrich teaching as well as learning. a teacher may think of a particular lesson that is to be taught to the student, but merely conveying it in words may cause some of its essence to be lost. words and images together, however, make the teacher’s thinking visible and vivid. trying to find your way through a thick forest of knowledge with no map in hand is indeed a challenge. the mind would start thinking of ways to reach the destination without getting lost. when these thoughts are made visible by putting them on paper, you have created a mind map! how you make it is through visual intelligence…!! an idea not put on paper remains locked in the brain. once it is put on paper it stimulates the brain to think more. mind mapping is the brain child of tony buzan. buzan has written books on mind mapping and how it helps you not only to organize yourself but also improve your memory/recall. he states that the mind map uses the full range of left and right human cortical skills, balances the brain, and taps into the alleged “99% of your unused mental potential.” mind maps are not restricted to any particular field like engineering or logic or biology or architecture. in fact, even a housewife can make a mind map to navigate her way through the daily chores. using them regularly for every task enhances your work potential. since they are created by you, your thoughts, your ideas and the associations and connections your mind makes, the ways you can make a mind map are limitless and absolutely unique. according to willingham (2007), critical thinking, which is the highest level of cognitive domain, occurs when a student possesses both domain knowledge and the capacity to penetrate beyond the surface structure of a problem to recognize how the problem can be solved(1). with time newer methods of learning are being constantly discovered and created. in the early 1970s, tony buzan invented mind mapping. he formulated seven steps to create a mind map. 7 steps to making a mind map 1. start in the centre of a blank page turned sideways. why? because starting in the centre gives your brain freedom to spread out in all directions and to express itself more freely and naturally. 2. use an image or picture for your central idea. why? because an image is worth a thousand words and helps you use your imagination. a central image is more interesting, keeps you focused, helps you concentrate, and gives your brain more of a buzz! 3. connect your main branches to the central image and connect your secondand third-level branches to the first and second levels, etc. why? because your brain works by association. it likes to link two (or three, or four) things together. if you mujawar nilofer mind maps and medical education panacea journal of medical sciences, may-august,2016;6(2): 52-53 53 connect the branches, you will understand and remember a lot more easily. 4. make your branches curved rather than straightlined. why? because having nothing but straight line is boring to your brain. 5. use one key word per line. why? because single key words give your mind map more power and flexibility(this rule, however, is flexible. you can use two or more words, phrases or even sentences in your mind maps…as per your purpose or needs, especially in study and similar mind maps.) 6. use colours throughout. why? because colours are as exciting to your brain as are images. colour adds extra vibrancy and life to your mind map, adds tremendous energy to your creative thinking, and is fun! 7. use images throughout. why? because each image, like the central image, is also worth a thousand words. so if you have only 10 images in your mind map, it’s already the equal of 10,000 words of notes! you will soon realize that you have a style of your own, quite different from others, in making a mind map. traditionally, mind maps have been used for problem solving, outline/framework design, anonymous collaboration, marriage of words and visuals, individual expression of creativity, condensing material into a concise and memorable format, team-building or synergy creating activity and enhancing work morale. in education, mind mapping is often used for:  brainstorming sessions  visualizing concepts  improving critical thinking  decision making  improving reading and writing skills  advanced research papers or graduate projects  outlining written documents  storyboarding presentations  project management farrand et al. (2002) studied the superiority of mind maps over traditional note taking in the recall of both shortand long-term factual information(2). 50 medical students (n=50) were exposed to a 600-word sample of text from scientific american and then administered 3 short tests based upon the text. recall was only slightly higher but significant in the mind map group after the second test (p=.016). comparison of mean scores on the third test (administered 1 week later) revealed that the mind map group had significantly higher factual recall compared to the self-study group (p=.013). there are many studies for and against mind maps in medicine. it is now recognized as an important tool for imparting medical education, too. it promotes critical thinking. mind maps establish non-linear relationships between two ideas. images and colors break the monotony of reading in print. the dynamic colors and the images help memory recall. and since the student himself/herself has made it, it promotes creativity, makes it coherent and imprints a vast amount of knowledge in a single map. mind mapping is also recognized as an assistive tool for children with asperger or dyslexia. there are websites that offer free software for mind maps in medicine. so…happy mind mapping….!! references 1. willingham dt. critical thinking. american federation of teachers 2007. available at www.aft.org/sites/default/files/periodicals/crit_thinking. pdf. 2. farrand p, hussain f, hennessy e. the efficacy of the ‘mind map’ study technique’. medical education 2002;36(5):426-431. http://www.aft.org/sites/default/files/periodicals/crit_thinking.pdf http://www.aft.org/sites/default/files/periodicals/crit_thinking.pdf original research panacea journal of medical science, september december 2015:5(3);150-152 150 prevalence of hypothyroidism in antenatal women attending opd at gandhi hospital shobha g. 1 , rajeswari. b 2 , srividya. r 3 abstract: the present study was carried out to study the prevalence of hypothyroidism in antenatal women attending obg department of gandhi hospital and to detect prevalence in relation to age, parity, body mass index, socio-economic status. in this prospective study, 400 antenatal women attending opd from period of conception to 26 weeks of pregnancy were included in this study. patients tested for fasting levels of tsh, patients with deranged tsh ft3, ft4 levels were checked. in the 400 antenatal women 90 were found to have hypothyroidism, remaining were euthyroid, prevalence of hypothyroid 22.5%. we concluded that the prevalence of hypothyroid is 22.5%. maternal complications like preeclampsia (17.7%), abruption (66%), and abortion (11.1%) were observed. significant adverse effects on maternal outcome were seen emphasizing the importance of routine antenatal thyroid screening. keywords: hypothyroidism, pregnancy, preeclamsia 1 professor, 2 assistant professor, 3 post graduate, department of obstetrics and gynaecology, gandhi medical college, secunderabad, telengana state dr.shobhagumdal@gmail.com introduction maternal hypothyroidism is the most common thyroid disorder in pregnancy has been associated with infertility, miscarriage, fetal loss, preeclampsia, preterm delivery, placental abruption and postpartum haemorrhage. fetal complications include low birth rate, preterm delivery, rates of iugr, high rates of still births and neonatal deaths, neonatal hypobilirubinemia, higher incidence of neonatal hypothyroidism and reduced intellectual function of the off spring and increased perinatal mortality(1). aim: 1. to study the prevalence of hypothyroidism in antenatal women, attending opd in gandhi hospital from february 2014. source: the study was conducted in the department of obg at gandhi hospital. inclusion criteria: all the antenatal mothers attending opd at gandhi hospital from period of conception to 26 weeks of pregnancy were included in the study. exclusion criteria: 1. all the antenatal mothers after 26 weeks of pregnancy. 2. known case of diabetes, hypertension and autoimmune disorders. 3. twin gestation. 4. pregnant women already diagnosed and on thyroid medication are excluded from the study. methodology after obtaining informed consent of 400 pregnant women randomly selected for study after fulfilling the inclusion criteria, patients tested for fasting levels of tsh, fasting tsh assayed by chemiluminicent immunoassay kit (clia kit) patients with deranged tsh, ft3, ft4 levels were checked. patients with hypothyroidism were treated with l thyroxin and followed up till delivery. the reference range used in the study was based on guidelines of the american thyroid association for diagnosis and management of thyroid disease during pregnancy (2). the clia kit is designed for the quantitative determination of tsh concentration in human serum. the tsh clia test is based on the principle of a solid phase enzyme linked immune sorbent assay. the assay system utilizes specific monoclonal antibody directing against a distant antigenic determinant on the intact tsh molecule. thyroid function tests were repeated every four weeks during pregnancy and drug dosage titrated accordingly. maternal outcome was noted in terms of pre eclampsia, abruptio placentae and abortions. results results of fasting tsh are grouped as normal, low and high. if high tsh is detected in those pregnant women they are subjected to further free t3, t4 levels and appropriate treatment was instituted. in the 400 antenatal women 90 were found to have hypothyroidism, remaining were euthyroid, prevalence of hypothyroid 22.5%. mailto:dr.shobhagumdal@gmail.com g.shobha et al. prevalence of hypothyroidism in antenatal women attending opd at gandhi hospital panacea journal of medical science, september december 2015:5(3);150-152 151 table 1: prevalence of hypothyroidism: no of patients normal patients patients with hypothyroidism prevalence of hypothyroidism 400 310 90 22.5% table 2: distribution of hypothyroid pregnant women based on tsh levels no of patients tsh (µg/ml) percentage 60 3 – 4.5 66.6% 22 4.5 – 6.5 24.4% 8 >6.5 8.8% table 3: prevalence of hypothyroidism in relation to age age in years no of patients patients with hypothyroidism percentage of prevalence <20 14 2 14.2% 20-25 160 30 18.5% 25-30 190 58 30.5% 30-35 36 0 total 400 90 table 4: prevalence of hypothyroidism in relation to gravida gravida no of patients hypothyroid patients percentage of prevalence g1 146 34 23.2% g2 166 30 18.07% g3 68 20 29.4% g4 16 6 37.5% g5 4 0 total 400 90 among 90 antenatal women with hypothyroidism, 34(37.7%) of them were primigravida and 56 (62.2%) were multigravida. table 5: prevalence of hypothyroidism in relation to bmi bmi no of patients patients with hypothyroidism percentage of prevalence <18 14 4 28.5% 18-25 220 30 13.6% 25-30 140 50 35.7% 30-35 20 6 30% 35-40 4 0 >40 2 0 total 400 90 among 90 antenatal women with hypothyroidism 50 of them in the bmi group of 25-30. table 6: maternal complications in the study maternal complications no of patients percentage of prevalence pre eclampsia 16 17.7% abruptio placentae 6 6.6% abortion 10 11.1% total 32 35.4% among 90 antenatal women with hypothyroidism 16 women presented with pre eclampsia, 6 women presented with abruption placentae, 10 women presented with abortions. table 7: incidence of maternal complicationscomparison with others study pe(%) abruption (%) abortion( %) my study 17.7 6.6 11.1 anjuman sn et all 2 16.6 16.5 16.6 sahu mt et all (3) 20.7 leung (4) 22 ablovich (5) 19% g.shobha et al. prevalence of hypothyroidism in antenatal women attending opd at gandhi hospital panacea journal of medical science, september december 2015:5(3);150-152 152 discussion the prevalence of hypothyroidism in the current study was 22.5%.these findings are consistent with reports from the study of the case bm at et al in their study prevalence of hypothyroidism was 23% which is comparable to my study. the mean age of prevalence of hypothyroidism in antenatal women was 25.04 years which is comparable with the study done by b. vidya vimal nambiat et al,(6) which was 25.19 years. it was seen that increase in maternal age was associated with high incidence of thyroid dysfunction. prevalence of hypothyroidism in primigravida is 23.2% and 2 nd gravida is 18.07 % and 3 rd gravida is 29.4% and fourth gravida is 37.5%. prevalence of hypothyroidism is high in bmi group of 25 to 30. high bmi group women had higher tsh concentration and were prone to hypothyroidism than normal weight women. regarding maternal outcome, hypothyroidism was associated with complications like preeclampsia (17.7%), abruptio (6.6%), and abortions (11.1%). conclusion significant adverse effects on maternal outcome were seen emphasizing the importance of routine antenatal thyroid screening. the early administration of treatment and maintenance of normal levels of thyroid hormone significantly minimised the risk of maternal and fetal complications and make it possible for the pregnancy may be carried to term without severe complications. so it is justified to recommend screening of thyroid in early pregnancy. references: 1. solb, mandel sj. thyroid disorders during pregnancy. endocrinol metab clin north am.2006;35:117-36. 2. cunningham, thyroid and other endocrine disorders, williams obstetrics, 23 rd edition,2010:1126_1144. 3. sahu mt. overt and subclinical thyroid dysfunction among indian pregnant women and effects on maternal fetal outcome. archives of gynaecology and obstetrics 2010; 281(2):215-20. 4. leung as, millar l.k, kooning pp, montorom, mestman j. perinatal outcomes in hypothyroid pregnancies obstet gynaecol 1993;81(3):349-353 5. abalovich m, amino n, barbour la, et al. management of thyroid dysfunction during pregnancy and postpartum: an endocrine society clinical practice guideline. j clin endocrinol metab.20007;92(8):1_47. 6. vaidya b, antony s, bilosum. detection of thyroid dysfunction in early pregnancy. universal screening of high risk targeted case finding? j clin endocronol metab 2007; 92(1):203-7. original research article panacea journal of medical sciences, may-august,2016;6(2): 69-73 69 extraction of broken intramedullary nail in ununited fractures of femur by doubling up the tip of guide wire: an innovative technique arun vashisht1,*, op gupta2, avinash rastogi3 1,3associate professor, 2assistant professor, dept. of orthopaedics, subharti medical college, meerut, uttar pradesh *corresponding author: email: drarunvst@gmail.com abstract femoral shaft fractures are treated by close intramedullary interlocking nailing, that allows early ambulation and preservation of fracture haeamatoma. but a good number of patients present with disturbed union and broken nail. extraction of the broken nail, especially of its distal segment, is quite challenging without opening and disturbing the fracture site. we describe an innovative technique of broken nail extraction with the help of a doubled up tip guide wire and a cannulated extractor. 12 patients with broken nails were subjected to our technique by first passing a guide wire through the broken nail up to the subchondral bone and then advancing through intercondylar notch into the flexed knee and then exiting the wire out of knee by a small incision. tip of the exited wire is then doubled up over itself like a loop, so that it may behave like a ball tipped wire. a cannulated extractor is threaded over the proximal part of the wire and screwed into the proximal end of the broken nail, which is then extracted. all broken nails were extracted easily. no patient developed heamarthrosis or compromise in knee function. no sign of early or delayed knee infection was seen. the mean follow up period was 15.4(range18-24) months. we found this innovative technique simple, safe, inexpensive, requiring no sophisticated instrumentation and steep learning curve. keywords: extraction, broken nail, innovative. access this article online website: www.innovativepublication.com doi: 10.5958/2348-7682.2016.00006.3 introduction the femoral shaft fractures are of common occurrence in young adults due to high energy trauma in road traffic accidents. the concept of intramedullary fixation of femoral shaft fractures is time tested since the advent of kuntscher’s intramedullary nailing. but after the introduction of interlocking intramedullary nails, close nailing became the treatment of choice for majority of the diaphyseal fractures of femur due to biomechanical advantages over plate osteosynthesis(1-2). advantages of early mobilization of the adjacent joints, early ambulation with walker or crutch support are the main attractions of close detention nailing without violation of the fracture heamatoma during surgery, which is essential for union. but despite that, a good number of cases of disturbed union are encountered during follow up of these fractures, the causes of which, though, may be multifactorial, but the most common causative factor appears to be premature and over enthusiastic weight bearing that too without walking aids. disturbed union of femoral shaft fractures after nailing is potentially a serious complication, which if not taken care well in time, will ultimately lead to either nonunion or fatigue failure of the implant. the management of disturbed union may require dynamization alone, autogenous bone grafting, or exchange nailing with or without bone grafting, but management of disturbed union with broken nail is a little bit challenging in terms of extraction of the broken nail without opening and disturbing the fracture site. though a battery of instruments and techniques have been developed for the extraction of the broken nail using hooks, olive wires, long grabbers etc.(3-13), but because of the difficulty of their easy availability everywhere and a higher cost, it often becomes necessary to open the fracture site to extract the distal portion of the nail. this brought forth the need to evolve a simple technique for the extraction of the broken nail. we, at our institution, developed an innovative technique for the same, which is simple, safe and inexpensive, by using a standard guide wire and a cannulated extractor only (fig. 1), and we could extract broken nails easily through this technique in 12 patients. arun vashisht et al. extraction of broken intramedullary nail in un-united fractures of femur…. panacea journal of medical sciences, may-august,2016;6(2): 69-73 70 fig. 1: a standard guide wire and a cannulated extractor material and method in this prospective study of 3 years from march 2012 to february 2015, conducted in department of orthopaedics, subharti medical college, swami vivekanand subharti university, meerut, twelve patients aged between 26 to 47 years, all male, who were treated initially by interlocking intramedullary nailing for fracture shaft of femur but presenting with disturbed union and broken femoral nail in the follow up, after obtaining approval from institutional ethics committee, were included. all these patients were counseled about the technique of extraction of the broken nail by passing a wire through the knee joint, followed by exchange nailing with one size larger nail, and an informed consent was obtained regarding the same. technique: after the spinal anaesthesia, the patient is laid supine over the fracture table. the limb is prepared and draped from umbilicus to the distal 1/3rd of the leg. the greater trochanter is exposed by longitudinal incision through the previous scar. the proximal interlocking bolts are removed by giving small incisions, the guide wire is then passed inside the nail and is negotiated in the distal broken portion of the nail, with some outside manual manipulation of the ununited fracture if at all required due to any angulation, up to the level of the distal interlocking bolts under c-arm control. now the distal bolts are removed by giving small skin incisions. the guide wire is then pushed distally up to the subchondral bone. at this point of time the leg is disengaged from the foot holder of the fracture table and wrapped into a separate sterile sheet and knee is flexed to 900 while the thigh is supported by one of the assistant. the guide wire is then advanced further distally to penetrate into the knee joint through an area of non-weight bearing articular cartilage in the intercondylar notch of femur, till it comes to lie under the skin after penetrating through the patellar tendon. an incision of about 1 to 1.5cm is made over the tip of the wire to exit it out of the skin, which is then pushed further about 2-3cm out of the skin (fig. 2, 3a, 3b). fig. 2: a sketch depicting the guide wire fig. 3(a): a c-arm ap image of exiting the guide wire out of the knee fig. 3(b): a c-arm lateral image of exiting the guide wire out of the knee now the tip of the wire is doubled over itself to make a loop of the wire at its terminal end, so that it may behave like a ball tipped guide wire (fig. 4, fig. 5). arun vashisht et al. extraction of broken intramedullary nail in un-united fractures of femur…. panacea journal of medical sciences, may-august,2016;6(2): 69-73 71 fig. 4: a sketch depicting the doubled-up tip of the exited guide wire fig. 5: a c-arm image of doubled up tip of the exited wire the patellar tendon is then spilt slightly at a point of wire protrusion and is widened slightly by a hemostat to pull the wire proximally avoiding damage to the tendon. the wire is then pulled back proximally into the lower end of the femur till it gets stuck up at the end of the distal piece of the broken nail. the knee is then extended and the foot of the limb is again secured into the foot holder of the fracture table. now a cannulated extractor of the femoral nail is threaded over the proximal portion of the guide wire and is screwed tightly into the proximal end of the femoral nail. the entire nail is then pulled out by gentle blows of the extractor hammer while one of the assistant keeps pulling the guide wire tightly and proximally with every blow of the extractor hammer. both the pieces of the broken nail are thus extracted together easily and safely (fig. 6). fig. 6: extracted both pieces of broken nail together with the help of a doubled up tip guide wire after extraction of the broken nail, exchange nailing is carried out in the usual fashion. results we used this technique in twelve patients who had disturbed union with broken intramedullary nails (table 1). these broken nails were extracted from march 2012 to february 2015. in all the 12 patients, the broken nail was extracted easily by this innovative technique developed at our institution without opening the fracture site and without disturbing whatever callus was present in the process of union. all these patients, after extraction of broken nail were managed by exchange nailing with one size larger nail after reaming of the medullary canal (fig. 7a, fig. 7b). fig. 7 (a): ap and lateral radiographs of femur with broken nail arun vashisht et al. extraction of broken intramedullary nail in un-united fractures of femur…. panacea journal of medical sciences, may-august,2016;6(2): 69-73 72 fig. 7 (b): ap and lateral radiographs of femur after exchange nailing none of these patients developed heamarthrosis after the extraction of the broken nail by this technique and also there was no compromise in the pre nail extraction knee range of motion, and/or function (table 1). none of the patient developed any sign of early or delayed infection and there was no impairment of knee function in any of the patient at the final follow up. all patients achieved union after exchange nailing within a mean period of 19.8(16-24) weeks (table 1). mean follow up period after exchange nailing was about 20.3 (range 18-24) months (table 1). table 1: showing clinical details of patients treated for broken femoral nails s. no. age (years) sex union time after exchange nailing (weeks) follow-up period (months) knee rom before removal of broken nail (degree) knee rom after exchange nailing (degree) 1. 36 m 20 21 0 – 130 0 – 130 2. 30 m 18 18 0 – 120 0 – 120 3. 26 m 16 20 0 120 0 – 120 4. 38 m 19 19 0 – 110 0 – 110 5. 45 m 21 21 0 – 130 0 – 125 6. 38 m 18 24 0 – 120 0 – 120 7. 47 m 22 21 0 – 110 0 – 110 8. 36 m 19 20 0 – 125 0 – 120 9. 45 m 23 18 0 – 130 0 – 130 10. 32 m 24 22 0 – 130 0 – 125 11. 30 m 18 20 0 – 120 0 – 120 12. 43 m 20 20 0 – 115 0 – 115 discussion closed retrieval of broken intramedullary femoral nails poses a great challenge for an orthopaedic surgeon. though several techniques with a battery of special instruments(6-13) are accessible in the orthopaedic literature for this challenging task but the difficulty of easy availability and higher cost of special instruments often compels the treating surgeon to open up the fracture site to take out the distal fragment of the fractured nail. our simple, aforementioned innovative technique was found to be quite effective in closed extraction of a broken intramedullary femoral nail in all the twelve patients included in this study. the results of the other techniques described using olive wires, laparoscopic grabbers(4-5) etc. have been described successful. the results of our technique are found to be quite comparable with the results of various other techniques described in the literature. our technique does not require any special instrument except a cannulated extractor and a standard guide wire. conclusion in our opinion, this innovative technique of broken nail extraction is quite simple, successful without causing any impairment of knee function despite penetration of the guide wire into the joint, and is very cost effective. the technique is so simple that it can be executed by any orthopaedic surgeon at any centre. the technique neither requires a steep learning curve, nor any sophisticated instrumentation. there are several techniques described in the literature for the extraction of broken nails. we are not claiming that our technique arun vashisht et al. extraction of broken intramedullary nail in un-united fractures of femur…. panacea journal of medical sciences, may-august,2016;6(2): 69-73 73 is superior to any of them rather we are just submitting that our technique is only a simple alternative to other proven techniques. we feel that an objection may be raised against the penetration of guide wire in an otherwise innocent knee joint during the course of extraction of broken nail by our technique, which, however, in our opinion is not very boldly sustainable as none of the patients treated by our technique developed any early or delayed problem in their knee joint. references 1. bucholtz rw, brumback rj. fractures of the shaft of the femur. in: rockwood j, green dp, bucholtz rw, heckman jd, editors. fractures in adults. philadelohia: lippincot-raven; 1996. pp. 1918-27. 2. winquist ra, hansen st, clawson dk. close intramedullary nailing of femoral fractures. j bone joint surg am 1984:66:529-39. 3. giannoudis pv, matthews sj, smith rm. removal of the retained fragment of broken solid nails by the intramedullary route. injury 2001;32:407-10. 4. franklin jl, winquist ra, benirschke sk, hansen st jr. broken intramedullary nails. j bone joint surg am 1988;70:1463-71. 5. brewster nt, ashcroft gp, scotland tr. extraction of broken intramedullary nails-an improvement in technique. injury 1995;26:286. 6. marwan m, ibrahim m. simple method for retrieval of distal segment of the broken interlocking intramedullary nail. injury 1999;30:333-5. 7. levy o, amit y, velkes s, horoszowski h. a simple method for removal of fractured intramedullary nail. j bone joint surg br 1994;76:502-3. 8. maini l, upadhyay a, aggarwal a, dhaon bk. a new method of removing fractured interlocked nail. injury.2002;33:261-2. 9. maini l, jain n, singh j, singh h, bahl a, gautam vk. removal of a multi-segmental broken nail by close technique using a ten nail. j trauma 2009;66:e78-80. 10. whalley h, thomas g, hull p, porter k. surgeon versus metalwork tips to remove a retained intramedullary nail fragment. injury 2009;40:783-9. 11. tadros am, blachut p. segmentally fractured femoral kuntscher nail extraction using a variety of techniques. am j orthop 2009;38:e59-60. 12. oberst m, schlegel k, mory c, suedkamp n. endoscopically controlled removal of a broken intramedullary nail: a new technique. injury extra 2005;36:582-5. 13. metikala s, mohammad r. closed retrograde retrieval of the distal broken segment of femoral cannulated intramedullary nail using a ball tipped guide wire. indian j orthop 2011;45:347-50. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2021;11(3):498–502 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a study on elective hysterectomies in a tertiary care hospital sanket kumar barik1, ajit kumar nayak1,*, sujata misra1, manju kumari jain2 1dept. of obstetrics and gynaecology, fakir mohan medical college & hospital, balasore, odisha, india 2dept. of transfusion medicine, scb dental college, cuttack, odisha, india a r t i c l e i n f o article history: received 14-04-2021 accepted 22-06-2021 available online 24-11-2021 keywords: hysterectomy indication route preservation of ovaries complication a b s t r a c t in spite of availability of many conservative methods to treat various benign gynaecological disorders, hysterectomy remains the mainstay of treatment. this is a hospital based cross sectional study on 200 cases of elective hysterectomies carried out in the department of obstetrics & gynaecology, fakir mohan medical college and hospital balasore, odisha, india, from november 2018 to october 2020. findings related to age, clinical presentations, indications, route of surgery, concurrent removal of ovaries, complications and histopathological study of uterine specimen were recorded and statistically analyzed. 48% were between the age group of 41-50 years. 52% presented with heavy menstrual bleeding. in 59% cases fibroid uterus was the indication for hysterectomy. 80% underwent abdominal hysterectomy and 20% vaginal hysterectomy. both ovaries were removed in 55% cases. 3 % cases had intraopertive bleeding and 4% had wound gaping who required secondary suturing. histopathological study of uterine specimen revealed endometrial hyperplasia in 14 % cases, non specific chronic cervicitis in 92% cases and leiomyoma in 59% cases. heavy menstrual bleeding is the most common clinical presentation. leiomyoma being the most common indication for hysterectomy. abdominal route is preferred over vaginal route. ovaries are preserved in several cases. bleeding and wound gaping are the most common surgical complications. proper selection of cases reduces the complication rate. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction hysterectomy is the surgical removal of uterus done for various benign and malignant conditions. with the emergence of many conservative approaches the indication for hysterectomy should be carefully evaluated as any surgical procedure is associated with risk of complications. approximately 600,000 hysterectomies are performed annually in the united states. 1 hysterectomy can be done through abdominal, vaginal and laparoscopic approach depending upon indication, nature of the disease, patient’s preference and operative skill of the surgeon. in some cases it is combined with removal of adnexa called hysterectomy * corresponding author. e-mail address: ajitnayak_og@yahoo.co.in (a. k. nayak). with salpingoophorectomy. hysterectomy through vaginal route is less invasive than abdominal hysterectomy and usually indicated in gynaecological disorders for prolapsed uterus. but nowadays vaginal hysterectomies are done for many benign conditions like uterine leiomyoma, adenomyosis and abnormal uterine bleeding with no uterovaginal descent, a term called non-descent vaginal hysterectomy. 2. materials and methods present study was carried out in the department of obstetrics & gynaecology, fakir mohan medical college & hospital, balasore, odisha, india to find out age distribution, clinical presentation, indications, route of hysterectomy, https://doi.org/10.18231/j.pjms.2021.097 2249-8176/© 2021 innovative publication, all rights reserved. 498 barik et al. / panacea journal of medical sciences 2021;11(3):498–502 499 complications and histopathological study of uterine specimen of patients underwent elective hysterectomies. it is a hospital based retrospective cross-sectional study done from november 2018 to october 2020 comprising of 200 cases. institutional ethics committee approval was obtained. cases of elective hysterectomies were identified from hospital records and data were analyzed by using microsoft excel. 3. results data on 200 elective hysterectomies cases were analyzed over a period of two years. majority of patients i.e. 48% were between age group of 41 to 50 years. hysterectomy was done at less than 40 years of age in 8.5% cases and at more than 60 years in12 % cases [table 1]. in 59% cases elective hysterectomy was done for fibroid uterus.16% cases for abnormal uterine bleeding, 15% cases for prolapsed uterus, 7% cases for benign ovarian mass and 3% cases for adenomyosis [table 2]. most common clinical presentation was heavy menstrual bleeding i.e., 52%, mass descending per vaginum 15%, lump per abdomen 14%, dysmenorrhoea13% and postmenopausal bleeding in 6% cases [table 3]. majority of cases i.e., 24% were anaemic followed by hypertension in 23% cases. other co-existing medical conditions were diabetes mellitus 18%, thyroid disorders 12% and heart disease in 2% cases.[table 4]. abdominal route was preferred in 80% cases. total abdominal hysterectomy (tah) done in 25% cases and total abdominal hysterectomy with bilateral salpingoophorectomy (tah with bso) done in 55% cases. vaginal route was preferred in 20% cases amongst which vaginal hysterectomy with pelvic floor repair (vh with pfr) was performed in 15% cases followed by ndvh (non-descent vaginal hysterectomy) in 5% cases [table 5]. in 110 patients (55%) both ovaries were removed during hysterectomy operation. bleeding was the most common intraoperative complication i.e. 3% followed by anaesthetic complications in 2% cases, bladder and ureteric injuries in 0.5% cases each. post-operative complications were wound gaping in 4% cases, burst abdomen in 1% and urinary tract infection (uti) in 1% [table 6]. proliferative endometrium was the most common endometrial study finding i.e. 48% followed by secretory endometrium 24%, simple hyperplasia 12%, atrophic changes 6%, complex hyperplasia 2%, endometritis 2%, progestational changes 1.5 % and endometrial carcinoma in 0.5% cases [table 7]. non specific cervicitis was the most common cervical histopathological finding i.e. 92% followed by papillary endocervicitis 2%, cervical dysplasia 1.5% and adenocarcinoma in 0.5% cases [table 8]. myometrial histopathological study revealed leiomyoma in 59% cases, adenomyosis in 3%, nonspecific changes in 37%, chronic myometritis in 0.5% and endometrial adenocarcinomain in 0.5% cases [table 9]. 4. discussion hysterectomy is a quite common major operative procedure. in our study 48% patients who underwent elective hysterectomy were between age group of 41-50 years. ajmera s k et al. have reported peak age group of hysterectomy was 40-49 years with 41.51% cases. 2 manik. s. sirpurkar and smita. s. patne have reported 51.3% of hysterectomy patients were in the age group of 41-50 years in their study done on 230 hysterectomy cases at j.k. hospital bhopal. 3 in the present study, the commonest indication was fibroid uterus i.e., 59% cases. manik. s. sirpukar et al. have reported that the commonest indication for hysterectomy was dysfunctional uterine bleeding (39.13%) followed by fibroid uterus (29.13%). 3 bala r et al. have reported fibroid uterus in 40.7% hysterectomy patients in their study done at rims, imphal on 1,285 cases of hysterectomy. 4 in the current study most common clinical presentation was heavy menstrual bleeding (52%). sucheta k l et al. in their prospective study of 200 cases of hysterectomy in bangalore, india have found abnormal menstrual flow in 62% of cases. 5 majority preferred abdominal route for hysterectomy (80%). total abdominal hysterectomy with bilateral salpingo-oophorectomy was done in 55% cases and total abdominal hysterectomy alone in 25% cases. vaginal hysterectomy was performed in 20% cases (15% for prolapsed uterus and 5% had no uterine descent). rekha rao et al. in their study on 150 hysterectomy patients observed that maximum no of hysterectomies were performed by abdominal route, total abdominal hysterectomy with bilateral/ unilateral salpingoophorectomy in 36.6.3% cases followed by vaginal hysterectomy with pelvic floor repair in 29.3% cases and 6.6% cases underwent non-descent vaginal hysterectomy. 6 in this study bilateral salpingoophorectomy was done in 55% cases while doing hysterectomy. rajeshwari bv and varsha hishikar have reported both ovaries were removed only in 14.23 % cases in their retrospective study on 260 cases of hysterectomy operation. 7 in the present study intraoperative complication rate during hysterectomy was 6%. shridevi as et al. in their study over 300 cases of hysterectomies at davanagere, karnataka, india reported the rate of intraoperative complication was 8.8%. 8 in our study 3% cases of hysterectomy had excessive bleeding and were managed medically and perioperative blood transfusion was given. one patient (0.5%) had bladder injury and another one (0.5%) had ureteric injury which was repaired with the help of surgeon. according to zaman s et al. most common 500 barik et al. / panacea journal of medical sciences 2021;11(3):498–502 table 1: age distribution of hysterectomy cases s.no. age in years no. of patients percentage (%) 1 31 40 17 8.5% 2 41 50 96 48% 3 51 60 63 31.5% 4 >61 24 12% total 200 100% table 2: indications for hysterectomy s.no. indications no. of patients percentage (%) 1 fibroid uterus 118 59% 2 abnormal uterine bleeding 32 16% 3 prolapsed uterus 30 15% 4 adenomyosis 6 3% 5 benign ovarian mass 14 7% total 200 100% table 3: clinical presentation s.no. complaints no. of patients percentage (%) 1 heavy menstrual bleeding 104 52% 2 lump per abdomen 28 14% 3 postmenopausal bleeding 12 6% 4 dysmenorrhoea 26 13% 5 mass descending per vaginun 30 15% total 200 100% table 4: co-existing medical conditions s.no. medical conditions no. of patients percentage (%) 1 anaemia 48 24% 2 diabetes mellitus 36 18% 3 hypertension 46 23% 4 thyroid disorders 24 12% 5 heart disease 4 2% 6 no medical disorders 42 21% total 200 100% table 5: routesof hysterectomy s.no. route type no. of patients percentage (%) 1 abdominal tah 50 25% tah with bso 110 55% 2 vaginal ndvh 10 5% vh with pfr 30 15% 3 laparoscopic tlh 0 0% lavh 0 0% total 200 100% complication of hysterectomy operation was secondary haemorrhage (1.12%) and bladder injury was in 0.56% of cases. 9 in our study 2 patients (1%) had burst abdomen and another 2 patients (1%) had urinary tract infection. 4% of cases of hysterectomies operation had wound gaping and secondary suturing was done. sivapragasam v et al. have reported wound infection in 4.54% cases and wound gaping requiring secondary suturing in 2% cases. 10 endometrial histopathological study of uterine specimen revealed endometrial hyperplasia in 14% cases in our study which is comparable to study done by ranabhat et al. who reported its incidence of 16%. 11 histopathological examination study of cervix revealed 92% cases had chronic non specific cervicitis. according to talukder s i et al. 87.8% cases had chronic non specific cervicites. 12 leiomyoma was detected in 59% cases on histopathological barik et al. / panacea journal of medical sciences 2021;11(3):498–502 501 table 6: complications of hysterectomy s.no. complications type no. of patients percentage (%) 1 intraoperative complications bleeding 6 3% bowel injury 0 0% bladder injury 1 0.5% ureteric injury 1 0.5% anesthetics complications 4 2% 2 postoperative complications wound gaping 8 4% burst abdomen 2 1% uti 2 1% total 24 12% table 7: histopathological changes (endometrium) s.no. endometrial changes no of patients percentage (%) 1 proliferative phase 96 48% 2 secretary phase 48 24% 3 atrophic changes 12 6% 4 simple hyperplasia 24 12% 5 complex hyperplasia 4 2% 6 endometrial carcinoma 1 0.5% 7 progestational changes 3 1.5% 8 endometritis 4 2% 9 normal endometrium 8 4% 10 total 200 100% table 8: histopathological changes (cervix) s.no. cervical changes no. of patients percentage (%) 1 chronic non specific cervicitis 184 92% 2 cervical dysplasia 3 1.5% 3 papillary endocervicitis 4 2% 4 squamous cell carcinoma 0 0% 5 adenocarcinoma 1 0.5% 6 normal cervix 8 4% total 200 100% table 9: histopathological changes (myometrium) s.no. myometrial changes no. of patients percentage (%) 1 leiomyoma 118 59% 2 adenomyosis 6 3% 3 unremarkable/ nonspecific 74 37% 4 chronic myometritis 1 0.5% 5 endometroid adenocarcinoma 1 0.5% total 200 100% study of myometrium, whereas abdullah l s in his study reported leiomyoma as myometrial lesion in 30.3% cases. 13 5. conclusion hysterectomy is a common operation in gynaecological practice. the conditions that may lead to a hysterectomy causes discomfort rather than threaten life. indication for hysterectomy should be thoroughly evaluated as it is having both intraoperative and postoperative complications like any other major surgery. at present many conservative methods are available to treat various benign gynecological conditions. so it is prudent to discuss with the patient regarding various options available before planning for major surgery. vaginal route should be preferred as it is associated with faster return to normal activity, shorter hospital stays, reduced intraoperative blood loss and fewer wound infection. 502 barik et al. / panacea journal of medical sciences 2021;11(3):498–502 6. acknowledgement we are very much thankful to all the doctors and staffs of the department of obstetrics & gynaecology, f.m medical college & hospital, balasore, odisha for their active involvement while conducting this study. 7. sources of funding no financial support was received for the work within this manuscript. 8. conflicts of interest no conflicts of interest. references 1. wu jm, wechter me, geller ej, nguyen tv, visco ag. hysterectomy rates in the united states. obstet gynecol. 2003;110(5):1091–5. 2. ajmera sk, mettler l, jonat w. operative spectrum of hysterectomy in a german university hospital. j obstet gynecol india. 2006;56(1):59–63. 3. sirpurkar ms, patne ss. a retrospective review of hysterectomies at a tertiary care centre in central india. asian j biomed pharm sci. 2013;3(21):48–50. 4. bala r, devi kp, singh cm, m c. trend of hysterectomy. a retrospective analysis in rims, imphal. int j gynaecol obstet india. 2013;29(1):4–7. 5. sucheta kl, manangi m, madhu kp, arun bj, nagaraj n. hysterectomy: clinical profile, indications and postoperative complications. int j reprod contracept obstet gynecol. 2016;5(7):2093–9. 6. rao pr, vijayalakshmi d, reddy ds. to study the trends in hysterectomy in a tertiary care hospital based on the indications of hysterectomy. iosr j dent med sci. 2019;18(4):49–53. 7. rajeshwari bv, hishikar v. views and reviews of hysterectomy: a retrospective study of 260 cases over a period of 1 year. bombay hospital j. 2008;50(1):59–61. 8. shridevi as, madhusoodana rb, gyatri gl, renuka. an analysis of elective hysterectomies at a tertiary care center in karnataka. int j clin obstet gynaecol. 2019;3(4):68–70. doi:10.33545/gynae.2019.v3.i4b.291. 9. zaman s, begum aa. hysterectomies at a rural medical college of assam: a retrospective study. j obstet gynaecol barpeta. 2014;1(2):85–9. 10. sivapragasam v, rengaswamy ck, patil ab. an audit of hysterectomies: indications, complications, clinico pathological analysis of hysterectomy specimens in a tertiary care centre. int j reprod contracept obstet gynaecol. 2018;7(9):3689–94. doi:10.18203/2320-1770.ijrcog20183778. 11. ranabhat sk, shrestha r, tiwari m, sinha dp, subedee lr. a retrospective histopathological study of hysterectomy with or without salpingo-oophorectomy specimens. jcmc. 2010;1(1):26–9. 12. talukder si, haque ma, mo a, roushan a, noor z, nahar k, et al. histopathological analysis of hysterectomy specimens. mymensingh med j. 2007;16(1):81–4. 13. abdullah ls. hysterectomy:a clinicopathologic correlation. bahrain med bull. 2006;28(2):1–6. author biography sanket kumar barik, senior resident ajit kumar nayak, associate professor sujata misra, professor manju kumari jain, senior medical officer cite this article: barik sk, nayak ak, misra s, jain mk. a study on elective hysterectomies in a tertiary care hospital. panacea j med sci 2021;11(3):498-502. http://dx.doi.org/10.33545/gynae.2019.v3.i4b.291 http://dx.doi.org/10.18203/2320-1770.ijrcog20183778 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2022;12(2):256–259 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article clinical characteristics of covid 19 (sars-cov-2) patients at a tertiary health care centre ravindra j shinde1, sushama dugad1,*, gauri kulkarni2, kappagantu surya chaitanya neeladrirao subbarao1 1dept. of respiratory medicine, dr vasantrao pawar medical college, nashik, maharashtra, india 2dept. of respiratory medicine, acpm medical college, dhule, maharashtra, india a r t i c l e i n f o article history: received 24-05-20-2021 accepted 20-07-2021 available online 17-08-2022 keywords: covid19 sars pandemic a b s t r a c t background: global pandemic started in early december 2019 from wuhan, china and this didn’t spare any part of the world. millions of deaths have been reported and the disease treatment has been itself challenging due to varied clinical presentation. hence, we studied to know the clinical characteristics and comorbidities associated with sars-cov-2. materials and methods: observational study was conducted during period of may 2020 to july 2020 on patients diagnosed positive for sars-cov-2 on rt-pcr method. study was don’t know the clinical characteristics, comorbidities and outcome of the patients. results: our study found out of 640 patients admitted, 70.31% were males while females were 29.68% and mostly affected were age group of 30-39 age (26.4%). fever was observed most commonly in our study group. 77.34% patients didn’t have any coexisting comorbidity in the admitted cases; hypertension was most common among the admitted cases. we found mortality in 12.66% cases and concomitant diabetes and hypertension was leading comorbidity in the deaths of sars-cov-2. conclusion: covid 19 has spread like wildfire globally since first reported in wuhan, china. it has a wide spectrum of clinical presentation with no particular signs and symptoms pinpointing the diagnosis. appropriate investigations with quicker results are needed to achieve the same. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction unknown cases of pneumonia were reported first from wuhan, hubei, china in early december 2019. 1 rna beta coronavirus was identified as the pathogen; 2 which was named as sars-cov-2 and was similar to sars-cov 3 (severe acute respiratory syndrome). coronaviruses, belonging to the family coronaviridae and the order nidovirales, are enveloped non-segmented positive sense rna viruses and are broadly distributed in humans and other mammals. 4 * corresponding author. e-mail address: sushamadugad@gmail.com (s. dugad). usually, coronaviruses infections in humans are mild, but the two beta coronavirus epidemics i.e., severe acute respiratory syndrome coronavirus (sars-cov) 5–7 and middle east respiratory syndrome coronavirus (merscov) 8,9 have been reported to cause more than 10000 cases in the last 20 years. the mortality rates for both sars-cov and mers-cov are 10% and 37% respectively. 10,11 2. materials and methods study was conducted by department of respiratory medicine of dr vasantrao pawar medical college hospital and research centre, nashik during may 2020 to july 2020. we included patients diagnosed as sars-cov-2 positive https://doi.org/10.18231/j.pjms.2022.049 2249-8176/© 2022 innovative publication, all rights reserved. 256 shinde et al. / panacea journal of medical sciences 2022;12(2):256–259 257 by rt-pcr diagnostic method admitted at our hospital and patients who gave informed consent forms. we excluded the patients if there is inability to obtain informed consent from patients. the objective of the study was to: 1. study the clinical features in covid 19 patients 2. know the co-morbidities in covid 19 patients 3. know the outcome of covid 19 (sars-cov-2) patients observational study was conducted. the bio data, detailed clinical history was noted in predesigned case proforma and consent was enrolled in the study. investigations done for the patients were noted. we defined patient as cured when he/she was asymptomatic on day 7th after discharge and didn’t complain of cough/cold/fever/breathlessness. patient was asked via telephonic conversation after day 7th of discharge from the centre. data was analysed with appropriate statistical methods. 3. results 3.1. demographic variables during the study period i.e., may 2020 to july 2020 total 640 patients of covid 19 (sars-cov-2) patients were admitted out of which 450 were males (70.31%) and 190 were females (29.68%). the most common age group affected was found to be between 30-39 years (26.4%) followed by 50-59 years group (21.71%) while the least affected group was below 10 years of age (4.53%). fig. 1: gender-wise distribution fig. 2: age-wise distribution 3.2. symptoms of covid 19 (sars-cov-2) patients asymptomatic patients were found to be leading in the study i.e.,30.31% (n=194). in symptomatic cases fever was found to be most common (30.15%) in the study. cough was second most common symptom (25.46%). 142 patients complained of breathlessness (20.22%). patients presenting with confusion, drowsiness had poor prognosis in the study. fig. 3: 3.3. contact history among covid 19 (sars-cov-2) patients the study period showed (may 2020 to july 2020) positive contact history among 59.68% cases (n=382). despite no positive contact history 40.31% patients had covid 19 (sars-cov-2) rt pcr positive status. 3.4. pattern of comorbidities among covid 19 (sars-cov-2) patients in this study we found that there was no any comorbidity history among 77.34% patients (n=495). hypertension was found to be associated more frequently in positive cases (7.03%) followed by diabetes plus hypertension found to be 5.46% among the total cases admitted during the study 258 shinde et al. / panacea journal of medical sciences 2022;12(2):256–259 fig. 4: contact history period. fig. 5: comorbidities 3.5. outcome of covid 19 (sars-cov-2) patients table 1: outcome outcome cured 559 87.34 death 81 12.66 640 100 87.34% patients (n= 559) were cured from the covid19 (sars-cov-2) after treatment while 12.66% patients (n= 81) died of covid 19 (sars-cov-2).table 1 3.6. demographic characteristics of deaths among the death patients most affected were the males (70.37%) while females (29.63%). age group more than 50 years were mostly prone.table 2 table 2: demographic characteristics of deaths sex male 57 70.37 female 24 29.63 age group <10 0 0 10 20 0 0 21 29 1 1.23 30 39 7 8.64 40 – 49 8 9.87 50 – 59 22 27.16 60 – 69 18 22.22 >= 70 25 30.86 table 3: comorbid characteristics of deaths comorbidity dm + htn 18 22.22 dm 9 11.11 htn 14 17.28 hypothyroidism 1 1.23 cardiac disease 3 3.70 ckd 2 2.46 ald 1 1.23 bhp 1 1.23 pih 1 1.23 no 26 32.09 other 5 6.17 81 the most common comorbid condition among the deaths was found to be diabetes plus hypertension (22.22%) followed by hypertension (17.28%).table 3 4. discussion in the present study the more disease affection to males was seen as compared to females and the age group most affected was between 30-39 years group which was similar to study conducted by shan-yan zhang et al in china. 12 in the study performed by w. guan et al, they concluded that diagnosis of the disease was complicated during the early stage of the covid-19 outbreak, due to the variety of symptoms and the spectrum of disease severity at the time of presentation. fever was identified in 43.8% of the patients on presentation. 13 on the other hand our study showed presence of fever only in 30.15% of study population. in concurrence with recent study of leung wk et al and assiri a., we found that dominant symptoms were fever (30.15%) and cough (25.46%). gastrointestinal symptoms (1.25%) were uncommon even in our study, which indicates differences in presentation of sars-cov, mers-cov, and seasonal influenza. 14,15 the term covid-19 positive is used to refer to patients who have laboratory-confirmed symptomatic cases without apparent radiologic manifestations. however, more insight shinde et al. / panacea journal of medical sciences 2022;12(2):256–259 259 into the spectrum of the disease is needed, since in 8.9% of the patients, sars-cov-2 infection was detected before the development of viral pneumonia or viral pneumonia did not develop at all. 13 breathlessness as presentation among the study population was consistent with the other studies which was later associated with poor outcome. our study found mortality of nearly 12.66%. in contrast to other studies; our study found no association of comorbidity and covid 19 (sars-cov-2). only 22.66% had co-morbidities; among them hypertension was most common (7.03%) followed by combination of diabetes mellitus and hypertension (5.46%) and isolated diabetes mellitus (5.46%). paudel ss et al and zhou f et al also found hypertension as most common comorbidity (15.8%) associated; diabetes being second (9.4%). 16,17 we found mortality of 12.66% in our study period. there was a preponderance of deaths in patients with hypertension, diabetes mellitus and in males. our study has few limitations. firstly, study was conducted only over 3 months hence extensive amount of data couldn’t be analysed. secondly, we included only indoor patients and the patients treated on outpatient basis and home quarantined during the duration weren’t included in participation. 5. conclusion covid 19 has spread like wildfire globally since first reported in wuhan, china. it has a wide spectrum of clinical presentation with no particular signs and symptoms pinpointing the diagnosis. appropriate investigations with quicker results are needed to achieve the same. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. huang c, wang y, li x. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020;395:497–506. 2. lu r, zhao x, li j, niu p, yang b, wu h, et al. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. lancet. 2020;395(10224):565–74. doi:10.1016/s0140-6736(20)30251-8. 3. zhu n, zhang d, wang w, li x, yang b, song j, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2019;382(8):727–33. doi:10.1056/nejmoa2001017. 4. richman dd, whitley rj, hayden fg. clinical virology, 4th edn. asm press; 2016. 5. ksiazek tg, erdman d, goldsmith cs, zaki sr, peret t, emery s, et al. a novel coronavirus associated with severe acute respiratory syndrome. n engl j med. 2003;348(20):1953–66. doi:10.1056/nejmoa030781. 6. kuiken t, fouchier ram, schutten m, rimmelzwaan gf, van amerongen g, van riel d, et al. newly discovered coronavirus as the primary cause of severe acute respiratory syndrome. lancet. 2003;362(9380):263–70. doi:10.1016/s0140-6736(03)13967-0. 7. drosten c, günther s, preiser w, van der werf s, brodt hr, becker s, et al. identification of a novel coronavirus in patients with severe acute respiratory syndrome. n engl j med. 2003;348(20):1967–76. doi:10.1056/nejmoa030747. 8. de groot r, baker sc, baric rs, brown cs, drosten c, enjuanes l, et al. middle east respiratory syndrome coronavirus (merscov): announcement of the coronavirus study group. j virol. 2013;87(14):7790–2. doi:10.1128/jvi.01244-13. 9. zaki am, van boheemen s, bestebroer tm, osterhaus a, fouchier ram. isolation of a novel coronavirus from a man with pneumonia in saudi arabia. n engl j med. 2012;367(19):1814–20. doi:10.1056/nejmoa1211721. 10. who. summary of probable sars cases with onset of illness from 1 november 2002 to 31 july 2003. dec 31, 2003. available from: https://www.who.int/csr/sars/country/table2004_04_21/en/. 11. who. middle east respiratory syndrome coronavirus (mers-cov). november, 2019. available from: http://www.who.int/emergencies/ mers-cov/en/. 12. zhang sy, lian j, jh h. clinical characteristics of different subtypes and risk factors for the severity of illness in patients with covid-19 in zhejiang, china. infect dis poverty. 2020;9:85. doi:10.1186/s40249020-00710-6. 13. guan w, ni z, hu y, liang w, ou c, he j, et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020;382:1708–20. doi:10.1056/nejmoa2002032. 14. leung wk, to kf, chan pk, chan hly, wu akl, lee n, et al. enteric involvement of severe acute respiratory syndrome-associated coronavirus infection. gastroenterology. 2003;125(4):1011–7. doi:10.1016/s0016-5085(03)01215-0. 15. assiri a, mcgeer a, perl tm, price cs, rabeeah aa, cummings dat, et al. hospital outbreak of middle east respiratory syndrome coronavirus. n engl j med. 2013;369(5):407–16. doi:10.1056/nejmoa1306742. 16. paudel ss. a meta-analysis of 2019 novel corona virus patient clinical characteristics and comorbidities. res square. 2020;2(8):1069–76. doi:10.21203/rs.3.rs-21831/v1. 17. zhou f, yu t, du r, fan g, liu f. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395(10229):1054–62. doi:10.1016/s0140-6736(20)30566-3. author biography ravindra j shinde, associate professor sushama dugad, professor and head gauri kulkarni, professor and head kappagantu surya chaitanya neeladrirao subbarao, junior resident2 cite this article: shinde rj, dugad s, kulkarni g, subbarao kscn. clinical characteristics of covid 19 (sars-cov-2) patients at a tertiary health care centre. panacea j med sci 2022;12(2):256-259. http://dx.doi.org/10.1016/s0140-6736(20)30251-8 http://dx.doi.org/10.1056/nejmoa2001017 http://dx.doi.org/10.1056/nejmoa030781 http://dx.doi.org/10.1016/s0140-6736(03)13967-0 http://dx.doi.org/10.1056/nejmoa030747 http://dx.doi.org/10.1128/jvi.01244-13 http://dx.doi.org/10.1056/nejmoa1211721 https://www.who.int/csr/sars/country/table2004_04_21/en/ http://www.who.int/emergencies/mers-cov/en/ http://www.who.int/emergencies/mers-cov/en/ http://dx.doi.org/10.1186/s40249-020-00710-6 http://dx.doi.org/10.1186/s40249-020-00710-6 http://dx.doi.org/10.1056/nejmoa2002032 http://dx.doi.org/10.1016/s0016-5085(03)01215-0 http://dx.doi.org/10.1056/nejmoa1306742 http://dx.doi.org/10.21203/rs.3.rs-21831/v1 http://dx.doi.org/10.1016/s0140-6736(20)30566-3 case report panacea journal of medical science, september december 2015:5(3);166-170 166 unruptured multi-compartmental left sinus of valsalva aneurysm with chronic dissection of inter-atrial septum and left ventricular free wall amarnath c 1 , sathyan g 2 , periakarupan a 3 , ganga devi r 4 , kanimozhi d 5 abstract: the sinus of valsalva aneurysm (sva) is a small dilatation caused by a separation between the aortic media and annulus fibrosus. a 30-year-old female presented with complaint of pain abdomen. she was evaluated with ct abdomen, scanogram showed ventricular wall calcifications. there was history of intermittent palpitation and exertional breathlessness. on further evaluation with echocardiogram and 64 slice ct scanner, it turned out to be unruptured aneurysm arising from the left coronary sinus. it is a unique aneurysm, which bifurcated into superior part giving origin to the left coronary artery and inferior part dissecting as a complex multilobated aneurysm. the aneurysm had three components in the groove between left atrium and aortic root, dissecting aneurysm into the inter-atrial septum with thrombus, and dissecting aneurysm into the anterolateral free wall of the left ventricle, protruding into the lumen. keywords: sinus of valsalva aneurysm, coronary sinus, aortic root, chronic dissection, ventricular wall aneurysm. 1 professor and head, 2 associate professor, 4 assistant professor, 5 resident, department of radio diagnosis, stanley medical college, chennai 600001, india 3 consultant radiologist, scans world research & education institute, chennai, amarrd02@yahoo.co.in introduction sinus of valsalva is dilatations at the aortic root wall that arise between the aortic valve annulus and the sinotubular ridge. each sinus is associated with a corresponding right, left or non-coronary aortic valve cusp (1-2). the right and left main coronary arteries arise simultaneously from their respective developing sinuses. aneurysm of sinus of valsalva is rare and may be congenital or acquired. they are most common in right coronary sinus followed by non-coronary sinus, left coronary sinus. the rupture of sinus of valsalva aneurysm (sva) causes fatal outcome. case history a 30-year-old female presented to our department with complaints of right loin pain. she was subjected to ct abdomen which showed right renal calculus (4.1 mm), no hydroureteronephrosis, and no ureteric calculus. no significant abnormality noted in other abdominal organs. scanogram showed cardiac calcification. on further detailed history, she had intermittent palpitation and exertional breathlessness. she revealed no history of chest pain, orthopnoea, pedal oedema, abdominal distension or hypertension, trauma, long term medications. general examination was unremarkable, no features suggestive of connective tissue disorders. on systemic examination, no evidence of thrill, heave, systolic / diastolic murmur, added sounds. abdomen examination showed no hepatomegaly. electrocardiogram showed sinus tachycardia, otherwise normal. she was further evaluated with 2d-transthoracic echocardiogram which showed normal left and right ventricular function, lvef – 58%, no regional wall motion abnormality. the left aortic sinus was dilated. a complex multilobated aneurysm arising from left aortic sinus was noted. as shown in the echo images in fig. 1, there were three components. one small component without thrombus was seen between the left atrium and the root of aorta. it measured 4.5 cm x 2.5 cm. another sac measuring 3.5 cm x 3.5cm, with thrombus was seen dissecting into the inter-atrial septum. the largest component measuring 5.5 cm x 4.5 cm with a small luminal thrombus was seen dissecting into the anterolateral free wall of the left ventricle and projecting into the lumen. amarnath c et al. unruptured multi-compartmental left sinus of valsalva aneurysm with chronic dissection… panacea journal of medical science, september december 2015:5(3);166-170 167 fig. 1: trans-thoracic echocardiogram a. parasternal long axis view, b. four chamber view, c. two chamber view. ►-aneurysm component in the groove between aorta and left atrium, « component of aneurysm dissecting into the inter-atrial septum with thrombus, # aneurysm component dissecting into the left ventricular free wall. la left atrium, ra right atrium, lv left ventricle, rv right ventricle, ao – aorta to further characterise the lesion, to know the size, extent, thrombus, she was further evaluated with a 64 slice ct scanner (philips brilliance 64). ct was done with476 ma, 120kv, 0.3mm slice thickness, 80ml of intravenous iohexol used as contrast material. the right aortic sinus, non-coronary aortic sinus, right coronary artery, ascending/ descending thoracic aorta, aortic arch, right ventricle were normal. there was abnormal dilatation of left sinus of valsalva. the sinus of valsalva aneurysm bifurcated, superior part giving origin to the left coronary artery and inferior part dissecting as a complex multilobulated unruptured sinus of valsalva aneurysm. the aneurysm had three components as shown in the fig. 2. 1. in the groove between left atrium and aortic root, 2. dissecting into the interatrial septum with thrombus, and 3. dissecting into the anterolateral free wall of the left ventricle, protruding into the left ventricular lumen. fig. 3 demonstrates the aneurysm from the reconstructed mdct image. of the above mentioned components, the first and the second components originated from a narrow neck of 4 mm length and 3 mm width. the first multilobulated component measuring 4.8 cm x 1.3 cm x 2.8 cm, was seen tracking posteriorly and superiorly, into the groove between left atrium and aortic root. the second component measuring 3.5 x 2.7 x 3.6 cm with a large thrombus, was seen dissecting into the interatrial septum. the third component was the largest measuring 5.7 cm x 4.3 cm x 4.5 cm, with a neck of 8.2 mm, was seen dissecting into the anterolateral free wall of the left ventricle protruding into the lumen. it contained a thrombus of in the anterosuperior aspect and calcifications in the wall. no shunt was present. amarnath c et al. unruptured multi-compartmental left sinus of valsalva aneurysm with chronic dissection… panacea journal of medical science, september december 2015:5(3);166-170 168 fig. 2: computed tomographic images a, b axial; c, dmultiplanar reconstructed images showing: ► aneurysm component in the groove between aorta and left atrium, « component of aneurysm dissecting into the interatrial septum with thrombus, # aneurysm component dissecting into in the left ventricular free wall with calcifications in the wall and thrombus in anterosuperior aspect, lca left coronary artery, la left atrium, ra right atrium, lv left ventricle, rvright ventricle, ao – aorta. fig. 3: ct volume rendered mip images showing the sva.lv left ventricle, ao aorta amarnath c et al. unruptured multi-compartmental left sinus of valsalva aneurysm with chronic dissection… panacea journal of medical science, september december 2015:5(3);166-170 169 conventional catheter coronary angiogram was then advised for assessing the flow character of the lesion and presence of any shunt. patient was subjected to catheter directed selective coronary angiogram which showed lobulated ‘wind sock’ like lesion originating from the left coronary sinus as shown in fig. 4. left coronary artery was originated from a superior out pouching of the left coronary sinus. no significant disease noted in both the coronary arteries. fig. 4: conventional catheter coronary angiogram spot images: awindsock like contrast filled structure arising from the root of aorta; b – right coronary artery; c – left coronary artery. in spite of the need to operate an unruptured aneurysm due to the risk of rupture, sudden cardiac failure and collapse, our patient was not willing for surgery due to the underlying risk. so, she is managed conservatively with propranolol for tachycardia. discussion sinus of valsalva is three subtle dilatations at the aortic root wall that arise between the aortic valve annulus and the sinotubular ridge. each sinus is associated with a corresponding right, left or non-coronary aortic valve cusp (1-2). during the 5 th week of embryogenesis, left and right truncoconal swellings develop along the inferior end of truncus, just before septation of the truncus into posterior aortic and anterior pulmonary channels. after septation, cusps of the aortic valve and the pulmonary valve are formed from the three tubercles in ventricular outflow tract. then, the valsalva sinuses and leaflets of aortic valve begin to form. the right and left main coronary arteries arise simultaneously from their respective developing sinuses. by the 9 th week, formation of the aortic valve leaflets and valsalva sinuses generally is complete (13). aneurysm of sinus of valsalva accounts for 0.14 % and very rare (1). aneurysm are most common in right coronary sinus (72%) followed by non-coronary sinus (22%), left coronary sinus (6%) (1-4). aneurysm of the aortic sinus can be either congenital or acquired. congenital aneurysms are due to localized weakness of the elastic lamina or an underlying deficiency of normal elastic tissue. common causes of acquired aneurysms included generative conditions (cystic medial necrosis, atherosclerosis), infectious diseases (bacterial endocarditis, syphilis and tuberculosis) and injury (deceleration trauma). they are more common in men (1,5). un-ruptured aneurysm may be asymptomatic and incidentally discovered. if symptomatic, it is due to mass effect on adjacent cardiac structures. the most common and dreaded complication of the sva is rupture. the rupture is most common if the aneurysm is located in the right sinus, followed by non-coronary and left aortic sinus. rupture may be spontaneous, after trauma, extreme physical exercise or due to endocarditis. rupture of a sva occurs principally into the right ventricle. extra cardiac ruptures are rare, usually fatal(3). ruptured sinus aneurysm result in an aorto-cardiac shunt and may manifest as insidiously amarnath c et al. unruptured multi-compartmental left sinus of valsalva aneurysm with chronic dissection… panacea journal of medical science, september december 2015:5(3);166-170 170 progressive congestive heart failure, severe acute chest pain with dyspnoea, or, in extreme cases cardiac arrest (6-8). after treatment, the prognosis is excellent. thus, prompt and early correct diagnosis is essential (1, 3-4). most sva are visualised at echocardiography. ecg gated mr and ct imaging are essential. the former provides valuable functional information, and latter provides excellent depiction of anatomy (2,5). medical management involves stabilization of patient clinical condition with medications for heart failure syndrome and peri-operative assessment. transcatheter closure using amplatz vascular plug has been performed for ruptured sva (9). it can also be performed in critically ill patients of ruptured sva, to avoid sternotomy and cardiopulmonary bypass. advanced percutaneous techniques are being performed to correct this condition. but, the treatment of choice is open-heart surgery with or without aortic valve replacement. this procedure carries a mortality of less than 2%.in all patients presenting with rupture, urgent surgical correction should be performed, especially in patients with intra-cardiac shunting. in patients diagnosed to have unruptured sva, surgical management is recommended to avoid the increased morbidity and mortality (1, 9-10). we present this case because, aneurysm from the left coronary sinus is rare, presence of multilobulated aneurysm from a single coronary sinus is rare, presence of multi compartmental extension with chronic dissection is hardly reported, coronary sinus aneurysm dissecting into either interatrial septum or left ventricular free wall is hardly reported, and large size of the aneurysms without rupture and without symptoms. references: 1. bricker aliye ozsoyoglu, avutu bindu, mohammed tanlucien h, williamson eric e, syed imran s, julsrud paul r, et al. valsalva sinus aneurysms: findings at ct and mr imaging. radio graphics 2010; 30:99–110. 2. hoey edward td, kanagasingam arulnithy, sivananthan mohan u. sinus of valsalva aneurysm: assessment with cardiovascular mri. ajr2010; 194:495–504. 3. galicia-tornell matilde myriam, marín-solís bertha, mercado-astorga oscar, espinoza-anguiano saúl, martínez-martínez manuel, villalpando-mendoza esteban. sinus of valsalva aneurysm with rupture: case report and literature review. cir ciruj 2009;77:441-5. 4. gonzalez joaquin b, koul sharat, sawardekar umayal, bhat pachalla k, kirshenbaum kevin j, sukerkar arun n. sinus of valsalva aneurysm: a unique case of giant aneurysms involving all 3 sinuses. circulation 2008;117:e308-e311. 5. vlachou paraskevi a, loke ian, chin derek, vlachou christina, alexiou christos, sosnowski andrzej w, et al. bilateral sinus of valsalva aneurysms: an extreme case. circulation 2006;114:e542-e543. 6. mookadam f, haley j, mendrick ed. rare cause of right heart failure: contained rupture of a sinus of valsalva aneurysm associated intraventricular septal aneurysm. eur j echocardiography 2005; 6: 221-224. 7. iadanza alessandro, fineschi massimo, pasqua alessia del, pierli carlo. echocardiography diagnosis of ruptured congenital right coronary sinus of valsalva aneurysm into right ventricle. eur j echocardiography 2006; 7: 387-9. 8. edwards jesse e, burchell howard b. the pathologicalanatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. thorax 1957; 12: 125. 9. reddy srikrishna modugula, bisoi akshay kumar, sharma pranav, das shambunath. case report – congenital surgical repair of multiple unruptured aneurysms of sinus of valsalva. interactive cardiovascular and thoracic surgery 2009; 9:709–11. 10. lijoi antonio, parodi enrico, passerone gian carlo, scarano flavio, caruso davide, iannetti mario vito. unruptured aneurysm of the left sinus of valsalva causing coronary insufficiencycase report and review of the literature. tex heart inst j 2002; 29:40-4. case report panacea journal of medical sciences, may-august,2016;6(2): 104-106 104 spontaneous monochorionic quadramniotic pregnancy: a case report rasika pise1, sulabha joshi2,* 1junior resident, 2professor & hod, dept. of obstetrics & gynaecology, nkp salve institute of medical sciences & research centre, nagpur *corresponding author: email: sulabhaajoshi@gmail.com abstract quadruplet pregnancy is very rare. all these pregnancies are multizygotic pregnancies. spontaneous monochorionic quadruplet pregnancy is extremely rare, quoted incidence being 1 in 15 million. one such case is reported here where a primigravida, who conceived within one year after marriage spontaneously, remained uninvestigated till 24 weeks was then diagnosed as triplet pregnancy. keywords: monozygotic, quadruplet, spontaneous, quadramniotic, hellin’s rule. access this article online website: www.innovativepublication.com doi: 10.5958/2348-7682.2016.00015.4 introduction quadruplet pregnancy is very rare. the incidence, according to hellin’s rule being 1 in 5,12,000(1) since the use of ovulation induction drugs the incidence is increasing in patients treated for infertility. but all these pregnancies are multizygotic pregnancies. spontaneous monochorionic quadruplet pregnancy is extremely rare, quoted incidence being 1 in 15 million(2). case history primigravida, aged 22 years, reported for first antenatal checkup at 16 weeks in antenatal opd. she was married since 1 year and it was a spontaneous conception. urine pregnancy test was done after 2 months at home and pregnancy was confirmed. there was no visit to any practitioner till 16 weeks gestation. no contraception was used after marriage. patient was from low socioeconomic status and there was no history of multiple pregnancies in family. general and systemic examination did not reveal any abnormality but uterine size was more than period of gestation. cervix and vagina were healthy on per speculum examination. usg and other investigations were advised but patient did not come for follow-up with usg and other reports. at 23 weeks of gestation, patient came to opd for antenatal check-up. on general examination pallor was present and on per abdomen examination height of the uterus was more than period of amenorrhoea and multiple fetal parts were felt. on per vaginal examination cervix was 1 cm dilated and 30 percent effaced. patient was advised admission in view of multiple pregnancies with moderate anemia. usg was done and revealed triplet pregnancy. patient was treated for anemia; parenteral iron was given after calculating required dose. patient stayed for 2 days and was not willing to stay thereafter and went against medical advise. at 27 weeks gestation patient directly reported to casualty with pain in abdomen. on examination vital signs were stable, uterus was 36 weeks pregnant size and patient was getting good uterine contractions. thus, patient was admitted. uterus was 36 weeks, tense and presentation of the baby could not be made out. on per vaginal examination cervix was fully effaced, fully dilated and first baby was presenting by vertex at ‘0’station. patient was admitted with the diagnosis of primigravida with triplet pregnancy in second stage of labour. she was immediately shifted to labour room and she delivered 3 preterm female babies at the interval of 5 to 7 min, all by vertex. after the 3 babies were delivered uterine size was still 28 weeks, to our surprise, 4th bulging bag of membranes was felt on per vaginal examination and patient delivered 4th female child by vertex after 7 min. the apgar scores of the 4 babies at 1 minute were 7/10, 6/10, 7/10, 8/10 respectively and 5 min were 8/10, 9/10, 8/10, 9/10 respectively and babies were weighing 600 gm, 700 gm, 680 gm and 740 gm respectively. there was no postpartum hemorrhage and none of the four female babies had obvious congenital anamolies. placental examination confirmed monochorionic quadramniotic placenta weighing 700 gm (fig. 1). pise rasika et al. spontaneous monochorionic quadramniotic pregnancy: a case report panacea journal of medical sciences, may-august,2016;6(2): 104-106 105 fig. 1: placenta with 4 sacs histopathology confirmed monochorionic and quadramniotic pregnancy (fig. 2). each baby had blood group o positive. all babies were shifted to nicu. 2 of them could not survive because of prematurity with hyaline membrane disease and pulmonary hemorrhage and 2 babies were doing well at the time of reporting. fig. 2: histology of dividing membrane discussion the reported incidence of spontaneous monozygotic quadruplet pregnancy is 1 in 10 to 15 million pregnancies(2). monozygosity increases markedly the likelihood of early fetal losses. this may explain in part the apparent rarity of viable monozygotic quadruplet pregnancies. spontaneous ohss is extremely rare event and cases are reported with quadruplet pregnancy complicated with ohss with spontaneous ovulation(3). multifetal pregnancies are prone for complications like preterm labour and preeclampsia. the loss of entire pregnancy is 50% for quadruplet pregnancy. only 2 documented cases with sonographic workup of placenta and successful perinatal outcome were reported till 2013(4). gestational age at delivery and birth weight are inversely proportional to the number of fetuses in the uterus. birth weight of quadruplets and quintuplets are significantly lower than in triplet pregnancy and early perinatal mortality is significantly higher in quadruplet and quintuplets. the average gestational age was 30 weeks for quadruplet pregnancy and mean birth weight is 1414(5). management recommended on diagnosis of multiple pregnancy include counseling of selective reduction, bed rest, beta mimetic, high protein diet, dexamethasone in 2nd trimester, selective circlage and intensive ultrasonography control which include doppler and biophysical parameters. many authors consider cesearean as the most suitable modality of birth. in our patient diagnosis of triplet was done but ideal management could not be initiated because of lack of cooperation of patient and her family in spite of proper counseling. for the successful management, in addition to the quality obstetric management, patient education, socioeconomic support, family and emotional support play a very important role which were lacking in this patient. and thus though patient was diagnosed 16weeks, the window of opportunity was lost. multiple studies have suggested that multiple births may experience excess morbidity including low birth weight, prematurity and higher risk for major birth defects. however in our case, in spite of lack of rest and antenatal supervision patient did not have any of the medical complication such as pih, gdm, uti and anemia and pregnancy was carried till 27 weeks(6). this case is published because of rarity of occurrence of spontaneous, monochorionic quadramniotic pregnancy and once again stressing the importance of correct antenatal management and patient education in prevention of perinatal morbidity and mortality. clinical significance spontaneous quadruplet pregnancy does occur and need early diagnosis and timely management. diagnosis of few sacs can be missed on usg especially late pregnancy and one must be prepared to deliver higher order pregnancy beyond usg diagnosis. conclusion from this case, it is concluded that spontaneous quadruplet pregnancy can occur and timely diagnosis and management is important. pregnancy which could progress to 27 weeks without rest could have progressed further if patient would have followed the instructions of treating doctors. references 1. fellman j, eriksson aw. on the history of hellin’s law. ptwin res hum genet 2009 april;12(2):183-90. 2. luke b. the changing pattern of multiple births in the united states: maternal and infant characteristics, 1973 and 1990. obstet gynecol 1994;84:101-106. 3. sugaya s, hiroi t. quadruplet pregnancy complicated by ovarian hyperstimulation syndrome with spontaneous ovulation. clin exp obstet gynecol 2012;39(3):402-4. pise rasika et al. spontaneous monochorionic quadramniotic pregnancy: a case report panacea journal of medical sciences, may-august,2016;6(2): 104-106 106 4. timor-tritch ie, fliescher a, monteagudo a, valderrama e. monochorionic quadraminotic quadruplets: sonographic workup. fetal diagn ther 1997;12:363-367. 5. seoud ma, toner jp, kruithoff c. outcome of twin, triplet and quadruplet in vitro fertilization pregnancies: the norflok experience. fertil steril 1992;57:825-34. 6. usha vikranth, neetal v borkar, sadhana k desai, premakania, nilofer h rangoonwala. quadruplet pregnancy. journal of obstet gynecol india 2007;57(5):439-441. case report doi: 10.18231/2348-7682.2017.0015 panacea journal of medical sciences, january-april,2017;7(1): 53-55 53 malignant perivascular epithelioid cell neoplasm of uterus: a great mimic of fibroid vaishali walke1,*, s. kawathalkar2, r. rane3, m. goel4, wk raut5 1assistant professor, 2associate professor, 3,4resident, 5professor & hod, dept. of pathology, govt. medical college, nagpur, maharashtra *corresponding author: email: drvaishaliw@yahoo.com abstract perivascular epithelioid cell (pec) neoplasms are an unusual group of mesenchymal tumors which arise from the perivascular epithelioid cell that characteristically expresses melanocytic and muscle markers. these neoplasms show a wide range of morphologic spectrum and have been described in multiple anatomical locations which includes uterus. we report a 46year-old patient diagnosed as uterine fibroid on ultrasonography in whom the hysterectomy specimen unveiled characteristic features of intramural pecoma consisting of small nests and sheets of clear epithelioid cells particularly present around the blood vessels in a background of loose oedematous stroma along with the foci of mature adipose tissue which exhibits myometrial infiltration. the correct diagnosis is crucial as there is an emerging role of mtor inhibitors which can provide a ray of hope to the patients of pecoma. keywords: pecoma of uterus, angiomyolipoma, uterine epithelioid cell tumour. introduction perivascular epithelioid cell tumor (pecoma) is a collection of rare neoplasms defined by the world health organization as mesenchymal tumors which on histology and immune staining reveal distinctive melanocytic and smooth muscle differentiation. hence thought to be derived from perivascular epithelioid cell.(1)the pecoma family of tumorincludes aml(angiomyolipoma), ccst(clear cell sugar tumor), lam (lymphangiomyomatosis), and less well-defined pecoma of other anatomic locations called perivascular epithelioid cell tumor not otherwise specified (pecoma-nos).(2) most of the published literature on pecoma-nos is as case reports and series, which emphasize on its presentation and morphology. here we report a case of uterine pecoma misdiagnosed as fibroid clinico-radiologically. we will discuss this case to stratify it along the risk stratification criteria which may help to improve upon its management. case history a 46-year-old married female visited hospital complaining of abnormal uterine bleeding of 5 months duration. her past medical history was unremarkable. there was no history of contraceptives use or hormonal therapy. on clinical examination, the uterus was enlarged approx. 24 wks with moderate tenderness in lower abdomen. ultrasonography showed 14 cm ×12 cm × 8 cm sized, hypoechoic lesion in the uterus with mild vascularity and necrotic changes suggestive of degenerative fibroid. her hemoglobin level was 8.0gm%, rest all laboratory findings were within normal limits. she underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy. on gross the uterus with cervix was of size 15 cm × 12 cm × 7cm. endometrial cavity was distorted by the tumor of size 12 cm ×10 cm ×7 cm. it was well circumscribed; the cut surface was solid, greyish white and fleshy. there was also a cyst in the left ovary of size 5 cm × 4 cm × 1.5cm. on cut section, cyst contained sebaceous material and hair. on histology, the tumor revealed two cell types. there was admixture of epithelioid to spindled shaped tumor cells (fig. 1). fig. 1: tumor composed of epithelioid, cells in diffuse sheets, groups of fat cells and thick walled blood vessels (10x) the individual cells had eosinophilic to clear cytoplasm with central to eccentric, round to oval nuclei with fine chromatin and inconspicuous nucleoli (fig. 1a). vaishaliwalke et al. malignant perivascular epithelioid cell neoplasm of uterus: a great mimic of fibroid panacea journal of medical sciences, january-april,2017;7(1): 53-55 54 fig. 1a: tumor cells having clear cytoplasm, round to oval nuclei with minimal atypia and low mitosis (h&e stain, 40x) epithelioid cells were seen arranged around thick walled blood vessels in clusters and diffuse sheets (fig. 1b). fig. 1b: classical perivascular distribution of clear cells (h&e stain, 20x) focally the tumor cells were infiltrating into the myometrium. the spindle cell component consisted of short fascicles and bundles having oval to plump nuclei with uniform chromatin. the mature adipocytes were seen in the groups and sheets. foci of extensive hyalinization and hydropic degeneration were seen. occasional mitotic figures were noted. there was no evidence of tumor necrosis. the neoplastic epithelioid cells were positive for hmb-45 (fig. 2). fig. 2: tumor cells showing cytoplasmic positivity (ihchmb45, 40x) considering the above features, the diagnosis of uterine perivascular epithelioid tumour (pecoma) was made. given the size of primary mass and the presence of myometrial infiltration, the high risk features proposed by folpe et al,(3) we classified it as malignant or high risk pecoma. endometrium showed combination of hypersecretory and cystically dilated glands with abundant secretion in the lumen. the lining cells showed stratification and at places there was lining of single layer of columnar to cuboidal cells. at places glands showed mucinous metaplasia. the stroma was loose edematous, abundant and showed pseudodecidualization with prominent spiral arterioles. in addition to the above findings there was presence of a mature cystic teratoma (dermoid cyst) in the contralateral ovary. discussion in 1994, bonetti et al(4) forwarded the concept of a family of tumor which comprised of angiomyolipoma, clear cell sugar tumors and lymphagiomyomatosis. it was observed that these three lesions shared a common morphological and immunophenotypical cell type which was previously designated as "perivascular epithelioid cell".(5) detailed study of these tumors in the different anatomic locations of these cell types suggested the name pecoma, first proposed by zamboni et alin 1996.these tumors are known for a myomelanocytic phenotype and show immune reactivity for both melanocytic (hmb‐45/melan‐a) and smooth muscle (actin /desmin) markers.(6) the most common primary sites for pecoma‐nos is female genital tract and more specifically the uterus.(7) some pecoma are seen in patients with tuberous sclerosis complex.(8) patients with uterine pecoma show symptoms such as abnormal uterine bleeding, lower abdominal pain and palpable mass, which is similar to other uterine tumors particularly fibroid.(1) thus, uterine pecoma are often misdiagnosed as uterine leiomyomas before surgery. therefore the correct diagnosis totally depends on pathologist high index of suspicion. vaishaliwalke et al. malignant perivascular epithelioid cell neoplasm of uterus: a great mimic of fibroid panacea journal of medical sciences, january-april,2017;7(1): 53-55 55 pecoma are usually composed of epithelioid cells having clear to granular eosinophilic cytoplasm with focal perivascular accentuation and spindled cell component.(1) in our case, tumor cell predominantly consist of epithelioid cells with clear to eosinophilic cytoplasm mainly seen around the blood vessels. in addition there is a component of numerous thick walled blood vessels, bundles of spindle shaped cells and adipocytes. the mitosis was a rare phenomenon. the tumor showed myometrial infiltration at places. the epithelioid cells showed cytoplasmic positivity for hmb45. school meester et al reported hmb-45 in pecoma as the most sensitive (16/16 positive, 100%) marker. desmin was positive in 15 out of 15 cases (100%) and sma in 14 of 15 (93%).(9) the diagnosis of uterine pecoma is challenging as it shares a distinct clinic-morphologic and immuno-phenotypic overlap with some myometrial smooth muscle neoplasm. amongst this category are epithelioid smooth muscle tumours (esm) which exhibit cells in nests or diffuse sheets displaying eosinophilic cytoplasm, although a clear appearance may be seen.(10) these tumours generally do not reveal vascular network that is characteristic of pecoma. extracellular myxoid material has been described in esm. uterine pecoma definitely display at least focal immunoreactivity for melanocytic markers in almost all cases (100%), while esm is rarely positive for hmb-45. pecoma need also to be differentiated from endometrial stromal sarcoma (ess). dominant spindle cell component seen as short fascicles and present around thin walled blood vessels is a classical feature of ess. it is negative for hmb-45, sma and desmin.(6,8) pecoma-nos even though rare has become an increasingly recognized entity. the evaluation of adverse risk factors like tumor size and infiltration of myometrium predicts the recurrence after surgical resection and help in postoperative counseling.(3) because both these adverse risk factors were evident in our case, we classified pecoma into high risk category. to conclude, the knowledge of morphological features are of great help in differentiating pecoma from epithelioid smooth muscle tumors and its mimics which is further established by immunohistochemistry. the correct diagnosis is indispensable for the reason that mtor inhibitors now can provide a ray of hope in the treatment of patients of pecoma. references 1. martignoni g, pea m, reghellin d, zamboni g, bonetti f. pecomas: the past, the present and the future. virchows arch 2008;452:119-132. 2. fadare o, parkash v, yilmaz y. perivascular epitheloid cell tumor (pecoma) of the uterine cervix associated with intraabdominal “pecomatosis”: a clinicopathological study with comparative genomic hybridization analysis. world j of surgical oncology 2004;2(1):35. 3. bleeker js, quevedo jf, folpe al. “malignant” perivascular epitheloid cell neoplasm: risk stratification and treatment strategies. sarcoma 2012;2012:541626. 4. bonetti f, pea m, martignoni g, doglioni c, zamboni g, capelli p, et al. clear cell ("sugar") tumor of the lung isa lesion strictly related to angiomyolipoma–the concept of a family of lesions characterized by the presence of the perivascular epitheloid cells (pec). pathology 1994;26:230-6. 5. pea m, bonetti f, zamboni g, martignoni g, fioredonati l. clear cell tumor and angiomyolipoma. am j surg pathol 1991;15:199-201. 6. zamboni g, pea m, martignoni g. clear cell sugar tumor of the pancreas: a novel member of the family of lesions characterized by the presence of perivascular epithelioid cells. am j surg pathol 1996;20:722-30. 7. fadare o. perivascular epithelioid cell tumor (pecoma) of the uterus: an outcome -based clinicopathologic analysis of 41 reported cases. adv anat pathol 2008;15:63-75. 8. lim gs, oliva e. the morphologic spectrum of uterine pec-cell associated tumors in a patient with tuberous sclerosis. int j gynecol pathol 2011;30(2):121-28. 9. schoolmeester jk, howitt be, hirsch ms, dal cin p, quade bj, nucci mr. perivascular epithelioid cell neoplasm (pecoma) of the gynecologic tract: clinicopathologic and immunohistochemical characterization of 16 cases. am j surg pathol 2014;38:176-88. 10. fadare o. uterine pecoma: appraisal of a controversial and increasingly reported mesenchymal neoplasm commentary. international seminars in surgical oncology2008;5:7. http://www.ncbi.nlm.nih.gov/pubmed/21293289 http://www.ncbi.nlm.nih.gov/pubmed/21293289 http://www.ncbi.nlm.nih.gov/pubmed/21293289 case report panacea journal of medical sciences, january-april,2016;6(1): 40-43 40 radiology of corrosive poisoning: report of three cases tyagi sagar1,*, hans parveen2, kumar hemant3, mohan virinder4 1,2,3junior resident, 4professor emeritus, dept. of radiodiagnosis, rohilkhand medical college and hospital, bareilly, u.p (243001), india. *corresponding author e-mail: sagartgi@gmail.com abstract ingestion of corrosive substances can produce severe injury to the gastrointestinal tract and can even result in death. the degree of damage depends on the type of the substance, morphologic form of the agent, and the quantity ingested. long term complications include stricture formation, antral stenosis, gastric ulcers and the development of esophageal carcinoma. three cases of corrosive poisoning diagnosed on the basis of barium studies and subsequent correlation with history of accidental corrosive intake in two and suicidal intake in one case are reported in this communication. the literature on the subject is scanty and hence the report. keywords: barium study, corrosive poisoning, radiology. introduction corrosives are a group of chemicals that cause tissue injury on contact. they most commonly affect the gastro intestinal tract, respiratory system and the eyes. corrosive ingestion has devastating effects on the upper gastrointestinal tract and present major problems in management. ingestion of corrosives either accidentally by children (80%) and alcoholics or intentionally for the purpose of suicide is a common form of poisoning in india (1-2). acids and alkalis are the two primary types of agents responsible for caustic exposures. upon ingestion alkalis primarily damage the oropharynx and esophagus whereas acids usually involve the distal part of esophagus and stomach. the acid pools in the antrum causing gastric outlet obstruction secondary to cicatritialantral stenosis(3). case history 1 a 22-year-old male presented to the ent department of our hospital with a history of accidental ingestion of acid 10 months back. he gave history of ingestion of mustard oil and water soon after. history of vomiting was present with difficulty in swallowing. his vital signs were normal. patient was afebrile. routine laboratory investigations were normal. on clinical examination the posterior pharyngeal wall was congested with a whitish patch on the tonsillar pillars. abdominal examination revealed tenderness and guarding. he was referred to the radiology department for a barium swallow examination. the barium swallow study revealed smooth narrowing of the lower half of the thoracic esophagus with minimal dilatation of the proximal segment. visualized portion of stomach revealed complete effacement of gastric rugae (fig. 1). fig. 1: barium swallow examination of case 1 the study was then extended to evaluate stomach and duodenum which revealed reduced capacity of stomach with absent peristalsis and smooth contour of stomach wall (fig. 2). tyagi sagar et al. radiology of corrosive poisoning: report of three cases panacea journal of medical sciences, january-april,2016;6(1): 40-43 41 fig. 2: small sized stomach with smooth contours, loss of peristalsis and antral narrowing evidence of gross narrowing of pylorus of stomach with delayed passage of barium through the duodenum was noted (fig. 3). thus the diagnosis of benign stricture of the esophagus and corrosive stricture of antrum of stomach with linitis plastic type appearance of stomach due to corrosive poisoning was made. fig. 3: gross antral and pyloric narrowing and delayed passage of the barium contrast case history 2 a 35-year-old male presented in the surgical services of our hospital with the complaints of dysphagia and occasional vomiting since last 4 months and was referred to the radiology department for a barium swallow examination with the provisional diagnosis of achalasia cardia. fig. 4: barium swallow examination of case 2 the barium swallow examination revealed smooth narrowing of lower third of the esophagus with minimal dilatation of the upper third (fig. 4). no peristalsis was noted in the esophagus and there was no obstruction to the passage of the contrast in to the stomach. the study was extended to evaluate the stomach and duodenum, which revealed a small sized, contracted, aperistaltic stomach with presence of multiple ulcers at the greater curvature and gross narrowing at the gastric pylorus and antrum (fig. 5 and fig. 6). fig. 5: continuous filling of the esophagus and stomach suggesting involvement of the gastric esophageal junction the gastro-esophageal junction was patulous. the gastric emptying time was markedly delayed with a small trickle of the contrast identified with great difficulty. the patient was asked about the history of any corrosive intake which he denied initially but admitted having ingested acid accidently about 7 months back. tyagi sagar et al. radiology of corrosive poisoning: report of three cases panacea journal of medical sciences, january-april,2016;6(1): 40-43 42 fig. 6: delayed film with same findings case history 3 a 26-year-old female presented with vomiting, loss of weight and pain in the abdomen for last one year. clinical examination revealed an emaciated and anaemic patient. local examination was unremarkable. she was referred to the radiology department with a provisional diagnosis of gastric malignancy with a request for barium meal study for evaluation. the study revealed normal passage of barium through the esophagus with no narrowing or filling defects. the stomach was however, reduced in size with no peristalsis. the gastric mucosa was completely effaced with narrowing and ulceration at the antrum (fig. 7). fig. 7: barium meal examination of case 3 the gastric emptying time was delayed. the barium meal findings were highly suggestive of corrosive poisoning. upon questioning, the patient agreed that she had drunk acid one and half years in a suicide attempt. discussion ingestion of corrosive substances, either accidentally or intentionally for suicide, is a common form of poisoning(1-2). both acid and alkali cause fibrosis and cicatrization. the nature of injury depends on the nature of corrosive agent consumed (acid or alkali), its physical state, amount, concentration of the agent consumed and the duration of contact with the mucosa(4). as acid intake accounts for only 5% of all reported cases, the knowledge about the radiological spectrum of injuries to upper gastrointestinal tract due to corrosive acidic substance is scanty. robert(5) reported the first case of corrosive induced pyloric stenosis while ciftci et al(6) reported gastric outlet obstruction in 5% cases of acid ingestion. acid induces coagulation necrosis with eschar formation which may limit tissue penetration. late sequelae include stricture formation and gastric outlet obstruction. stricture formation may become symptomatic within 3 months or may even manifest a year later. symptoms of early satiety and weight loss may suggest gastric outlet obstruction. this however, tends to occur less frequently than stricture formation,with an incidence of 4 cases out of 214 in one study(7). few earlier studies have suggested that acid cause maximal damage to stomach and minimal damage to the esophagus because of relative resistance of squamous epithelium to acids, rapid transit through the esophagus due to low viscosity and less specific gravity, reservoir function of stomach allowing large volume of acids, and reflex pylorospasm increasing the contact time between the acid and the stomach mucosa(8-9). we tend to agree with this observation as all our patients had swallowed acid and were found to have evidence of gastric outlet obstruction and ulcer formation. zargar et al(1) reported 41 cases were esophageal injury was seen in 87.5% cases, gastric injury in 85.4% and duodenal injury in 34.1% cases. they concluded that acid injury of ugi tract is a serious condition that effects esophagus and stomach equally and results in high mortality and morbidity. isolated stomach injury although rare has been reported as a diffuse injury, which results following ingestion on an empty stomach. similarly gastric injury is believed to be less common with alkalis as they are neutralized by the acidic contents; however one study reported evidence of gastric injury in 93% of patients with alkali ingestion(2). after a latent period of 4-6 weeks patients present with persistent vomiting, early satiety, and post prandial fullness(10-11). vomiting, loss of weight and decreased oral intake remains the most noticeable features. retractive phase is characterized by progressive fibrosis which gives rise to symptoms of esophageal and gastric outlet obstruction. obstructive symptoms usually tyagi sagar et al. radiology of corrosive poisoning: report of three cases panacea journal of medical sciences, january-april,2016;6(1): 40-43 43 appear within 2-3 weeks of corrosive ingestion but may sometimes be delayed for many months. grossly the stomach appears to be firm, contracted, and nodular. the lumen may be completely obliterated. in most of the cases, the only change is scarring of the pyloric antrum or the pyloric ring with surrounding adhesions. the diagnosis is easy in those cases where history of corrosive ingestion is available. upper gi contrast studies remain a useful diagnostic tool in patients with associated esophageal stricture. later changes include blurring of mucosa, intramural pseudo diverticulosis, deep linear ulcers with intramural dissection, retention and pocketing of contrast and intramural gas collection. the stomach may show evidence of ulceration, bullae and pseudopolyps(1-2). late complications include esophageal stricture, gastric cicatrization and cancer of the esophagus. corrosive injury most often causes pyloric or antral stenosis though shortening and irregularity of lesser curvature and hour glass deformity of stomach may also occur. gastric outlet obstruction due to antral or pyloric stenosis is less common as compared to esophageal stricture. early surgical intervention remains the treatment of choice with the aim to restore normal passage for food from stomach to small intestine. partial gastrectomy with billrothtype i reconstruction remains the procedure of choice in patients with complete luminal obstruction. conclusion three cases of corrosive ingestion resulting in advanced changes in stomach are reported. all cases referred for barium swallow examination, showing normal esophagus or benign stricture formation should have barium meal examination done to know about the status of stomach and duodenum. moreover in all cases of dysphagia/vomiting in young patients, it should be mandatory to extend the barium swallow examination to barium meal studies so that the cases of stomach injury are not missed, increasing the morbidity and mortality. also it is a simple opd procedure that is also cost effective. conflict of interest: none source of support: nil references 1. zargar sa, kochhar r, nagi b, mehta s, mehta sk. ingestion of corrosive acids: spectrum of injury to upper gastrointestinal tract and natural history. gastroenterology 1989;97:702-7. 2. zargar sa, kochhar r, nagi b, mehta s, mehta sk. ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. am j gastroenterol 1992;87:337-41. 3. sharma s, debnath pr, agrawal ld, gupta v. gastric outlet obstruction without esophageal involvement: a late sequelae of acid ingestion in children. j indian assoc pediatr surg 2007;12:47-9. 4. lahoti d, broov s. corrosive injury to upper git. ind journ gastroenterol 1993;12:135-41. 5. howard kg, holmes cl. pyloric stenosis caused by ingestion of corrosive substances: report of case. surg clin north am 1948;28:1041-56. 6. ciftci ao, senocak me, buyukpamukcu n, hicsonmez a. gastric outlet obstruction due to corrosive ingestion: incidence and outcome. pediatr surg int 1999;15:88-91. 7. ramasamy k, gumaste vv. corrosive ingestion in adults. j clin gastroenterol 2003;37(2):119-24. 8. dilwari jb, singh s, rao pn. corrosive acid ingestion in man – clinical and endoscopic study. gut 1984;25:183-7. 9. chodak gw, passaro e jr. acid ingestion: need for gastric resection. jama 1978;230:225-6. 10. howard kg, holmes cl. pyloric stenosis caused by ingestion of corrosive substances: report of case. surg clin north am 1948;28:1041-56. 11. zamir o, hod g, lemau oz, mogle p, nissan s. corrosive injury to the stomach due to acid ingestion. am surg 1985;51:170-2. panacea journal of medical sciences 2022;12(2):284–288 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article evaluating the efficacy of urinary trypsinogen-2 dipstick test in diagnosing acute pancreatitis manoj kumar sethy1, manita tamang1,*, dhirendra nath soren1, jaganath subedhi1, m sivarama krishna1 1dept. of general surgery, m.k.c.g. medical college, berhampur, odisha, india a r t i c l e i n f o article history: received 17-03-2021 accepted 02-08-2021 available online 17-08-2022 keywords: acute pancreatitis negative predictive value positive predictive value urinary trypsinogen-2 dipstick test a b s t r a c t background: acute pancreatitis (ap) is a very common cause of acute abdomen in emergency department. the disease may vary from mild self-limiting symptoms to multi organ failure and has high mortality rate. although most of the cases are treated by mild symptomatic treatment but severe cases require intensive monitoring, so early diagnosis and goal directed treatment is very essential to reduce mortality and morbidity of disease. aims and objective: the present study aims to know the efficacy of urinary trypsinogen-2 dipstick test in early diagnosis of acute pancreatitis. materials and methods: the prospective study sample included 98 patients who were presented to emergency department of maharaja krishna chandra gajapati medical college & hospital (mkcgmch), berhampur between august 2018 and july 2020 with acute severe pain abdomen suggestive of acute pancreatitis. urine sample were obtained and results were recorded. blood sample of all the patients were sent for serum amylase, lipase. urinary trypsinogen (ut)-2 dipstick test, based on principle of immunochromatographic, was done at the time of admission and serum amylase and lipase were sent for all patients. serum lipase was done through calorimetric method and serum amylase was done through coupled enzymatic assay method. ultrasonography (usg) and contrast-enhanced computed tomography (cect) abdomen were sent after 4-5 days of admission and final diagnosis was made on the basis of cect report. results: of 98 patients, 47 cases were final diagnosed to have acute pancreatitis. sensitivity and specificity of urinary trypsinogen (ut)-2 was found to be 91.48% and 94.11% respectively and positive predictive value (ppv) and negative predictive value (npv) was found to be 93.47% and 92.30% respectively. sensitivity, specificity, ppv and npv of serum amylase was found to be 76.5%, 74.5%, 74.5% and 74.5% respectively and similarly, sensitivity, specificity, ppv and npv was found to be 80.85%, 72.5%, 73.1% and 80.4% respectively. conclusion: urinary trypsinogen (ut)-2 dipstick test has high sensitivity, specificity, ppv and npv and therefore can be used reliably in emergency setting for diagnosis and thereby start a goal directed treatment and thus, reduce the mortality and morbidity of the disease. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com * corresponding author. e-mail address: manitatamang1992@gmail.com (m. tamang). 1. introduction acute pancreatitis (ap) is defined as the form of disorder that is related to pancreas and it is characterized by edema and when severe, necrosis. it is common and challenging https://doi.org/10.18231/j.pjms.2022.054 2249-8176/© 2022 innovative publication, all rights reserved. 284 sethy et al. / panacea journal of medical sciences 2022;12(2):284–288 285 disease that can develop local and systemic complication. 1 ap can be categorized as a mild form (interstitial edematous pancreatitis) and severe form (necrotizing pancreatitis). the mild form is categorized by interstitial edema of the gland and minimal organ dysfunction and majority of the patients will have milder form of disease and the mortality is around 1%. severe form of pancreatitis is seen about 5-10% and is characterized by pancreatic necrosis, a severe systemic inflammatory response and multi-organ failure. 2 early diagnosis of pancreatitis is essential because goal directed treatment may improve the outcome of the disease. 3 ap clinical representation is very much alike like many other acute abdomen conditions, the diagnosis only on the basis of symptoms and signs is difficult. an atlanta classification has revised the standard form of performing diagnosing of ap. here, for the purpose to examine the acute condition of pancreatitis, assistance is taken from 2 or more criteria. the very first criteria is of analyzing serum as well as lipase >300 iu/l. a second criterion is for examining the abdominal pain. the third criteria is of characteristic finding in computed tomography (ct) scan. 4 none of the above is very effective in diagnosis of the disease in early stage. contrast enhanced ct-scan, although it is considered gold standard but it takes at least 72 to 96 hours to show characteristic finding for diagnosis. 5 trypsinogen, a precursor of trypsin is required for protein digestion. premature trypsin activation leads to pancreatic self-digestion. trypsinogen is a 25-kd pancreatic proteinase. in human pancreatic juice, there are three trypsinogen (tps) isoenzymes, namely, cationic (tps-1) and anionic tps (tps-2), and a minor isoenzyme (tps-3). 6 trypsinogen-2 is secreted in low concentration in normal individual. in the initial phase of the ap disease, it is strongly raised. further, it remains increased for the different other weeks and days. 7 however, for the purpose to examine the initial phase acute pancreatitis urinary trypsinogen-2 dipstick test is taken into consideration. it is effective as well as simple method of performing testing. moreover, dipstick test is used for the purpose to assess the concentration in urine trypsinogen-2. the given test can test up to 50 ng/ml. 8 this test is simple and can be taken through strip. if two lines occur in strip then the given thing will indicate positive result. one line will indicate negative result. in this urine can be dropped on strip and it can be read after 5 minutes. 9 after doing this study, we can analyse the efficacy of urinary trypsinogen-2 dipstick test for the purpose to examine the initial phase of ap. 2. materials and methods this prospective study encompasses 98 patients who were admitted to the emergency section with sudden onset of acute severe epigastric radiating to back and other symptoms suggesting of acute pancreatitis was admitted to general surgery department, maharaja krishna chandra gajapati medical college & hospital (mkcgmch) berhampur for evaluation of acute pancreatitis. it is a prospective study conducted between august 2018 and july 2020. study was approved by the institutional ethical committee of m.k.c.g, medical college & hospital on human subject research.urinary trypsinogen (ut)-2 dipstick test, based on principle of immunochromatographic, was done at the time of admission and serum amylase and lipase were sent for all patients. serum lipase was done through calorimetric method and serum amylase was done through coupled enzymatic assay method. ultrasonography (usg) and contrast-enhanced computed tomography (cect) was done for all patients at day 4-5 of admission, final diagnosis was made on the basis of cect report. 2.1. inclusion criteria 1. the patients who has the features of the acute pancreatitis. 2. an adults who is willing to give their consent. 2.2. exclusion criteria 1. this includes those individual who do not want to participate in research. 2. all the people who do not want to give their informed consent. 3. the cases that are associated with the pancreatic cancer as well as critical condition of pancreatitis. 2.3. patient data collection and evaluation all the selected patients were resuscitated with intravenous fluids and analgesics. in this stage the medical details of the patients is carried out along with the physical analysis and it is recorded in standard proforma. in this dipstick test is used for the purpose to analyse the urine of patients. serum amylase and serum lipase level estimation tests with other routine test were also simultaneously sent to laboratory for these patients. data was collected according the predesigned standard case proforma and compiled and tabulated in microsoft® excel and statistical analysis was done using ibm statistical packages for social science (spss) version22.0 and using appropriate formulas. 3. results 3.1. following is the result examined from the conducted analysis there were around 98 patients who were diagnosed with the feature of suggestive pancreatitis. thus, they were taken in the study. around (16.32%) were in age group of 2130 years, 33 patients (33.62%) in 31-40 years, 40 patients (40.82%) in 41-50 years, 8 patients (8.16%) in 51-60 years and 1 patient (1.02%) >60 years. the very first figure entails 286 sethy et al. / panacea journal of medical sciences 2022;12(2):284–288 about the age distribution of cases. here, it is assessed that majority of the individual belongs to age category of 31-40 years. the standard deviation for the same is 8.34. fig. 1: age distribution. out of 98 patients there were around 11 females as well as 87 were males. however, their ratio was 7.9:1. figure 2 depicts gender distribution. fig. 2: gender distribution there were 47.9% patients who are identified with the condition like acute pancreatitis. but, rest of the individuals were diagnosed with the condition of abdominal pain and it is not because of the pancreatitis. this thing is presented in 3rd figure. the table that is given below entails regarding the reasons behind the acute pain. table 1: other causes of acute pain abdomen: causes number percentage (%) acute gastritis 26 50 acute calculus cholecystitis 11 21.56 acute acalculous cholecystitis 2 3.9 hollow viscus perforation 6 11.7 abdominal malignancy 4 7.8 liver abscess 2 3.9 total 51 100 fig. 3: cause of acute pain abdomen 3.2. serum amylase and lipase there is a limit of around to 300iu/l of serum amylase and lipase and it is taken as the cut off for the purpose to consider the case of acute pancreatitis. there were 36 positive results that were true. however, 38 negative results that were consider as true. 11 negative report followed by 13 positive report that was consider as false with sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of 76.5%, 74.5%, 74.5% and 74.5% respectively. serum lipase gave 38 true positive reports, 37 true negative, 14 false positive report and 9 false negative reports with sensitivity, specificity, ppv and npv of 80.85%, 72.5%, 73.1% and 80.4% respectively. table 2: analysis of serum amylase: serum amylase (iu/l) acute pancreatitis others >300 36 (true positive) 13 (false positive) ≤300 11 (false negative) 38 (true negative) table 3: analysis of serum lipase: serum lipase (iu/l) acute pancreatitis others >300 38 (true positive) 14 (false positive) ≤300 9 (false negative) 37 (tue negative) 3.3. ultrasound of abdomen here, ultrasound was conducted for the purpose to examine acute pain related with acute pancreatitis. here, bulky head as well as peri-pancreatic fluid are consider as some of conditions that were associated with the acute pancreatitis. out of 98 cases, 39%of cases were diagnosed as a case of acute pancreatitis and rest 61% to have other disease or had normal reports as shown in figure 4. sensitivity, specificity, ppv and npv was found to be 63.08%, 88.23%, 84.21% and 75% respectively. sethy et al. / panacea journal of medical sciences 2022;12(2):284–288 287 fig. 4: usg diagnosis of acute pain abdomen 3.4. urinary trypsinogen-2 dipstick test out of 47 cases of acute pancreatitis, ut-2 was positive in 43 cases (true positive), negative in 48 cases (true negative), falsely positive in 3 cases (false positive) and falsely negative in 4 cases (false negative). hence in our study sensitivity, specificity, ppv and npv of ut-2 was found to be 91.48%, 94.11%, 93.47% and 92.30% respectively. table 4: analysis of urinary trypsinogen-2 dipstick test urinary trypsinogen-2 dipstick test acute pancreatitis others positive 43 (tue positive) 3 (false positive) negative 4 (false negative) 48 (tue negative) 4. discussion acute pancreatitis continues to be a diagnostic and therapeutic challenge due to lack of a single pathognomonic laboratory test or a clinical sign. early aggressive fluid resuscitation is recommended by the clinical practice guidelines and is a long-established corner stone in the initial management of acute pancreatitis. 9 however, for instituting early fluid therapy, the diagnosis of acute pancreatitis needs to be confirmed at the earliest. in order to digest protein, trypsinogen will be required. here, self-digestion of pancreatic occurs when premature trypsin will be activated. in this regard, it is examined that the trypsinogen will be around 25-kd pancreatic. 10 there are around three major types of trypsinogen (tps) isoenzymes examined in the juice of human pancreatic. it consists of minor isoenzyme, cationic and anionic tps. on the other hand, trypsinogen that is not active will be stored in the cytoplasmic zymogen granules. after this, it is secreted in the duct lumen and then it is sent to the small intestine. in the intestine, the aspect like enterokinase is activated. however, it can be said that the premature activation associated with the trypsinogen to the trypsin will be consider as the major pathophysiologic event. this finally leads to the acute pancreatitis. but, in the normal situation trypsinogen will be stowed in the fluid of pancreatic. here, very small amount will be entered in the circulation. here, because of no reason the trypsinogen-1 is higher than trypsinogen-2. 11 thus by performing ut-2 dipstick test on the spot at emergency setting we can diagnose a case of acute pancreatitis with very much accuracy. for the purpose to examine the acute pancreatitis, the laboratory maker takes help from the aspect like serum amylase and lipase. but, it is identified that in the serum amylase the concentration will immediately increases to the peak within several hours of diagnosis. but, there are some that only rose for 3 to 5 days and after sometime it will came back to normal. 8 this, it can be said that both severity of pancreatitis as well as serum amylase are not correlated with each other. serum lipase though its specific to pancreas but remains elevated for 8-14 days where as ut-2 remains elevated for up to 30 days. cect though is the most accurate method of diagnosis and assessment of severity of disease but cannot always perform because of its cost, limited availability and contrast related side effects and often fails to demonstrate the pancreatic necrosis in first 72-96 hours of disease. 5 in the present study with the population of 98 patients, a total of 47 patients were diagnosed to have acute pancreatitis and rest 51 were diagnosed to have other disease such as acute gastritis, acute calculus and acalculous cholecystitis, hollow viscus perforation, abdominal malignancy, liver abscess etc. the sensitivity, specificity, ppv and npv of ut-2 was high compared to serum amylase and lipase. it was found to be 91.4%, 94.11%, 93.4% and 92.30% respectively which was comparable to kemppainenen et al. (1997) 3 where sensitivity, specificity, ppv and npv was found to be 94%, 95%, 68% and 99% respectively. study conducted by abraham et al. (2011) 12 they found that the sensitivity, specificity, ppv and npv of ut2 was found to be 73.9%, 94.6%, 94.4% and 73.3% respectively. similarly, in the study conducted by anandh et al. (2016) 13 they found that the sensitivity, specificity, ppv and npv was found to be 90%, 84.5%, 80% and 93.5% respectively. jang et al. (2007) 8 found sensitivity and specificity of ut 100% and 96% respectively. similarly, nittala et al. (2017) 14 found sensitivity and specificity of ut as 100% and 85.71% respectively. in the study conducted by niveditha et al. (2016) 15 they found that sensitivity and specificity of urine trypsinogen-2 were found to be 97.2% and 93.75% respectively. 5. conclusion it can be concluded that urinary trypsinogen-2 dipstick test is consider as simple. it is very cheap as well as can be conducted easily with the help of strip. by using this method, the problem can be detected at the initial phase and thus individual can get timely treatment. this will reduce the rate of mortality related with given disease. 288 sethy et al. / panacea journal of medical sciences 2022;12(2):284–288 table 5: comparison of diagnostic accuracy of different tests parameters sensitivity specificity ppv npv serum amylase 76.5% 74.5% 74.5% 74.5% serum lipase 80.85% 72.5% 73.1% 80.4% usg 63.08% 88.23% 84.21% 75% urinary trypsinogen-2 91.48% 94.11% 93.47% 92.30% table 6: indices kemppainenen et al. 3 jang et al. 8 nittala et al. 14 niveditha et al. 15 abraham et al. 12 anandh et al. 13 present study sensitivity 94% 100% 100% 97.2% 73.9% 90% 91.4% specificity 95% 96% 85.71% 93.75% 94.6% 84% 94.11% ppv 68% 94.4% 80% 93.4% npv 99% 73.3% 92.5% 92.30% 6. acknowledgment we acknowledge all the patients who gave their consent for the study and helped in completing the study successfully. 7. authors contribution all the authors put equal contribution in collecting and analysing data and writing the final paper. 8. source of funding no financial support was received for the work within this manuscript. 9. conflict of interest the authors declare they have no conflict of interest. references 1. fisher we, anderson dk, windsor ja, dudeja v, pancreas fcb. schwartz’s principles of surgery. 11th edn. usa: mcgraw-hill education; 2019. p. 1429–515. 2. bhattacharya st, pancreas. bailey and love’s short practice of surgery. 27th edn. in: n w, pr o, a m, editors. the pancreas. boca raton: crc press; 2018. p. 1212–39. 3. kemppainen ea, hedström ji, puolakkainen pa, sainio vs, haapiainen rk, perhoniemi v, et al. rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis. n engl j med. 1997;336(25):1788–93. 4. banks pa, bollen tl, dervenis c, gooszen hg, johnson cd, sarr mg, et al. classification of acute pancreatitis–2012: revision of the atlanta classification and definitions by international consensus. gut. 2013;62(1):102–11. 5. bouwense sa, gooszen hg, santvoort hc, besselink mg. shackelford’s surgery of the alimentary tract. 8th edn. in: demeester s, matthews j, mcfadden dw, fleshman j, editors. acute pancreatitis. philadelphia: elsevier;. p. 1076–84. 6. petersson u, appelros s, borgström a. different patterns in immunoreactive anionic and cationic trypsinogen in urine and serum in human acute pancreatitis. int j pancreatol. 1999;25(3):165–70. 7. kimland m, russick c, marks wh, borgström a. immunoreactive anionic and cationic trypsin in human serum. clin chim acta. 1989;184(1):31–46. 8. jang t, uzbielo a, sineff s, naunheim r, scott mg, lewis lm, et al. point-of-care urine trypsinogen testing for the diagnosis of pancreatitis. acad emerg med. 2007;14(1):29–34. 9. chen yt, chen cc, wang ss, chang f, lee sd. rapid urinary trypsinogen-2 test strip in the diagnosis of acute pancreatitis. pancreas. 2005;30(3):243–7. 10. petersson u, appelros s, borgström a. different patterns in immunoreactive anionic and cationic trypsinogen in urine and serum in human acute pancreatitis. int j pancreatol. 1999;25(3):165–70. 11. kimland m, russick c, marks wh, borgström a. immunoreactive anionic and cationic trypsin in human serum. clin chim acta. 1989;184(1):31–46. 12. abraham p. point-of-care urine trypsinogen-2 test for diagnosis of acute pancreatitis. j assoc physicians india. 2011;59:231–2. 13. anandh p, rekha a. to evaluate the efficacy of urinary trypsinogen 2 dipstick test in diagnosing acute pancreatitis. j evid based med healthcare. 2016;3(64):3501–9. doi:10.18410/jebmh/2016/752. 14. nittala r, basheer otm, sasi mp. acute pancreatitis: a study of urine trypsinogen-2 measurement as a screening test. int j res med sci. 2017;2(3):897–902. 15. niveditha sc, rigved n, kartheek s, srujith ch, kumar aa. comparison of urine trypsinogen with serum amylase and lipase in acute pancreatic-case study. int j scientific res. 2016;5(5):159– 61. author biography manoj kumar sethy, associate professor manita tamang, junior resident dhirendra nath soren, assistant professor jaganath subedhi, assistant professor m sivarama krishna, junior resident cite this article: sethy mk, tamang m, soren dn, subedhi j, krishna ms. evaluating the efficacy of urinary trypsinogen-2 dipstick test in diagnosing acute pancreatitis. panacea j med sci 2022;12(2):284-288. http://dx.doi.org/10.18410/jebmh/2016/752 original research article doi: 10.18231/2348-7682.2017.0020 panacea journal of medical sciences, may-august,2017;7(2): 68-71 68 comparison between 70 degree endoscopy, direct laryngoscopy and ct scan in t staging of laryngeal cancer parul sobti1, vivek harkare2, sonali khadakkar3, rahul varma4, prajakta gupta5 1senior resident, 2hod, 3assistant lecturer, 4,5junior resident, dept. of ent, nkp salve institute of medical sciences & research centre, nagpur, maharashtra *corresponding author: email: parulsobti@yahoo.com abstract the purpose of the study was to study and compare the importance of 70 degree endoscopy, direct laryngoscopy and ct scan in showing the extent of laryngeal tumours which would then decide the course of treatment for the patient. a total of 25 patients were included in the study and all patients underwent 70 degree endoscopy, direct laryngoscopy and ct scan examination. the ct scan findings were taken as gold standard and the t staging of the laryngeal tumours was compared with 70 degree endoscopy and direct laryngoscopy which was done using cohens kappa statistics. the sensitivity of 70 degree endoscopy in staging t1 laryngeal tumors was 100%, t2 tumors was 57.1%, t3 tumors was 62.5 % and t4 tumors was 0. the overall staging accuracy of 70 degree endoscopy was 0.44. the sensitivity of direct laryngoscopy in staging t1 laryngeal tumors was 100%, t2 tumors was 100%, t3 tumors was 62.5 % and t4 tumors was 0. the overall staging accuracy of direct laryngoscopy was 0.56. keywords: 70 degree endoscopy, direct laryngoscopy, ct scan t staging, laryngeal cancer. introduction cancer of the larynx remains the second most common head and neck malignancy, constituting 25% of all tumors. in 2002, 8,900 new cases of larynx cancer were predicted with a 3.5:1 male to female ratio and a total of 3,700 cancer deaths associated with these malignancies.(1) for supraglottic tumors, patients will often describe pain, sore throat, otalgia, dysphagia, foreign body sensation, and, if the cancer extends to the vocal folds, hoarseness. patients with supraglottic tumours frequently have cervical lymph node metastases. glottis cancer nearly always causes hoarseness as the initial symptom, with some patients experiencing a chronic cough or need for throat clearing. it is rare for true vocal cord cancers without extension outside the glottis to metastasize to cervical lymph nodes. subglottic tumors are very rare and have similar symptoms, but are known to spread to cervical lymph nodes.(2) office endoscopy is critical in laryngeal cancer patients to assess not only the exact structures involved by the tumour, but also to evaluate the mobility of the true vocal cords, which is important in staging of laryngeal cancers.(2) imaging studies give important information regarding the extent of the tumour which helps to stage the cancer and plan treatment. for example, invasion of the pre-epiglottic space, paraglottic space, or thyroid cartilage are features that can be seen on imaging but not on physical examination. cervical lymph nodes are evaluated as well.(2) imaging studies also help in the post-therapeutic surveillance and follow-up of patients with laryngeal cancers.(3) for patients with suspicious laryngeal lesions, tissue diagnosis is accomplished by biopsy in the operating room, during the laryngoscopy, precise tumor mapping can be performed. in this study we compared the extent of laryngeal cancer by t staging between 70 degree endoscopy, direct laryngoscopy and ct scan. materials and method this is a retrospective study that was carried out in the department of e.n.t for a period of two years, from october 2013 to september 2015, in a tertiary care hospital. patients of either sex, above the age of 10 years and who presented with a laryngeal lesion which was diagnosed as laryngeal cancer by histopathological examination were included in the study. each patient was thoroughly examined clinically, including indirect laryngoscopy. this was followed by routine investigations, plain x-ray neck (ap/lateral) and ba swallow wherever required, endoscopic examination of the laryngeal and laryngopharyngeal regions with 70 degree endoscope, direct laryngoscope under required anesthesia and contrast enhanced ct examination of the neck. histopathological examination was done in all cases. a total of 25 patients were included in this study. 70 degree endoscopy: a karl storz 70 degree, 4mm rigid endoscope was used for examination of the larynx and laryngopharynx. the procedure was explained to the patient. the patient’s soft palate and posterior tongue were anaesthetized with 4% xylocaine spray (lidocaine). cect neck: after taking written and informed consent, contrast enhanced ct scan examination was done by mdct 16 slice, toshiba activion. axial, parul sobti et al. comparison between 70 degree endoscopy, direct laryngoscopy and ct scan in…. panacea journal of medical sciences, may-august,2017;7(2): 68-71 69 coronal and saggital slices with 3 mm thickness were acquired after intravenous, iodinated contrast media injection at a dose of 1.0–2.0 ml/kg, and 60–76% concentration, with the patient in supine position with neck extension, during calm respiration and without deglutition. very thin sections (1.0–1.5 mm) with multiplanar reconstructions limited to the larynx were obtained. direct laryngoscopy: direct laryngoscopy with biopsy for suspected malignant growths was performed under general anesthesia without neuromuscular blockage and intraoral endotracheal intubation. the patient was placed in the ‘sniffing the morning air’(4) position i.e. the head well extended on the atlas and the neck flexed. the kleinsasser laryngoscope with fibre optic channel for illumination was used. the laryngeal lesions were examined and biopsies were obtained. patients presenting with stridor underwent tracheostomy before undergoing direct laryngoscopy. the extent, i.e. t staging, of the diagnosed malignant laryngeal lesions was compared between direct laryngoscopy, 70 degree endoscopy and ct scan. taking ct scan as gold standard comparison of 70 degree endoscopy and direct laryngoscopy for staging and extent of the malignant lesions was done using cohens kappa statistics. results an overall population of 25 patients was included in this study, of whom 23 (92%) were males and 2 (8%) were females. the highest incidence was seen in the 6th decade i.e. 10 patients (40%). out of the 25 cases of laryngeal malignancy 24 patients (96%) had squamous cell carcinoma and 1 (4%) patient had verrucous carcinoma on histopathological examination. based on ct scan (taken as gold standard), 2 (8%) malignancies had t1 staging, 7 (28%) malignancies had t2 staging and 8 (32%) malignancies had t3 and t4 staging each. based on 70o endoscopy, 5 (20%) malignancies had t1 stage, 7 (28%) malignancies had t2 and 13 (52%) had t3 staging. there were no cases staged as t4. using direct laryngoscopy, 2 (8%) malignancies had t1 stage10 (40%) malignancies had t2 staging and 13 (52%) malignancies had t3 staging. there were no cases staged as t4. table 1: distribution of patients with laryngeal malignancies according to t staging diagnosed by 70 degree endoscopy, direct laryngoscopy and ct t stage ct scan 70 degree endoscopy direct laryngoscopy t1 2 (8%) 5 (20%) 2 (8%) t2 7 (28%) 7 (28%) 10 (40%) t3 8 (32%) 13 (52%) 13 (52%) t4 8 (32%) 0 0 total 25 25 25 on comparing 70 degree endoscopy to ct scan findings there were 2 cases of t1, 4 cases of t2 and 5 cases of t3 stage that showed perfect agreement between the methods. eight cases of t3 staging on 70o endoscopy were diagnosed as t4 by ct scan. further, 3 cases of t2 staging on 70o endoscopy were diagnosed as t3 on ct scan. the overall agreement between two methods was obtained using cohen’s kappa coefficient. the estimate obtained was 0.2424 (95% ci: -0.0208 – 0.5057) with standard error of 0.1343 indicating fair agreement. the z-statistic obtained was 1.8049 with a p-value of 0.0355 (p < 0.05). this implies the agreement between the two methods is not by chance. the overall staging accuracy of 70 degree endoscopy was 0.44 (95% ci: 0.244 – 0.651). table 2: validation parameters for 70o endoscopy compared to ct scan statistical parameter stages t1 t2 t3 t4 sensitivity 100 57.1 62.5 0.000 specificity 86.9 83.3 52.9 100 on comparing direct laryngoscopy to ct scan findings two cases were identified with t1 staging by both the methods, while 7 were identified as t2 and 5 cases identified as t3 by both. there were 8 cases identified as t3 by direct laryngoscopy and t4 by ct scan. three cased were identified as t2 on direct laryngoscopy and t3 on ct scan. cohen’s kappa coefficient was obtained on the data set which results into an estimate of 0.3848 (95% ci: 0.1127 – 0.6569) and standard error of 0.1388 indicating fair agreement. the z-statistic obtained was 2.7723 with associated pvalue of 0.0027 (p <0.05). this implied that the estimated kappa coefficient was not a chance occurrence. the overall staging accuracy of direct laryngoscopy was 0.56 (95% ci: 0.349 – 0.756). table 3: validation parameters for direct laryngoscopy compared to ct scan statistical parameter stages t1 t2 t3 t4 sensitivity 100 100 62.5 0.00 specificity 100 83.3 52.9 100 discussion in our study out of 25 patients, 23 (92%) were males and 2 (8%) were females. in a study by aragao jr agm et al,(5) out of 39 patients of laryngeal cancer, thirty-three patients (84.6%) were men and six (15.4%) women, corresponding to men: women ratio of 5.5:1. in our study the highest incidence was seen in the 6th decade i.e. 10 patients (40%). joshi et al(3) reported that the mean age of laryngeal carcinoma is between 50 parul sobti et al. comparison between 70 degree endoscopy, direct laryngoscopy and ct scan in…. panacea journal of medical sciences, may-august,2017;7(2): 68-71 70 and 70 years. in our study, out of the 25 cases of laryngeal malignancy 24 patients (96%) had squamous cell carcinoma and 1 (4%) patient had verrucous carcinoma on histopathological examination. in our study out of 25 cases of laryngeal malignancies 2 cases (8%) presented in the t1 stage, 7 cases (28%) presented in the t2 stage and 8 cases (32%) each presented in the t3 and t4 stage. mastronikolis et al(6) in their study reported that more than 95% of laryngeal tumors are squamous cell carcinomas. in a study by iseh kr et al,(7) out of 37 cases of laryngeal tumours, histological diagnosis was obtained for 30 cases out of which 20 (66.7%) showed squamous cell carcinoma. in our study, out of 25 cases of laryngeal malignancies there were 2 (8%) cases staged as t1, 7 (28%) cases staged as t2, 8 (32%) cases staged as t3 and t4 each. in a study by aragao jr. agm et al(5) 39 patients of laryngeal cancer (supraglottic) were studied retrospectively. there were 5 (12.82%) cases staged as t2, 23 (58.97%) staged as t3 and 11(28.2%) staged as t4. there were no cases staged as t1. in a study by rashad rafiq matoo et al(8) newly diagnosed 25 patients with laryngeal and hypo pharyngeal malignancies over a period of one and a half year from april 2014 to september 2015 were studied. out of a total of 25 patients, there were 12 (48%) patients with glottic malignancy out of which 7 (58.33%) belonged to t2 and 5 (41.67%) belonged to t3 class. there were 8 (32%) patients with supraglottic malignancy out of which 6 (75%) belonged to t2 and 2 (25%) belonged to t3 class. out of 5 (20%) patients with hypopharyngeal malignancy 4 (80%) patients belonged to t2 and 1 (20%) patient belonged to t3 class. in our study out of 25 cases of laryngeal malignancies 70 degree endoscopy correctly staged 11 cases (44%) and it failed to correctly stage 14 cases (56%) due to invasion of subglottis (3 tumours), preepiglottic space (3 tumours) and paraglottic and extralaryngeal spread (8 tumours). ct scan staged all cases correctly. on comparison, statistical analysis indicated a fair agreement between 70 degree endoscopy and ct scan in t staging of laryngeal malignancies. the sensitivity of 70 degree endoscopy in staging t1 laryngeal tumors was 100%, t2 tumors was 57.1%, t3 tumors was 62.5% and t4 tumors was 0. the overall staging accuracy of 70 degree endoscopy was 0.44. direct laryngoscopy correctly staged 14 cases (56%) and it failed to correctly stage 11 cases (44%) due to invasion of preepiglottic space (3 tumours) and paraglottic and extralaryngeal spread (8 cases). ct scan staged all cases correctly. on comparison, statistical analysis indicated a fair agreement between direct laryngoscopy and ct scan in t staging of laryngeal malignancies. the sensitivity of direct laryngoscopy in staging t1 laryngeal tumors was 100%, t2 tumors was 100%, t3 tumors was 62.5% and t4 tumors was 0. the overall staging accuracy of direct laryngoscopy was 0.56. in a study by zbaren p et al,(9) out of 40 cases of laryngeal carcinoma, clinical/endoscopic evaluation failed to correctly stage 17 tumors due to invasion of the paraglottic space (1 tumor), preepiglottic space (2 tumors), and extralaryngeal soft tissues (14 tumors). clinical/endoscopic evaluation had a staging accuracy of 57.5%. in a study by t. ferri et al,(10) the staging accuracy of direct laryngoscopy was 51.3% and ct scan was 70.1%. out of the 25 cases of laryngeal malignancies 70 degree endoscopy staged 5 cases (20%) as t1, 7 cases (28%) as t2 and 13 cases (52%) as t3. no case was staged as t4. 70 degree endoscopy correctly assessed 2 cases (8%) of t1 stage, 4 cases (16%) of t2 stage and 5 cases (20%) of t3 stage. 14 lesions (56%) were wrongly staged by endoscopy i.e. 3 cases (12%) as t1 stage, 3 cases (12%) as t2 stage and 8 cases(32%) as t3 stage. direct laryngoscopy staged 2 cases (8%) as t1, 10 cases (40%) as t2 and 13 cases (52%) as t3. no case was staged as t4. direct laryngoscopy correctly assessed 2 cases (8%) of t1 stage, 7 cases (28%) of t2 stage and 5 cases (20%) of t3 stage. 11 lesions (44%) were wrongly staged by direct laryngoscopy i.e. 3 cases (12%) as t2 stage and 8 cases(32%) as t3 stage. ct scan staged 2 cases (8%) as t1, 7 cases (28%) as t2 and 8 cases (32%) each as t3 and t4. all cases were correctly assessed. in a study by barbosa mm et al,(11) out of 52 glottic and supraglottic laryngeal squamous cell carcinoma patients, clinical endoscopic classification was correct in 40.38% of cases (40% for t1, 29.41% for t2, 46.43% for t3, and 50% in t4). in our study 70 degree endoscopy correctly assessed 8% of t1 stage, 16% of t2 stage and 20% of t3 stage and direct laryngoscopy correctly assessed 8% of t1 stage, 28% of t2 stage and 20% of t3 stage. in our study ct scan resulted in upstaging of 14 (56%) cases out of 25 cases of laryngeal cancer, as compared to endoscopy and substaging was not present in any case. charlin b et al(12) in 1989 compared endoscopic findings in 66 consecutive previously untreated cases of laryngeal cancer. ct scan alone under staged laryngeal cancer in 10.6% of cases, all of them being superficial spreading tumours within the larynx or juxta laryngeal. ct scan caused upstaging in 22.7% cases, all of them being deep invasion overlooked by endoscopy. ct was most useful in lesions initially classified as t2 and t3, which included all those reclassified by ct. none of the t1 lesions were upgraded by ct scan. in our study ct scan did not understage any tumour and caused upstaging in 14 (56%) as compared to endoscopy. out of these 3 cases (12%) staged as t1 parul sobti et al. comparison between 70 degree endoscopy, direct laryngoscopy and ct scan in…. panacea journal of medical sciences, may-august,2017;7(2): 68-71 71 on endoscopy were upstaged to t2, 3 cases (12%) staged as t2 on endoscopy were upstaged to t3 and 8 cases (32%) staged as t3 on endoscopy was upstaged to t4. ct scan was useful in lesion initially classified as t1, t2 and t3. lisa barbera et al(13) in a study of 1195 patients with laryngeal cancer showed that ct scan altered t class in 20.2% patients and most of them being upstages. in our study ct scan upstaged 56% of the cases. in the study by aragao jr agm et al,(5) ct scan resulted in upstaging of 38.5% lesions and substaging of 5.12% of lesions. in a study by rashad rafiq matoo et al(8) the comparison of clinical tumor staging with clinicradiological tumor staging of the patients under study was done. they observed that there were 10 (40%) patients in stage ii clinically and after radiological evaluation only 8 (32%) patients belonged to stage ii while as remaining 2 (8%) patients were upstaged to stage iv. there were 13 (52%) patients in stage iii clinically and after radiological evaluation 8 (32%) patients were in stage iii while as remaining 5 (38.46%) patients were upstaged to stage iv. there were 2 (8%) patients in stage iv clinically and after radiological evaluation 9 (36%) patients were recorded in stage iv. overall there were 7 patients (28%) who were upstaged which included 2 patients (8%) from stage ii and 5 patients (20%) from stage iii. conclusion for laryngeal tumours, staging accuracy of ct scan is the best. 70 degree endoscopy understages the tumours due to inability to see the hidden areas of the larynx and laryngopharynx. also 70 degree endoscopy and direct laryngoscopy understages tumours due to inability to see the extent of tumours into the paraluminal spaces and extra laryngeal region. thus, ct examination in laryngeal and laryngopharyngeal cancer is an extremely crucial step, after clinical examination and laryngoscopic evaluation, to know the extent of the tumour, on the basis of which further management is decided for the patient. references 1. smith rv, fried mp. advanced cancer of the larynx. byron j. bailey, jonas t. johnson, shawn d. newlands (eds). head & neck surgery—otolaryngology, volume 1. 4th ed. philadelphia: lippincott williams & wilkins; 2006. pp. 1758-59. 2. head and neck cancer: current perspectives, advances, and challenges. springer science & business media 2013. pp. 535. 3. varsha m joshi, vineet wadhwa, suresh k mukherji. imaging in laryngeal cancers. indian j radiol imaging 2012;22(3):209–226. 4. gray r. laryngoscopy and micro laryngoscopy. hugh dudley, david carter(eds). rob & smith’s operative surgery 4th ed. london: chapman & hall; 1994. pp. 25256. 5. aragaojr agm, de souza rp, rapaport a. computed tomography contribution to the staging of supraglottic squamous cell carcinoma. radiologia brasiliera 2007;40(4). 6. nikolaos s mastronikolis, theodoros a papadas, panos d goumas, irene-eva; head and neck. laryngeal tumors: an overview. atlas genet cytogenet haematol 2009;13(11):888-893. 7. iseh kr, abdullahi m, aliyu d. laryngeal tumours: clinical pattern in sokoto, northwestern nigeria. niger j med 2011;20(1):75-82. 8. rashad rafiq mattoo, sajad majid qazi, basharat rashid, zubair lone, junaid nazir dandroo. clinicoendoscopic and radiological assessment in the pretherapeutic staging of laryngeal and hypopharyngeal malignancies. j biol sci opin 2016;4(5):159-170. 9. zbären p, becker m, läng h. pre-therapeutic staging of laryngeal carcinoma: clinical findings, computed tomography, and magnetic resonance imaging compared with histopathology. cancer1996;77(7):1263-73. 10. ferri t, de thomasis g, quaranta n, bacchi g, bottazi d. the value of ct scans in improving laryngoscopy in patients with laryngeal cancer. european archives of otorhino-laryngology 1999;256(8):395-99. 11. barbosa mm, araujo v, boasquevisqu e, carvalho r, romano s. anterior vocal commissure invasion in laryngeal carcinoma diagnosis. laryngoscope 2005;115(4):724-730. 12. charlin b, brazeau-lamontagne l, guerrier b, leduc c. assessment of laryngeal cancer: ct scan versus endoscopy. journal of otolaryngology 1989;18(6):283-8. 13. lisa barbera. the role of computed tomography in the t classification of laryngeal carcinoma. cancer 2001;91(2):394-407. http://www.ncbi.nlm.nih.gov/pubmed/?term=zb%c3%a4ren%20p%5bauthor%5d&cauthor=true&cauthor_uid=8608501 http://www.ncbi.nlm.nih.gov/pubmed/?term=becker%20m%5bauthor%5d&cauthor=true&cauthor_uid=8608501 http://www.ncbi.nlm.nih.gov/pubmed/?term=l%c3%a4ng%20h%5bauthor%5d&cauthor=true&cauthor_uid=8608501 http://www.ncbi.nlm.nih.gov/pubmed/8608501 original research article doi: 10.18231/2348-7682.2017.0024 panacea journal of medical sciences, may-august,2017;7(2): 89-91 89 study of oxidative stress in vitiligo sushil pande1, madhur gupta2 1associate professor, dept. of dermatology, 2professor & head, dept. of biochemistry, nkp salve institute of medical sciences & research centre, nagpur, maharashtra *corresponding author: email: drsushilpande@gmail.com abstract vitiligo vulgaris is an autoimmune disease of the skin characterized by depigmented macules. apart from autoimmune etiology, damage to melanocytes by oxidative stress has been postulated as one of the causative factors in pathogenesis of vitiligo. the current study was conducted at our tertiary care center to estimate oxidative stress in the blood of patients suffering from vitiligo. a total of 40 patients were included after informed consent. all treatment-naïve patients of vitiligo of >15 years of age of either sex and those patients who have not received systemic treatment in the last 3months for vitiligo or topical treatment in the last 2 weeks were included. detailed history was taken and clinical assessment of vitiligo was done. venous blood samples were collected for estimation of malondialdehyde (mda), superoxide dismutase (sod) and glutathione peroxidase (gpx) which is considered as markers for oxidative stress in the blood. majority of vitiligo cases belonged to younger age groups. a total of 60% cases were in the age group of 16–25years followed by 20% in 26–35years. a total of 50% cases were having active or unstable disease while 50% cases were having stable disease. as assessed by mda, 35/36(97.22%) was found to have raised oxidant stress. as assessed by gpx, all i.e. 36/36 patients were (100%) were found to have raised oxidant stress. as assessed by sod, 34/36 (94.44%) were found to have raised oxidant stress. mean values of mda in our patients were 4.3±2.75sd nmol/ml. mean values of gpx in our patients were 2864±1008sd u/l. mean values of sod were 97.11±91.46sd u/ml. mean values of mda, gpx and sod in matched controls were 0.91±0.21sd nmol/ml, 6058.60±1694sd u/l and 189.43±23.57sd u/ml respectively. as compared to controls, increased mda levels and reduced gpx and sod levels were suggestive of oxidative stress in patients of vitiligo in our study. more studies of relatively larger sample size are required to further confirm these variations of mda, sod and gpx in the blood. keywords: vitiligo, oxidative stress, malondialdehyde, superoxide dismutase, glutathione peroxidase. introduction vitiligo or leukoderma is an acquired autoimmune skin disorder of pigmentation characterized by well demarcated depigmented macules and patches of different sizes and shapes. destruction of melanocytes due to autoimmune inflammatory process is considered to be the main pathogenesis of resultant depigmentation over the skin. however exact cause is unknown. different hypothesis has been put forward with regard to pathogenesis of vitiligo. damage to melanocytes due to oxidative stress has been reported as one of the etiological factors in causation of viltiligo.(1-2) oxidative stress is postulated to be one of the etiologic factors for decreased pigmentation in the vitiliginous area through modification of melanocyte antigens. various researchers have reported either increased antioxidant levels, no change or even decreased levels of markers like superoxide dismutase(sod), glutathione peroxidase (gpx), malondialdehyde (mda), nitric oxide (no), and catalase. during oxidative stress, molecular oxygen (o2) is reduced to form superoxide radicals. further, superoxide radicals undergo dismutase reaction to hydrogen peroxide(h2o2). this happens spontaneously or by enzyme superoxide dismutase (sod). we decided to estimate oxidative stress in the blood of patients suffering from vitiligo using sod, mda and gpx as markers for oxidative stress. materials and method this prospective cross sectional study was conducted in the department of dermatology, venereology and leprosy and department of biochemistry of our tertiary care hospital in central india after approval from institutional ethics committee. a total of 40 patients were included with an informed consent. the inclusion criteria were all clinically diagnosed cases of vitiligovulgaris, all patients >15years of age of either sex and untreated or treatment-naïve patients or those patients who have not received systemic treatment in the last 3 months for vitiligo or topical treatment in the last 2 weeks. the exclusion criteria were patients of segmental or localized vitiligo, patients on antioxidant medications and/or immune-suppressive during the last 3months for vitiligo, pregnant a lactating females and patients who have any concomitant systemic or dermatological disease. detailed history was taken and clinical examination was done in all subjects of the study group. venous blood samples were collected for estimation of mda, sod and gpx. estimation of mda: mda was measured by spectrophotometry method. the method was based on the fact that lipid peroxide condenses with 1-methyl 2 phenyl indole (mpi) under acidic conditions resulting in the formation of red chromophore. sushil pande et al. study of oxidative stress in vitiligo panacea journal of medical sciences, may-august,2017;7(2): 89-91 90 estimation of superoxide dismutase (sod): superoxide dismutase (sod) assay in whole blood samples was done according to 1983 randox kit by williams j.a et al.(3) this method employs xanthine and xanthine oxidase (xod) to generate superoxide radicals which react with 2-(4-iodophenyl)-3-(4-nitrophenol)-5phenyltetrazolium chloride (int) to form a red formazan dye. the superoxide dismutase activity is measured by the degree of inhibition of this reaction. one unit of sod is that which causes a 50% inhibition of the rate of the reduction of int under the conditions of the assay. estimation of glutathione peroxidase (gpx): assay of glutathione peroxidase (gpx) in whole blood samples was done by the paglia and valentine method(4) using randox kit as per manufacturer’s instructions. glutathione peroxidase (gpx) enzyme catalyzes glutathione (gsh) oxidation by the enzyme cumenehydroperoxide. in the presence of glutathione reductase (gr) and nadph the oxidised glutathione (gssg) is immediately converted to the reduced form along with concomitant oxidation of nadph to nadp+. blood levels of mda, sod, gpx and normal ranges as reported by the manufacturers are 0.8-1.3 nmol/ml, 164-240 u/ml and 4171-10881 u/l respectively. elevated mda indicated presence of oxidative stress while decreased levels of sod and gpx indicated presence of oxidative stress. data are expressed as mean ±sd. the chi square test and p values are used for the interpretation of results in which p value of less than0.05 is considered as statistically significant. results in our study, a total of 40 patients were enrolled. out of these 40 patients a sample was hemolyzed in 4 patients. a data of 36 patients was analyzed. a total of 18 patients (50%) were females and 18 patients were males (50%). majority of vitiligo cases belonged to younger age groups. a total of 60% cases were in the age group of 16–25 years followed by 20% in 26–35years. the most common type of vitiligo seen clinically is vitiligo vulgaris (75%) followed by 25% of acral vitiligo. leuokotrichia was seen in 26% cases. a total of 50% cases were having active or unstable disease while 50% cases were having stable disease. as assessed by mda, 35/36 (97.22%) was found to have raised oxidant stress. as assessed by gpx, all i.e. 36/36 patients were (100%) were found to have raised oxidant stress. as assessed by sod, 34/36 (94.44%) were found to have raised oxidant stress. mean values of mda in our patients were 4.3±2.75sd nmol/ml. mean values of gpx in our patients were 2864±1008sd u/l. mean values of sod were 97.11±91.46sd u/ml. mean values of mda, gpx and sod in matched controls were 0.91±0.21sd nmol/ml, 6058.60±1694sd u/l and 189.43±23.57sd u/ml respectively. discussion in our study, we observed that the most common age group affected by active vitiligo is 16–25years. there was no male or female preponderance observed in our study. however the study was hospital based and involving lesser number of patients as compared to studies done earlier. shajil et al(1) and danesh pazhooh et al(2) noted female preponderance in vitiligo. vitiligo vulgaris was found to be the most common clinical type of vitiligo observed in our study. oxidative stress is induced by reactive oxygen species (ros) generation. excess production of ros and insufficient protection by anti-oxidants results in tissue damage including that of melanocytes. it is also proposed that they may modify melanocyte antigens to trigger autoimmune response.(5) we observed significantly higher levels of mda in our patients indicating oxidative stress in 92.22% of cases of vitiligo. our study indicates that mda levels are elevated in patients of leukoderma as compared to controls. mda is an end product of lipid peroxidation. results of our study are in concordance with previous studies on estimation of mda levels in patients of vitiligo.(6-9) all of these studies are done in indian population suffering from vitiligo. results of our study and that of previous studies confirm mda as a reliable marker for increased oxidative stress. with regard of mda levels in subtypes of vitiligo, there was no statistically significant difference. our study measured serum levels of mda. shin et al suggested use of erythrocyte mda as more reliable and accurate marker for measurement of oxidative stress. they proposed that serum mda levels are too low to be reliable in many cases and erythrocyte mda reflect more accurately the oxidative stress in patients of vitiligo.(10) superoxide dismutase (sod) is an important antioxidant enzyme which converts the pro-oxidant superoxide into h2o2. sod, an antioxidant enzyme catalyzes the dismutation of superoxide anion (o2−) into o2and h2o2. in oxidative stress, to scavenge superoxide anions, sod is increased and catalase is reduced. it is not clear whether sod levels are elevated as a result of increased activity or decreased as a result of increased consumption in antagonizing oxidative stress. results are therefore conflicting in various clinical studies that had been done in the past. some studies done in the past have shown raised whole blood sod levels. a case control study of 100 patients of vitiligo showed significantly higher levels in unstable or active vitiligo patients (90%) as compared to controls while in stable vitiligo a total of 92% had normal sod levels.(11) this study showed that oxidative stress is likely to be involved in the aetiopathogenesis of vitiligo, as indicated by the high levels of serum superoxide dismutase activity. sample size in this study sushil pande et al. study of oxidative stress in vitiligo panacea journal of medical sciences, may-august,2017;7(2): 89-91 91 was comparable to that of our study. some studies have shown raised erythrocyte sod(12) or raised sod in vitiligenous skin.(13) results as shown in our study showed decreased levels of sod as compared to controls. this is similar to findings by khan et al who reported that sod levels are significantly lower in 30 patients of vitiligo as compared to controls.(6) findings of low levels sod in the blood was comparable to low levels of sod in our study done on 40 patients of vitiligo. koca r et al also found increased levels of mda and low levels of sod in 27 patients of vitiligo.(14) more studies are therefore needed to exactly know whether sod are indeed increased due to enhanced activity or decreased due to enhanced consumption in neutralizing superoxide ions. glutathione peroxidase was found to be reduced in our study. studies done in the past reveal inconsistent pattern in the level of gpx. increased level of gpx is reported by passi et al(15) whereas agrawal et al reported decreased levels in vitiligo cases.(16) hazneci e et al reported increased levels of erythrocyte gpx.(17) zedan h et al reported low levels of gpx in patients of vitiligo as compared to controls.(18) gpx is an antioxidant enzyme like sod which prevents oxidative damage to the skin of vitiligo patients as a result of disturbed oxidant-antioxidant system. trends of decreased sod and gpx and increased mda are similar to study done by karsali n et al(19) who studied pre-treatment oxidative stress in patients of vitiligo. in this study after nb-uvb phototherapy, mda was found to be reduced and sod and gpx were found to be elevated indicating role of phototherapy in reducing oxidative stress. conclusion in summary, blood estimation of mda, sod and gpx is relatively easy and simple to perform diagnostic tests to assess status of oxidative stress in patients of vitiligo. as compared to controls, increased mda levels and reduced gpx and sod levels were suggestive of oxidative stress in patients of vitiligo in our study. more studies of relatively larger sample size are required to further confirm these variations of mda, sod and gpx in the blood. references 1. shajil em, agrawal d, vagadia k, marfatia ys, begum r. vitiligo: clinical profiles in vadodara. indian j dermatol venerol. 2006;51(2):100–4. 2. daneshpazhooh m, mostofizadeh gm, behjati j, akhyani m, robati rm. antithyroid peroxidase antibody and vitiligo: a controlled study. bmc dermatology. 2006;6:3. 3. wooliams ja, wiener g, anderson ph, mc murray ch. variation in the activities of glutathione peroxidase and superoxide dismutase and in the concentration of copper in the blood in various breed crosses of sheep. res vet sci. 1983;34:253–6. 4. paglia de, valentine wn. studies on the quantitative and qualitative characterization of erythrocyte glutathione peroxidase. j lab clin med. 1967;70:158. 5. simon hu, haj-yehia a, levi-schaffer f. role of reactive oxygen species (ros) in apoptosis induction. apoptosis 2000;5:415–8. 6. khan r, satyam a, gupta s, sharma vk, sharma a. circulatory levels of antioxidants and lipid peroxidation in indian patients with generalized and localized vitiligo. arch dermatol res 2009;301:731–7. 7. jain d, misra r, kumar a, jaiswal g. levels of malondialdehyde and antioxidants in the blood of patients with vitiligo of age group 11-20 years. indian j physiol pharmacol 2008;52:297–301. 8. singh s, singh u, pandey s. study of total antioxidants status in indian vitiligo patients. egyptian dermatol online j 2011;7:1–7. 9. laddha nc, dwivedi m, gani ar, shajil em, begum r. involvement of superoxide dismutase isoenzymes and their genetic variants in progression of and higher susceptibility to vitiligo. free radic biol med 2013;65c:1110–25. 10. shin jw, nam km, choi hr, huh sy, kim swl. erythtocyte malondialdehyde and glutathione levels in vitiligo patients. ann dermatol. 2010 aug; 22(3):279– 283. 11. jain a, mal j, mehandiratta v, chander r, patra sk. study of oxidative stress in vitiligo. indian j clin biochem 2011;26:78-81. 12. yildirim m, baysal v, inaloz hs, kesici d, delibas n. the role of oxidants and antioxidants in generalized vitiligo. j dermatol 2003;30:104-8. 13. ravani pv, babu nk, gopal k, rama rao gr, rao ar, moorthy b, et al. determination of oxidative stress in vitiligo by measuring superoxide dismutase and catalase levels in vitiliginous and non-vitiliginous skin. indian j dermatol venereol leprol 2009;75:268-71. 14. koca r, armutcu f, altinyazar hc, gürel a. oxidantantioxidant enzymes and lipid peroxidation in generalized vitiligo. clin exp dermatol 2004;29:406-9. 15. passi s, grandinetti m, maggio f, stancato a, luca c. epidermal oxidative stress in vitiligo. pigment cell res. 1998;11(2):81–5. 16. agrawal d, shajil em, marfatia ys, begum r. study on the antioxidant status of vitiligo patients of different age groups in baroda. pigment cell res. 2004;17(3):289–94. 17. hazneci e, karabulut ab, oztürk c, batçioğlu k, doğan g, karaca s, et al. a comparative study of superoxide dismutase, catalase, and glutathione peroxidase activities and nitrate levels in vitiligo patients. int j dermatol. 2005;44:636-40. 18. zedan h, abdel-motaleb aa, kassem nm, hafeez ha, hussein mr. low glutathione peroxidase activity levels in patients with vitiligo. j cutan med surg 2015 marapr;19(2):144-8. 19. karsli n, akcali c, ozgoztasi o, kirtak n, inaloz s. role of oxidative stress in the pathogenesis of vitiligo with special emphasis on the antioxidant action of narrowband ultraviolet b phototherapy. j int med res. 2014 jun; 42(3):799-805. https://www.ncbi.nlm.nih.gov/pubmed/?term=koca%20r%5bauthor%5d&cauthor=true&cauthor_uid=15245542 https://www.ncbi.nlm.nih.gov/pubmed/?term=armutcu%20f%5bauthor%5d&cauthor=true&cauthor_uid=15245542 https://www.ncbi.nlm.nih.gov/pubmed/?term=altinyazar%20hc%5bauthor%5d&cauthor=true&cauthor_uid=15245542 https://www.ncbi.nlm.nih.gov/pubmed/?term=g%c3%bcrel%20a%5bauthor%5d&cauthor=true&cauthor_uid=15245542 https://www.ncbi.nlm.nih.gov/pubmed/15245542 http://www.ncbi.nlm.nih.gov/pubmed/?term=hazneci%20e%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=karabulut%20ab%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=ozt%c3%bcrk%20c%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=bat%c3%a7io%c4%9flu%20k%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=do%c4%9fan%20g%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=do%c4%9fan%20g%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=karaca%20s%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/?term=e%c5%9frefo%c4%9flu%20m%5bauthor%5d&cauthor=true&cauthor_uid=16101862 http://www.ncbi.nlm.nih.gov/pubmed/16101862/ http://www.ncbi.nlm.nih.gov/pubmed/?term=zedan%20h%5bauthor%5d&cauthor=true&cauthor_uid=25775636 http://www.ncbi.nlm.nih.gov/pubmed/?term=abdel-motaleb%20aa%5bauthor%5d&cauthor=true&cauthor_uid=25775636 http://www.ncbi.nlm.nih.gov/pubmed/?term=kassem%20nm%5bauthor%5d&cauthor=true&cauthor_uid=25775636 http://www.ncbi.nlm.nih.gov/pubmed/?term=hafeez%20ha%5bauthor%5d&cauthor=true&cauthor_uid=25775636 http://www.ncbi.nlm.nih.gov/pubmed/?term=hussein%20mr%5bauthor%5d&cauthor=true&cauthor_uid=25775636 http://www.ncbi.nlm.nih.gov/pubmed/25775636 http://www.ncbi.nlm.nih.gov/pubmed/25775636 http://www.ncbi.nlm.nih.gov/pubmed http://www.ncbi.nlm.nih.gov/pubmed/?term=karsli%20n%5bauthor%5d&cauthor=true&cauthor_uid=24709883 http://www.ncbi.nlm.nih.gov/pubmed/?term=akcali%20c%5bauthor%5d&cauthor=true&cauthor_uid=24709883 http://www.ncbi.nlm.nih.gov/pubmed/?term=ozgoztasi%20o%5bauthor%5d&cauthor=true&cauthor_uid=24709883 http://www.ncbi.nlm.nih.gov/pubmed/?term=kirtak%20n%5bauthor%5d&cauthor=true&cauthor_uid=24709883 http://www.ncbi.nlm.nih.gov/pubmed/?term=inaloz%20s%5bauthor%5d&cauthor=true&cauthor_uid=24709883 http://www.ncbi.nlm.nih.gov/pubmed/24709883 http://www.ncbi.nlm.nih.gov/pubmed/24709883 http://www.ncbi.nlm.nih.gov/pubmed/24709883 http://www.ncbi.nlm.nih.gov/pubmed/24709883 http://www.ncbi.nlm.nih.gov/pubmed 429 too many requests you have sent too many requests in a given amount of time. original research article doi: 10.18231/2348-7682.2017.0035 panacea journal of medical sciences, september-december 2017;7(3):131-135 131 effect of mobile phone use on hearing status of medical students of tertiary healthcare hospital nitin deosthale1,*, sonali khadakkar2, neeti kedia3, vivek harkare4, priti dhoke5, kanchan dhote6 1professor, 2senior resident, 3m.b.b.s. student, 4professor & hod, 5associate professor, 6senior resident, dept. of ent, nkp salve institute of medical sciences and research centre, nagpur, maharashtra, india *corresponding author: email: nvdeosthale@rediffmail.com abstract the present study was carried out to evaluate the hearing status in chronic mobile phone users and alteration in hearing status depending on years of mobile usage, per day use and longest dialogue duration in a day. this was a cross sectional observational study. preliminary questionnairewas asked to mbbs students of a medical college and 60 volunteers were selected who were using mobile phones for at least 1 year and not having any other causes of hearing loss. in the study group, dominant ear of the subjects was included and non-dominant ear was considered as a control group. pure tone audiometry was done to evaluate the hearing status. out of 60 subjects, in 76.66% subjects, right ear was dominant and in 23.33% of subjects, left ear was dominant for mobile use 52 (86.66%) dominant ears had normal hearing and 8 (13.33%) had hearing loss in high frequencies (4000 and 8000 hz). hearing was normal in nondominant ear of all subjects. mean hearing threshold in dominant ear was 10.54 + 5.75 db while in non-dominant ear, it was 6.67 + 3.76 db. the difference was statistically significant (p value <0.05). hearing loss in the dominant ear was seen in subjects who were using mobile phones for 1-3 hours per day, with total duration of use > 3years and in those with longest call duration of >30 minutes. our conclusion is that hearing threshold increases in dominant ear with long term use of mobile phone and hearing loss is more in higher frequencies in such subjects. keywords: audiometry, dominant ear, hearing loss, pure tone. introduction mobile phones are in use since 1983. it receives and transmits signals using electromagnetic fields (emf) in radiofrequency bands through a network of base stations. currently, most widely used digital mobile phone service is global system for mobile communications (gsm) which operates at 900 to 1800 mhz frequency bands.(1) medical literatures report that mobile phone use may cause lack of concentration, dizziness, discomfort, headache, skin burning sensation. more adverse health problems caused by mobile phones are sleep disturbances, impairment of short-term memory and even significant increase in the frequency of seizures in epileptic children, brain tumour, increased blood pressure. the effect of emfs leading to cancer is still a subject of debate and research.(2) the inner ear, is the direct recipient of electromagnetic radiations (emr), so it is a commonly affected organ. use of “hands-free” devices provide a much lower exposure to the radiofrequency fields than that of holding the handset against their head.(3) listening to music using headphones has become one of the most popular functions of mobile phones apart from making and receiving calls. usually, high intensity sound is delivered via headphones. hair cells of organ of corti are sensitive to chronic exposure to loud noise and don’t have regenerative properties. hence, the ear is at risk of exposure to noise from mobile phone as well as to the emr emitted by the device. substantial number of studies have been conducted to evaluate the effect of mobile phones on hearing. there is increased degree of hearing loss with its longterm use than its short-term use. the present study was conducted with the aims and objectives to evaluate the hearing status in chronic mobile phone users and the impact of long-term exposure to mobile phones, to study the effect of total duration use per day and total years of usage of mobile phone on hearing and to compare the hearing status of dominant versus nondominant ears of mobile phone users. material and methods it was a cross-sectional, observational study. it was carried out in the department of ent, tertiary health care institute of central india. institutional ethics committee approval was achieved. 60 healthy m.b.b.s. students of medical institute were selected, based on the preliminary questionnaire which included, if they use mobile phone or not, what is the average duration of their daily use of mobile phone, what is the maximum duration of a call, what is the total duration of usage (in years), which ear is often used with mobile phone (dominant ear) etc. those fulfilling inclusion criteria were included in the study. m.b.b.s. students of medical institute using mobile phones for at least a year and ready to participate in the study voluntarily were included in the study. students with hard of hearing due to tympanic membrane perforation, secretary otitis media, otosclerosis, exposure to loud noise without adequate protection, head injury, and ototoxic drug intake were excluded from the study. users of bluetooth devices, portable music players and hands-free devices nitin deosthale et al. effect of mobile phone use on hearing status of medical students…… panacea journal of medical sciences, september-december 2017;7(3):131-135 132 and the subjects with bilateral hearing loss were also excluded from the study. consent of participants was obtained after informing them about the purpose and the procedure of the study. dominant ear of the subjects was taken as study group and non-dominant ear (not used or rarely used with mobile phone) as control group. detail ent examination including otoscopic examination and tuning fork tests were done by senior ent surgeon to rule out any ear disease. pure tone audiometry was done using “elkon eda giga 3” audiometer and frequencies used were 250, 500, 1000, 2000, 4000 and 8000 hz. audiologist was not knowing about the dominant ear and non-dominant ear of the subject thus making it a single blind study. pure tone audiometry was done by using carhart and jerger’s technique (5 up and 10 down technique).(4) subjects having hearing threshold of 25db and below were considered as normal hearing and those having hearing threshold above 25db from the air conduction threshold level, the deafness can be graded into several categories like below.(5) < 25db – normal, 2640db – mild hearing impairment, 4160db – moderate hearing impairment, 61-70db – severe hearing impairment, 71-90db – profound hearing impairment, 91db and above – total deafness. the data from case record forms were tabulated in a microsoft excel spreadsheet. chi square test, fischer exact test and student t-test were used for analysis. p values <0.05 was considered statistically significant. results in this study, 60 healthy m.b.b.s students were included. mean age of study participants was 20.5 years (sd + 1.14) with agerange of 18 to 23 years. among these 60 students, females were 42 (70%) and 18 (30%) were males thus females outnumbered males. almost all participants were using the mobile phone on only one ear (dominant ear). we grouped dominant ear as a study group and non-dominant ear (not used with mobile phone) as control group. among our subjects, 46 (76.66%) were dominant on right ear and 14 (23.33%) were dominant on left ear. as shown in table 1, out of all 60 students, 52 (86.66) had normal hearing level while 8 subjects (13.33%) found to have sensorineural hearing loss in dominant ear. non-dominant ear in all students had hearing level with in a normal range (0-25 db). the difference was statistically significant with p value of < 0.05 under fischer exact test. table 1: distribution of subjects according to hearing status in dominant and nnon-dominant ear (n=60) group hearing status totalnormal hearing n (%) hearing loss n (%) dominant ear 52 (86.66%) 8 (13.33%) 60 non-dominant ear 60 (100%) 0 60 fisher exact test, p value= 0.006 (p value < 0.05statistically significant) as shown in table 2, mean hearing threshold of dominant ear was 10.54+ 5.75 db and that of nondominant ear of mobile users was 6.67 + 3.76 db. the difference was statistically significant with p value < 0.05 using ttest. table 2: comparison of mean hearing threshold in dominant ear and non-dominant ear in mobile phone users dominant ear (n= 60) nondominant ear (n= 60) ttest p value* mean hearing threshol d + sd (in db) 10.54 + 5.75 6.67 + 3.76 4.36 0.0002 *p value < 0.05statistically significant as shown in fig. 1, frequency specific mean hearing threshold in dominant and non-dominant ear, in all subjects was found to be within normal limit but hearing threshold in all frequencies in dominant ear was increased than that of non-dominant ear and this was a statistically significant difference at all frequencies with p value < 0.001under t-test. fig. 1: frequency specific mean hearing threshold in dominant and non-dominant ears in all subjects on studying frequency specific hearing threshold in 8 subjects having hearing loss, mean hearing threshold was 31.25 db (sd + 2.31) at both 4000 and 8000 hz indicating mild hearing loss in dominant ear at high frequencies. mean hearing threshold in lower frequencies was normal. in non-dominant ear, hearing threshold in all frequencies was normal. (table 3) nitin deosthale et al. effect of mobile phone use on hearing status of medical students…… panacea journal of medical sciences, september-december 2017;7(3):131-135 133 table 3: frequency specific mean hearing threshold in dominant and non-dominant ears in 8 subjects having hearing loss frequency mean hearing threshold + sd (in db) p value* dominant ear nondominant ear 250 hz 15 + 3.8 8.75+ 2.31 0.0013 (hs) 500 hz 15 + 3.8 8.75+ 2.31 0.0013 (hs) 1000 hz 15 + 3.8 8.75+ 2.31 0.0013 (hs) 2000 hz 16.25 + 4.43 8.75+ 2.31 0.0008 (hs) 4000 hz 31.25 + 2.31 9.38 + 1.77 < 0.0001(hs) 8000 hz 31.25 + 2.31 9.38 + 1.77 < 0.0001(hs) paired ttest used. * p value< 0.05statistically significant, hshighly significant table 4 shows that, out of 60 subjects, maximum subjects i.e. 30 students were using mobile phone for 30-60 minutes per day and 19 subjects were using it for 60 min to 3 hours followed by 11 subjects using it for 1530 minutes per day for making or receiving calls. we couldn’t find any subject using mobile phone for <15 minutes or > 3hours per day for making or receiving calls. on studying the relation between total duration of use of mobile per day with hearing loss, we found that, out of 30 subjects with mobile phone usage for 30mins – 1 hour per day, 27 subjects (90%) had normal hearing while 3 subjects (10%) were having mild hearing loss. out of 19 subjects with mobile phone usage between 13 hours per day, 14 subjects (73.68%) had normal hearing while 5 subjects (26.31%) had mild hearing loss. all 11 subjects, using mobile phones between 1530 minutes per day had normal hearing as shown in table 4. the difference was statistically insignificant. (fischer exact test p value >0.05) table 4: distribution of subjects according to total duration of usage of mobile phone per day and its relationship with hearing loss in dominant ear (n= 60) total duration of usage per day no. of subjects (n=60) hearing status in dominant ear normal hearing n (%) hearing loss n (%) <15 min 0 0 0 1530 min 11 11 (100%) 0 30 min-1 hour 30 27 (90%) 3 (10%) 13 hours 19 14 (73.68%) 5 (26.31%) > 3 hours 0 0 0 total 60 52 (86.66%) 8 (13.33%) for statistical analysis subjects were grouped in < 30 mins mobile usage per day and > 30 mins per day. fischer exact testp value = 0.35 as shown in table 5, on studying the relationship of longest dialogue duration in a day with hearing loss, 1 subject (4.36%) out of 23 was found to have hearing loss whose longest dialogue duration in a day was of 1020 minutes. 3 subjects (23.08%) out of 13 had hearing loss with longest dialogue duration on mobile in a day between 2030 minutes. 4 (36.36%) out of 7 subjects longest dialogue duration in a day of >30 minutes. with use of chi square test, there was statistically significant association between dialogue duration and hearing loss (p<0.05). table 5: distribution of subjects according to longest dialogue duration (in min) in a day and its relation with hearing loss in dominant ear (n= 60) longest dialogue duration (in min) in a day no. of subjects (n=60) hearing status in dominant ear normal hearing n (%) hearing loss n (%) <10 mins 13 13 (100%) 0 10-20 mins 23 22 (95.65%) 1(4.35%) 20-30 mins 13 10 (76.92%) 3 (23.08%) >30 mins 11 7(63.63%) 4 (36.36%) total 60 52 (86.66%) 8 (13.33%) chi square test value= 9.72, p value =0.02, statistically significant (p value<0.05statistically significant) as shown in table 6, 3 students, using mobile phones between 1-2 years had no hearing loss. out of 15 subjects with mobile phone usage for 2-3 years, 1 subject (6.66%) had hearing loss in high frequencies. 7 subjects (16.66%) out of 42 had hearing loss who were using mobile phone for >3 years. on statistical analysis with fisher exact test, p value was insignificant (p>0.05). table 6: distribution of subjects according to total duration of usage of mobile phone in years and its relationship with hearing loss in dominant ear (n= 60) total duration of usage in years no. of subjects hearing status in dominant ear normal hearing n (%) hearing loss n (%) <1 year 0 0 0 1-2 years 3 3 0 2-3 years 15 14 (93.33%) 1(6.66%) >3 years 42 35 (83.33%) 7 (16.66%) total 60 52 (86.66%) 8 (13.33%) for statistical analysis subjects were grouped in < 3 years of mobile usage and > 3 years. fischer exact testp value = 0.47 (statistically not significant) it appears that longer duration of dialogue, long usage of mobile per day and long duration of total nitin deosthale et al. effect of mobile phone use on hearing status of medical students…… panacea journal of medical sciences, september-december 2017;7(3):131-135 134 usage years of mobiles phones can predispose to hearing loss. discussion there has been a growing concern about possible detrimental effects of use of mobile phone on health. first organ that receives thermal and non-thermal effects of mobile phone is inner ear as it is in close proximity to the ear. the present study was conducted to evaluate the effect of mobile phone on hearing function by means of pure tone audiometry. in a randomized comparative case control study conducted by prajapati et al,(6) 60 healthy volunteers were included. mean age of the study group was 26.17 + 2.65 years and that of the control subjects 26 + 3.93 years. in the study done by hegde et al,(7) participants’ age ranged from 18 to 30 years and in the study of velayutham et al,(8) mean age of the volunteers was 27 years with age range between 2045 years. in the present study, age range of healthy mbbs students was between 18-23 years and mean age was 20.5 + 1.14 years. in most of the studies, participants were young adults. preferred ear for mobile usage: velayutham et al(8) in his study found that, in 63% subjects, dominant ear was the right ear and in 22% subjects,left ear was dominant whereas 15% had no preference. in karthikeyan et al(9) study, in 80% of subjects, right ear was dominant for mobile use and left ear was dominant in 8 % users. in our study, in 76.63% subjects, right ear was dominant for making and receiving calls and left ear was dominant in 23.33%. mobile usage and hearing loss: in shayani nasab et al(10) study, in both the users and non-users of mobile telephones,mean pure-tone thresholds (250 to 8000 hz) were +0.12 ± 5.93 db and -3 ± 4.73 db, respectively which was statistically significant difference (p value < 0.01). in prajapati et al6study, the mean hearing lossat high frequenciesin both the ears in study group was of 8.47 + 4.15 db and in control group, it was 0.33 + 1.826 db. this difference was statistically significant. the study done by velayutham et al(8) showed statistically significant loss in high frequencies in dominant ear as compared to nondominant ear (p< 0.05) under chisquare tests. in his study, 62% volunteers had normal hearing while 38% had hearing loss greater than 20 db in frequencies between 250 and 16000hz. in hegde et al7 study, sensorineural hearing loss was observed in 26.6% of subjects in study group and in 3.3% subjects incontrol group. we found statistically significanthigh frequency hearing loss in dominant ear in 13.33% of all subjects. mean hearing threshold (250 to 8000 hz) in all subjectsin dominant ear was 10.54 + 7.57 db and that in non-dominant ear was 6.67 + 3.76 db. our findings are consistent with above mentioned studies. total years of exposure: in panda et al(11)study, high frequency hearing loss was found in those subjects who were using the phone for more than 4 years (p = 0.04). patel et al(12) found mild to moderate high frequency hearing loss in 87.5% of subjects using mobile for 2-4 years and moderate high frequency hearing loss in all subjects using mobile phone for>4years. in shayani nasab et al(10) study, there was greater threshold increase with the greater use of mobile phones (p < 0.05). in hegde et al(7)study, sensorineural hearing loss was found in 32% of those who have been using mobile phone since 2 years and in 22% of those who have been using it since 3 years, thus indicating that the minimal hearing loss (5-15 db) noted in the study group was not only dependent onyears of exposure, but also on hours of exposure per day and type of exposure. in the present study, high frequency hearing loss was seen in 6.66% of subjects using mobile phone for 2-3 years and 16.66 % of subjects using mobile phone for >3 years.subject with mobile usage <2 years had no hearing loss. hours of exposure per day: in hegde et al(7) study, hearing loss of 5 db was found in 10% of those using mobile phones for 2-3 hours daily, 10 db hearing loss was seen in 3.3%, and 15 db in 1.6% in the same group. in those using mobile phones for 3-4 hours daily, hearing loss of 5 db was seen in 6.6% and 10 db in 3.3% of subjects. in patel et al(12) study, mild to moderate high frequency hearing loss was seen in those who were using mobile phone for > 1 hour in comparison to those using it for < 1 hour in a day. velayatham et al(8) in his study found statistically significant difference in usage time between the no hearing loss group (17.4 ± 13.6 min/ day) and hearing loss present group (40.8 ± 24.2 min/ day). in the study by callejo and santamaria,(13) audiometric evaluation was done in 323 healthy volunteers with normal hearing at the beginning of use of mobile phones and 3 years later. inquiry was done about the period of time per day use and ear in contact with mobile phone. a healthy control group not using mobile phones with normal hearing threshold werealso studied. audiometric results were similar in cases and controls at the beginning of the study. after follow-up of 3 years, cases showed an increase in hearing threshold between 1 and 5 db more than controls in speech tones (p < 0.001).(13) inoktay and dasdag(14) study, bera results showed no difference in hearing status among study and control groups (p>0.05). in pta measurements, hearing threshold in moderate mobile phone users (10-20 minutes per day) and the control subjects (never used cell phones) was similar. however, those who talked approximately 2 hours per day were found to have higher hearing threshold than moderate users and control subjects. in our study, 10 % subjects (3 out of 30 subjects)using mobile phone for 30mins–1 hour per day had mild hearing loss while 26.31% subjects (5 out of 19 subjects) using mobile phone for 1hr-3hrs per day had mild hearing loss. even if the difference was statistically not significant, increase in duration of mobile usage found to affect more number of subjects. nitin deosthale et al. effect of mobile phone use on hearing status of medical students…… panacea journal of medical sciences, september-december 2017;7(3):131-135 135 longest dialogue duration in a day: dialogue duration on mobile can also have significant effects on hearing function. but not much work has been done on relation of longest call duration and hearing loss. according to patel et al(12) study, all those having longest dialogue duration of > 45 minutes were found to develop mild to moderate high frequency hearing loss. in our study, there was statistically significant relation between longest dialogue duration in a day and hearing loss. conclusion our study shows that use of mobile phones for longer duration can predispose to hearing loss. although mean hearing threshold for frequencies 2508000 hz was within a normal range in dominant ear of mobile phone users but hearing threshold in dominant ear was more as compared to non-dominant ear and the difference was statistically significant. mild degree hearing loss was seen in higher frequencies (4000 & 8000 hz) in dominant ear of mobile phone users. relationship was found between duration of use of mobile phones and pure tone threshold changes. more the use of mobile phones, more was the threshold change. hearing loss due to long term use of mobile phone is serious health hazard which can be easily prevented. we recommend for long term follow up studies in chronic mobile phone users to come to the concrete conclusion. references 1. mostfapour sp, lahargoue k. noise induced hearing loss in young adults. laryngoscope 1998;108(12):1832-1839. 2. kan p, simomsen se, lyon jl, kestle jr. cellular phone use and brain tumour. j neurooncol 2008;86:71-78. 3. who. mediacentre. elecromagneticfeilds and public health base stations and wireless technologies. fact sheet no 193;june 2006. 4. arlinger s. psychoacousicaudiomery. in: gleeson m, browning gg, burton mj, clark r, hibbert j, jones ns, et al (editors). scott brown’s otorhinolaryngology, head and neck surgery.7thed, great britain: edward arnold ltd; 2008;3:3260-3275. 5. ministry of social justice and empowerment, govt. of india. subguidelines for evaluation of various disabilities and procedure for certification. new dehli; 1st june 2001:no.16-18/97-ni. 6. prajapati v, bhikhu j, gami g, thakor n. effect of chronic use of mobile phone on hearing of young adult age group: a case control study. int j res med sci. 2015;3(10):2664-2668. 7. hegde mc, shenoy vs, kamath pm, rao ra, prasad v, varghese bs. mobile phones: its effect on hearing. indian j otol. 2013;19(3):122-6. 8. velayutham p, govindasamy gk, raman r, prepageran n, ng kh. high-frequency hearing loss among mobile phone users. indian j otolaryngol head neck surg. 2014;66 (suppl 1):s169–s172. 9. karthikeyan p, christian js, audhya a. hearing evaluation in mobile phoneusers at tertiary care hospital. indian j of otol. 2014;20(1):24-28. 10. shayani-nasab m, safavinaiianni sa,. fathol alolomi mr, makaremi a. effects of mobile telephones on hearing. acta medicairanica. 2006;44(1):46-48. 11. panda nk, jain r, bakshi j, munjal s. audiological disturbances in longterm mobile phone users. j otolaryngology head neck surg. 2010 feb;39(1):5-11. 12. patel h, qureshi r. effects of long term use of mobile phones on hearingstatus of healthy individuals compared to infrequent mobile phone users inage group of 1540 years. international j of sciences and research. 2013;2(1):177-179. 13. garcía callejo fj, garcía callejo f, peña santamaría j, alonso castañeira i, sebastián gil e, marco algarra j. hearing level and intensive use of mobile phones. actaotorinolaringolesp 2005;56:187-91. 14. oktay mf, dasdag s. effects of intensive and moderate cellular phone useon hearing function. electromagn biol med 2006;25(1):13-21. 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. original research article panacea journal of medical sciences, january-april,2016;6(1): 20-25 20 effectiveness of educational intervention to enhance communication skills among interns rajavel murugan p.1,*, padmavathi t2 1senior assistant professor, dept. of general medicine, 2senior assistant professor, dept. of pharmacology, government thoothukudi medical college, tamilnadu. *corresponding author e-mail: drrajavelmurugan8@gmail.com abstract communication skills are required for medical professionals to carry out multiple tasks in their daily practice. an effective doctor-patient communication is vital for satisfying needs and expectations of patients, lack of which leads to conflicts between patients and doctors. this skill is found to be deficient among practitioners and interns as teaching or training on communication skill is not included in the present curriculum. studies have proved that many educational interventions including interactive workshops can enhance the skills of students in effectively communicating with patients. 25 interns were involved each in study and control groups after obtaining approval from institutional ethics committee. after assessing levels of domains of communication for both groups by questionnaire, workshop (lecture, video play, small group discussion, role play and feedback) was conducted for the study group for two hours. assessment was done by osce for the study and control group. prior to intervention, 24% interns had knowledge about communication skills and only 8% felt confident in communication. comparison of overall scores of post workshop osce between two groups by unpaired t test showed significant difference (p value < 0.0001). of the 10 variables used in osce rating scale, four showed no significance. the levels of knowledge and confidence of interns are low in communicating with patients. hence intervention like workshop can improve this skill if included in curriculum. keywords: communication skill, interns, osce, workshop. introduction communication is the process by which we exchange information between individuals or groups of people and is successful only when both the sender and the receiver understand the same information. communication skills are required for medical professionals to carry out tasks such as medical interviewing, explaining a diagnosis or prognosis, giving instruction to undergo diagnostic or therapeutic procedures and providing counselling to motivate the patients in the course of treatment. an effective doctorpatient communication is vital for satisfying the needs and expectations of patients, lack of which leads to conflicts between them and doctors. this miscommunication also increases their symptoms of anxiety and depression. unfortunately, only half of the complaints and concerns of patients are likely to be addressed by the doctors since the practitioners often falter to perceive fully the physical, emotional, and social impact of the problems of the patients. good communication can influence biological, social and psychological outcomes of a patient such as decrease in the use of analgesics, reduction in the duration of hospital stay and improvement in recovery from any prolonged serious illnesses and surgeries. moreover, poor communication often results in medical accidents and subsequent litigation. efficient communication will provide greater job satisfaction, less work stress and will help in accurate identification of the problems of the patients. hence excellent communication skills are essential for an indian medical graduate to achieve successful medical professionalism(1). however, this skill is found to be deficient among practitioners and interns as the teaching on this skill is not included in the present curriculum(2-3). this knowledge deficiency of interns may be attributed to the fact that interns have never been trained to consult in the general practice setting, and their skills are limited to making value judgements(4). it is also clear that good communication skills in medical practice are not innate, can be learned, and can always be enhanced(5). our present curriculum pays very little attention to ensure that our graduates acquire skills necessary to effectively communicate with patients. so far, medical graduates acquire communication skills only from hidden curriculum, that too very meagre. since the ways to accomplish this mission are less defined, it is the responsibility of faculties in medical education to emphasise the importance of communication skill among medical students and to find newer methods to educate them. it is the need of the hour to instigate this into overt curriculum. recent research has demonstrated that training in communication skills is both feasible and effective. it should become an integral part of medical education. studies have proved that educational interventions in the form of interactive workshops, interviews of simulated patients, role modelling, role-play, videotape review, and skills practice can enhance the skills of students in communicating with patients(6-7). though murugan rajavel et al. effectiveness of educational intervention to enhance communication skills among…... panacea journal of medical sciences, january-april,2016;6(1): 20-25 21 many interventions have been proved to be effective individually, being a multimodal intervention, workshop which incorporates most of the teaching methods may enhance the skill still more. based on this perspective, we intended to study the present level of knowledge and confidence of medical students about communication and the impact of workshop as an educational intervention in augmenting the skill. material and methods this prospective, comparative study was conducted in a tertiary care hospital during the month of august 2015 after obtaining approval from institutional ethics committee. among the 100 students undergoing internship in our hospital, the 25 interns posted in department of general medicine were included in the study group and the 25 posted in department of general surgery were assigned to the control group. informed consent was obtained from all of them. a 10 point questionnaire graded by likert scale was distributed to participants from the study and control groups for pre intervention assessment. questions were framed giving value to three attributes of communication skill such as knowledge on communication, importance of communication, and confidence in communicating to patients (table 1). table 1: questions in the pre/post questionnaire sr. no. questions domains 1 i know all the steps in communicating with patients knowledge 2 i introduce myself before starting history 3 i used to listen to what patients say and allow ample time for them to talk 4 i will explain in details pros and cons, necessity, steps of any procedure before doing it. importance 5 i can build good rapport with patients in op an ip. 6 i usually give details to patients and relatives about illness 7 i usually prefer to give counselling to patients and relatives about therapeutic options 8 i usually show good empathy to patients of serious illness? confidence 9 i can handle situation of breaking bad news or dil to patients or relatives with ease 10 i am confident in obtaining consent from patients or relatives. source: a s khan et al (8) the workshop for intervention was designed in multimodal way incorporating a power point lecture, role play, small group discussion based on case scenarios, video play and a open ended feedback(7,9)(table 2). the session started with power point lecture detailing about kalamazoo statement and spikes protocol on communication(10-11). slides in power point were designed in accordance with macy model of doctor patient communication. the didactic session was followed by role play depicting good communication between a doctor and patient which is an effective means of acquisition of knowledge of communication skills(6). then the 25 participants were divided into small groups each comprising of eight and case scenarios expressing faltered communication between doctor and patient were distributed to each group. time was allowed for discussion on the scenario among group members before presenting their final opinion to the forum. workshop was completed with videos on effective and bizarre communication between doctor and patient. after the intervention, answers for post intervention questionnaire and written feedback were obtained from all participants of study group. table 2: workshop synopsis (2hours) sr. no. teaching method duration 1 lecture with power point 30 minutes 2 role play 15 minutes 3 small group discussion 15 minutes 4 video play 30 minutes 5 feedback 30 minutes several reliable methods have been suggested to assess communication skill. of all, we thought osce can be used effectively in our study, since it is already in use for routine summative evaluation. even though reliability of global scoring by examiners as observers is debatable, osce has been proved to be successful tool in assessing physician – patient communication which is a highly complex process(12). hence, we subjected the participants of both the groups to assessment by osce in the subsequent days following workshop. other studies have used more number of stations and more than one examiner per station. but, being a pilot study in its aspect, and for the sake of feasibility we decided to have 10 stations of osce to evaluate the three domains of communication(7). murugan rajavel et al. effectiveness of educational intervention to enhance communication skills among…... panacea journal of medical sciences, january-april,2016;6(1): 20-25 22 pre and post intervention questionnaire were analysed by descriptive statistics. the mean of osce scores obtained by the participants of both the groups were compared by unpaired student t test. the scores obtained for individual variables in osce rating scale were also compared by unpaired student t test. results on analysing pre intervention questionnaire answered by the participants of study group, it was found that among three attributes stressed, 24% interns agreed that they possess some knowledge on communication, 56% felt the importance and only 8% expressed their confidence in communicating with patients (table 3). table 3: interpretation of pre intervention questionnaire for both groups measure agree not clear disagree control study control study control study knowledge 5 (20%) 6 (24%) 7 (28%) 8 (32%) 13 (52%) 11 (44%) importance 16 (64%) 14 (56%) 4 (16%) 5 (20%) 5 (20%) 6 (24%) confidence 3 (12%) 2 (08%) 5 (20%) 7 (28%) 17 (68%) 16 (64%) review of post workshop questionnaire revealed that the interns of study group expressed significant increase in their knowledge and confidence on communication skill. only two of the interns were not clear about the importance of communication skill (fig. 1). fig. 1: comparison of attributes between both groups in questionnaire analysis on comparing mean osce scores obtained by control group (9.8) and study group (14.18), we found significant difference between both the groups (p = 0.001) (fig. 2). murugan rajavel et al. effectiveness of educational intervention to enhance communication skills among…... panacea journal of medical sciences, january-april,2016;6(1): 20-25 23 fig. 2: comparison of mean score in osce between both groups individual scores obtained for each variable in 10 point rating scale was compared between both groups for significance. of these 10 variables, except four (highlighted in the table), all others showed significant difference between the groups (table 4). table 4: individual variables in osce check listcomparison of performance between study and control groups sr. no variable control study p value mean sd mean sd 1 introduction of self to patient 0.48 0.71 1.64 0.64 <0.001 2 consent taken for history taking 0.24 0.44 1 0.5 <0.001 3 good listener (didn’t interrupt patients) 1.16 0.55 1.28 0.68 >0.05 4 understand effect of problem 1.2 0.41 1.56 0.51 <0.05 5 able to explain diagnosis 1.52 0.51 1.85 0.37 <0.05 6 communicate to patient about his/her concerns 0.60 0.76 0.88 0.6 >0.05 7 patients can understand explanation 1.24 0.66 1.6 0.5 <0.05 8 offer help in a polite way 1.04 0.69 1.25 0.45 >0.05 9 share decision for management 0.84 0.55 1.12 0.44 >0.05 10 eye to eye contact 1.36 0.57 1.88 0.33 <0.001 discussion though it has long been accepted that communication is of central importance and a core aspect of clinical practice, there is no proper training for students and interns. since communication skills have not been embedded in the present curriculum, concerns over poor doctor patient relation is increasing among stakeholders. communication cannot be taught in one single step but many simple and complex skills like medical interviewing, empathy, breaking bad news, getting informed consent, and dealing with emotions of patients in terminal illnesses. many of the studies have revealed that intervention like workshop proves to improve communication skill among students and interns. our study proves that the knowledge level of interns on communication and their confidence in handling difficult situations like breaking bad news and declaring terminal illness are very low. majority of interns agreed that they do not possess ample knowledge in this skill (76%) and felt poorly confident to deal with bad situations (92%). this fact goes in accordance with revelation of a study by mohsen tavakol et al(2) who used csks (communication skill knowledge scale) to assess knowledge level of interns about communication skills which was found to be limited. this deficit in knowledge has also been reported by researchers in other countries(11). the knowledge deficiency may be attributed to the fact that students are not properly trained in such skill and they have never been exposed to general practice setting. our interns who participated in the study did not seem to know the importance of this skill in applying to their practice. again this may be due to under exposure of interns to complex situations and real life problems which may arise because of lack of communication skill. the interns do not give due importance to this aspect since there is either absence of structured murugan rajavel et al. effectiveness of educational intervention to enhance communication skills among…... panacea journal of medical sciences, january-april,2016;6(1): 20-25 24 curriculum or scarcity of role models practicing good communication with patients. post intervention questionnaire analysis clearly shows improvement in knowledge, importance and confidence levels of interns in communication. all the interns (100%) of study group reported that their knowledge of communication was very much boosted up after the workshop. they also felt that apart from improving their knowledge, the workshop made them very much confident to effectively communicate with patients. some interns mentioned role play as very special one since it helped them to sort out so many unanswered questions in facing difficult patient encounters. a study by majmin sheikh hamza et al(12) explained the effectiveness of workshop in improving communication skill among medical students, in which, majority of the students (81.4%) rated the workshop as useful and beneficial and about 84.3% of them rated that the workshop had achieved its objectives. similarly study by jong won jung et al(13) also concludes that communication skills training for interns facilitates their reflection and development of communication skills, as well as their competency of situational problem solving. a very significant improvement was observed in post graduates, in patient encounters of breaking bad news after communication skill workshop for 4 days in a cohort study by anthony l. back et al(14) involving 115 postgraduates. coinciding with facts of above studies, our studyshows extreme significance in improving the communication skill which is expressed by comparison of overall score obtained in assessment by osce between control study groups. the efficacy of intervention like workshop proved by researchers across the world was reiterated in our study as the study group interns scored much higher than those of control group. though overall score of study group was much higher over score of control group interns, four of ten skills assessed in osce such as listening, addressing emotions, politeness and sharing decision in management showed no significance between control and study group. this observation of non-significance of above parameters indirectly means that these four skills are being learnt by interns in hidden curriculum either from their teachers or peers through role modelling. hence, while planning the module for communication training, other six parameters should be given priority. in the written, open ended feedback, the interns expressed higher interest in looking forward to more workshop in future or regular inclusion in curriculum to make them more comfortable and confident in communicating with patients. overall, all the interns expressed their willingness to undergo more such workshop since they feel that it certainly will help in their day to day practice. on analysing effect of gender difference on communication skill, male interns scored higher (71%) than female interns (50%) due to unknown reason. one randomised study, two open effect studies and one descriptive study show that females score better than males after a training course in communication skills(911). a recent meta-analysis indicated that female physicians are likely to perform more patient-centred communication behaviours such as collaborative communication, empathic communication and giving psychosocial information(15-16). on contrary, our study expresses preponderance in males who have scored more than 75%. we owe this contradictory finding of this study in gender effect to small number of participants included in the study. the limitations of our study are less number of interns, shorter duration of workshop and single examiner observing all stations per candidate. conclusion since levels of knowledge and confidence of interns are low in communicating with patients, intervention targeting affective learning of communication skills, in conjunction with cognitive and behaviourral training, need to be developed to help medical students understand the importance of communication and the complexity of communication issues in health care. intervention like workshop will help medical students to perceive these skills as important and retain knowledge of them. inclusion of such workshop in curriculum will definitely help all the students to acquire the important competency of communication, a part of professionalism in practice. conflict of interest: none source of support: nil references 1. stern dt. measuring medical professionalism pp15-39;. oxford text book of medical education, oxford university press 2013. 2 mohsen tavakol, sima torabi, owen d lyne, ali a zeinaloo. a quantitative survey of intern's knowledge of communication skills: an iranian. bmc medical education 2005;5:6. 3 smith rc. a strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study. academic medicine 1995;70:729-32. 4 tavakol m, murphy r, torabi s. a needs assessment for a communication skills curriculum in iran. teach learn med 2005,17:36-41. 5 makoul g. essential elements of communication in medical encounters: the kalamazoo consensus statement. acad med 2001;76:390-3. 6 yogeeta sushant walke, padmanabh vaman rataboli. introduction of the role play: an effective innovation in medical education technology. pharmacologyonline 2011;3:1234-41. 7 knut aspegren. teaching and learning communication skills in medicine: a review with quality grading of articles. medical teacher 1999;21(6):563-70. 8 abdul sattar khan, riaz qureshi, hamit acemoğlu, syedshabi-ul-hassan. comparison of assessment scores murugan rajavel et al. effectiveness of educational intervention to enhance communication skills among…... panacea journal of medical sciences, january-april,2016;6(1): 20-25 25 of candidates for communication skills in an osce by examiners, candidates and simulated patients. creative education 2012; 3(special issue):931-6. 9 kevin b. wright, carma bylund, jennifer ware, patricia parker, jim l. query, walter baile. medical student attitudes toward communication skills training and knowledge of appropriate provider-patient communication: a comparison of first-year and fourthyear medical students. med educ 2006;11:18. 10 walter f. baile. spikes—a six-step protocol for delivering bad news: application to the patient with cancer. the oncologist 2000;5:302-31. 11 singh v, khandelwal r, bohra s, gupta r, gupta bs. evaluation of communication skills of physicians about asthma. j assoc physicians india 2002;50:1266-9. 12 majmin sheikh hamzah, mohd najib mat pa, shima sepehr, muhamad saiful bahri yusoff, rosniza abd aziz, nor azwany yaacob. experience from a communication skills workshop for medical students. education in medicine journal 2010;2(1):e37. 13 jong won jung, young-mee lee, byungsookim, ducksunahn. analysis of the perceived effectiveness and learning experience of medical communication skills training in interns. korean j med educ 2010;22(1):33-45. 14 anthony l. back. efficacy of communication skills training for giving bad news and discussing transitions to palliative care. archives of internal medicine 2007;167(5):453-60. 15 marteau tm. factors influencing the communication skills of first-year clinical medical students. medical education 1991;25:127. 16 smith rc. a strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study. academic medicine 1995;70:729-32. 429 too many requests you have sent too many requests in a given amount of time. original research panacea journal of medical science, september december 2015:5(3);153-157 153 study of obstetric outcome in antepartum haemorrhage jejani ayushma 1 , kawthalkar anjali 2 abstract: the aim of the present study was to study the demographic profile, type of antepartum haemorrhage, maternal and perinatal complications in cases of antepartum haemorrhage and to formulate preventive guidelines so as to reduce maternal and perinatal complications in cases of antepartum haemorrhage. this retrospective study period extends from 1st may 2013 to 30th june 2013. fifty-seven diagnosed cases of antepartum haemorrhage were included in the study. the data was collected on a predesigned proforma and percentage analysis was done. out of total 57 diagnosed cases of antepartum haemorrhage, multiparty was the major risk factor observed in present study. placenta previa was the commonest type of antepartum haemorrhage, abruptio placentae being the second major type. in spite of tertiary care, there was 1 maternal death and high perinatal mortality (21.1%). the present study indicates that uncorrected anaemia (71.9%) is still common in india contributing to increased maternal mortality and also necessitating high requirement of blood transfusion (66.7%). multiparty (61.4%), previous lscs (21%) were the major etiological factors contributing to antepartum haemorrhage. based on the observations made during the study, it can be concluded that antepartum haemorrhage is the major cause of maternal morbidity and perinatal mortality. keywords: antepartum haemorrhage, placenta previa, abruptio placentae, maternal mortality. 1 intern, 2 associate professor, department of obstetrics and gynaecology, nkpsims & rc, digdoh hills, hingana road, nagpur-440019. jejaniayushma12@gmail.com introduction obstetric haemorrhage is the world’s leading cause of maternal mortality (1). antepartum haemorrhage is defined as bleeding from or into the genital tract after 28weeks of pregnancy and before delivery of the baby (2). it is one of the most frequent emergencies in obstetrics occurring at a prevalence of 0.5-5% (3). antepartum haemorrhage is a grave obstetrical emergency and is a leading cause of maternal and perinatal mortality and morbidity. it complicates about 2-5% of all the pregnancies. it can be due to placenta previa, abruption placentae, indeterminate cause or local causes of genital tract. maternal mortality due to antepartum haemorrhage has significantly decreased in the developed countries due to better obstetrical outcome. in india maternal and perinatal mortality is still very high due to associated problems like anaemia, difficulties in transport in cases of emergency and restricted medical facilities (4). zeeman’s study of obstetric critical care provision identifies haemorrhage as one of the most frequent reasons for admission to intensive care unit (5). maternal complications of antepartum haemorrhage are malpresentation, premature labour, postpartum haemorrhage, shock, retained placenta. it also includes higher rates of caesarean sections, peripartum hysterectomies, coagulation failure and death. foetal complications are premature delivery, low birth weight, intrauterine death, congenital malformations and birth asphyxia (6-10). in modern obstetrics there is an increase in the caesarean section rates of 30-40%. in a case of previous caesarean section there is an increase in the incidence of placenta praevia. morbidly adherent placenta poses a challenge in these cases. folic acid deficiency is considered as one of the etiological factor for abruptio placentae. in developing countries like india, there is high incidence of untreated pre-eclampsia which is the main etiological factor for development of abruptio placentae. so it is important to analyse various causes of antepartum haemorrhage in present day obstetrics in india (11-13). antepartum haemorrhage goes hand in hand with postpartum haemorrhage as there is high incidence of postpartum haemorrhage in cases of antepartum haemorrhage. untreated anaemia is universally found in our scenario. blood transfusion facilities are still inadequate in rural india. late referral, lack of transport facilities and inadequate knowledge of medical and paramedical staff contributes to poor prognosis in cases of antepartum haemorrhage in developing countries like india. the present study is of importance to understand the aetiology of antepartum haemorrhage and to formulate preventive guidelines to improve the obstetric outcome. materials and method study design: this study is a retrospective analysis. study setting: the study was conducted at our tertiary care centre. the data was collected from the case record files obtained from the record section for retrospective analysis. inclusion criteria: the diagnosed cases of antepartum haemorrhage were included in the study. methodology: the data was obtained from the case record files obtained from the record section of the jejani ayushma et al. study of obstetric outcome in antepartum haemorrhage panacea journal of medical science, september december 2015:5(3);153-157 154 tertiary care centre after getting institutional ethics committee clearance. the data was analysed retrospectively. 57 diagnosed cases of antepartum haemorrhage were included in the study. statistical analysis of the data has been done. the data was collected on a predesigned proforma and percentage analysis has been done. results the medical records of 57 diagnosed cases of antepartum haemorrhage were studied and it was observed that 56 (98.2%) cases were registered and only 1 (1.8%) case was not registered. 37 (64.9%) females were from urban areas and 20 (35.1%) of them were from rural areas. out of the 57 diagnosed cases, 35 (61.4%) cases were multipara and 22 (38.6%) cases were primipara. of these 57 cases of antepartum haemorrhage, 23 (40.4%) cases were those of placenta praevia, 22 (38.6%) cases were those of abruption and only 12 (21%) cases were those of undetermined aph ( fig.1). placenta praevia type i was the commonest constituting about 39.1% (09) of cases followed by type ii 07 (30.4%), type iv 05 (21.8%) and type iii 02 (8.7%) respectively (fig.2). fig. 1: types of antepartum haemorrhage fig. 2: types of placenta previa 0 5 10 15 20 25 30 35 40 45 placenta previa (40.4%) abruptio placentae (38.6%) undetermined aph (21%) placenta previa (40.4%) abruptio placentae (38.6%) undetermined aph (21%) 0 5 10 15 20 25 30 35 40 placenta previa type i (39.1%) placenta previa type ii (30.4%) placenta previa type iii (8.7%) placenta previa type iv (21.8%) placenta previa type i (39.1%) placenta previa type ii (30.4%) placenta previa type iii (8.7%) placenta previa type iv (21.8%) jejani ayushma et al. study of obstetric outcome in antepartum haemorrhage panacea journal of medical science, september december 2015:5(3);153-157 155 anaemia 41 (71.9%) was found to be the most common maternal disorder followed by previous lscs 12 (21.1%) and malpresentation 05 (8.8%) respectively (fig.3). lscs 41 (71.9%) and blood transfusion 38 (66.7%) were found to be the most common maternal complications (fig.4). in case of neonates that were delivered, 29 (50.9%) of them were preterm, 20 (35.1%) were full term and 8 (14%) were iud. 56.1% (32) of the neonates were male and 43.9% (25) of them were female. 68.4% (39) of the babies were low birth weight babies and 50.9% (29) of them were premature (fig.5). fig. 3: maternal disorders fig. 4: maternal complications 0 20 40 60 80 anemia (71.9%) pre eclampsia (5.3%) rh negative (3.5%) multiple pregnancy (1.8%) previous lscs (21%) malpresentation (8.8%) anemia (71.9%) pre eclampsia (5.3%) rh negative (3.5%) multiple pregnancy (1.8%) previous lscs (21%) malpresentation (8.8%) 0 20 40 60 80 postpartum haemorrhage (3.5%) blood transfusion (66.7%) lscs (71.9%) puerperal pyrexia (0%) coagulation failure (0%) maternal mortality (1.8%) postpartum haemorrhage (3.5%) blood transfusion (66.7%) lscs (71.9%) puerperal pyrexia (0%) coagulation failure (0%) maternal mortality (1.8%) jejani ayushma et al. study of obstetric outcome in antepartum haemorrhage panacea journal of medical science, september december 2015:5(3);153-157 156 fig. 5: perinatal complications discussion the incidence of antepartum haemorrhage in the present study is 0.8% which is significantly less as compared to sheikh et al (5.4%) and singhal et al (3.01%) (3-4). table 1: statistical comparison of types of aph with previous studies study placenta praevia abruptio placenta undetermined aph s.r. singhal et al 52.64% 29.65% 17.7% fouzia sheikh et al 51.7% 44.6% 2.5% present study 40.4% 38.6% 21% the incidence of placenta praevia is slightly less in the present study (40.4%) as compared to sheikh et al (51.7%) and singhal et al (52.64%) (3-4). the incidence of abruptio placentae in the present study (38.6%) is comparable to sheikh et al (44.6%) but it is higher than singhal et al (29.65%). the incidence of undetermined aph of present study (21%) and singhal et al (17.7%) is comparable as compared to sheikh et al (2.5%) which is significantly less. table 2: statistical comparison of maternal complications with previous studies complications s.r. singhal et al fouzia sheikh et al present study postpartum haemorrhage 21.84% 19% 3.5% blood transfusion 78.77% 77.4% 66.7% lscs 43.80% 57.1% 71.9% coagulation failure 3.8% puerperal pyrexia 10.61% maternal mortality 2.21% 1.8% the above table signifies that in the maternal complication, postpartum haemorrhage (3.5%) is significantly less in the present study as compared to singhal et al (21.84%) and sheikh et al (19%). the decreased incidence of postpartum haemorrhage in present study may be due to prophylactic measures taken for prevention of postpartum haemorrhage such as prophylactic use of prostaglandin f2alpha, methyl ergometrine, uterine and ovarian artery ligation. blood transfusion rate is comparable in all the three studies. incidence of lscs is higher in present study as compared to the other two studies. maternal mortality rate is comparable in singhal et al (2.21%) and present study (1.8%). the incidence of iugr and apgar <7 is significantly high in singhal et al as compared to present study. perinatal mortality in present study (21.1%) is comparable to singhal et al (23.70%) however it is significantly high in sheikh et al (49.66%). the incidence of low birth weight and prematurity is comparable in present study (68.4%) and singhal et al (83.18%). 0 20 40 60 80 low birth weight (66.7%) prematurity (50.9%) iugr (3.5%) shifted to perinatal mortality (21%) nursery (40.4%) pbu (15.8%) nicu (22.8%) jejani ayushma et al. study of obstetric outcome in antepartum haemorrhage panacea journal of medical science, september december 2015:5(3);153-157 157 conclusion present study has been carried out at tertiary care centre as a retrospective study named “study of obstetric outcome in antepartum haemorrhage”. 57 diagnosed cases of antepartum haemorrhage were studied. demographic profile of the cases indicates that antenatal registration is satisfactory in cases coming to this tertiary care centre. multiparity was the major risk factor observed in present study. placenta praevia was the commonest type of antepartum haemorrhage, abruptio placentae being the second major type. in spite of tertiary care, there was 1 maternal death out of 57 cases and high perinatal mortality (21.1%). the present study indicates that uncorrected anaemia (71.9%) is still common in india contributing to increased maternal mortality and also necessitating high requirement of blood transfusion (66.7%). multiparity (61.4%), previous lscs (21%) were the major etiological factors contributing to antepartum haemorrhage. reducing the family size to 1-2 child norm, reducing the primary lscs will help in reducing antepartum haemorrhage. there is a need for directed efforts for correction of anaemia in pregnancy and antepartum haemorrhage. introduction of availability of injectable iron at rural level can lead to a major reduction in anaemia complicating pregnancy. national anaemia prevention programme needs to be modified by incorporating the facility for injectable iron at rural level. based on the observations made during the study, it can be concluded that antepartum haemorrhage is the major cause of maternal morbidity and perinatal mortality. hence to avoid the complications of antepartum hemorrhage, preventive guidelines include: • a female admitted with antepartum haemorrhage must be considered at high risk and timely management must be given by a trained group of doctors. • good antenatal and postnatal care is most important and it must be ensured to all the pregnant females to avoid antepartum haemorrhage. • improved referral, transport facilities, adequately trained medical and paramedical staff, improved blood transfusion facilities can aid in decreasing the incidence of antepartum haemorrhage. • above all is the generation of awareness among all the females regarding antenatal care, postnatal care, various government schemes like janani suraksha yojana, importance of institutional delivery, importance of family planning, importance of iron folic acid supplementation and immunization will be a big step towards decreasing maternal and perinatal morbidity and mortality due to antepartum haemorrhage. • considering high perinatal mortality, neonatal care units must be improved. references 1. lolonde a, davis ba, acosta a. postpartum haemorrhage today: icm/figo initiative 2004-2006 ugo; 2006, 94:243253. 2. dutta dc. antepartum haemorrhage. in konar. hl ed. textbook of obstetrics. 6 th ed. kolkatta: new central book agency: 2006.p. 243-46. 3. sheikh f, khokhar s, sirichand p, shaikh r. a study of antepartum haemorrhage: maternal and perinatal outcome. medical channel 2010; 16(2): 268-71. 4. singhal s, nymphaea, nanda s. maternal and perinatal outcome in antepartum haemorrhage: a study at a tertiary care referral institute. the internet journal of gynaecology and obstetrics 2008, 9(2): 5580/1b6. 5. zeeman g. obstetrical critical care: a blue print for improved outcomes. crit care med 2006; 34: 208-14. 6. williams obstetrics. obstetrical haemorrhage. in cunningham fg, leveno kj, bloom sl, hauth jc et al. 22 nd edition. mcgraw hill companies, inc: 2005: 810-820. 7. konje je, taylor dj. bleeding in late pregnancy. in james dk, steer pj, weiner cp, gonik b, editors. high risk pregnancy management options, 2 nd ed. london: harcourt 2000. 8. neilson jp. antepartum haemorrhage. in: edmonds dk editor. dewhursts textbook of obstetrics and gynaecology for post graduates 6 th ed. blackwell scientific london. oxford. 1995:164-74. 9. neilson jp. intervention for treating placental abruption (cochrane review) in: cochrane library, issue 3, 2003. oxford: update software (level i). 10. khosla a, dahiya v, sangwan k, rathore s. perinatal outcome in antepartum haemorrhage. j obstet gynae india 1989; 71-3. 11. krohn m, voigt l, mcknight b, doling jr, starzyk p, benedetti tj, correlates of placenta abruption. br j obstet gynecol 1987; 94:333-40. 12. demissie k, brekenridge mb, joseph l. rhoads gg. placenta previa: preponderance of male sex at birth. am j epidemiol 1999; 149: 824-30. 13. sinha p, kuruba n. antepartum haemorrhage: an update. j obstet gynaecol. 2008; 28(4): 377-81. 25 1 2 junior resident, msw social 3 worker, assistant professor, 4 5 associate professor, professor 6 and head, professor, department of psychiatry, nkpsims&rc, hingna road, digdoh hills, nagpur 440019. deepanjali.deshmukh@hotmail .com abstract: alcohol is one of the leading causes of death and disability globally. alcohol use has association with physical and psycho-social implication. we studied the socio-demographic and psycho-social factors in patients of alcohol dependence and to find the correlations among them. 50 consecutive male alcoholic patients of 18 years or older admitted in psychiatry ward, who fulfilled the diagnostic criteria for alcohol dependence as per diagnostic and statistical manual of mental disorder iv, text revision were included in the study after obtaining written informed consent. each patient was individually interviewed, by using a semi-structured proforma prepared for the study. data thus collected was tabulated and analyzed. most of the subjects in our study belonged to lower economic group. majority of the subjects were earning less than 10,000 rupees per month and 42% were spending more than 2000 rupees per month on alcohol. motivation was low in majority of the participants. around 64% of the subjects had more than 2 admissions in psychiatry ward. compliance to the treatment was poor in 90% of the patients. there was positive correlation between presence of stress and more number of admissions. keywords: alcoholics, psycho-social aspects, admission. introduction: alcohol consumption has been considered as one of the leading cause of death and disability worldwide. according report of world health organization, about 2 billion people consume alcohol containing drinks and about one third may have diagnosable alcohol use disorder (1). about 3.2 % of all deaths can be attributable to alcohol use (2). alcohol use has been increasing in south east asian countries including india (3-4). the estimated prevalence of alcohol use in india is said to be 21 % in male, with increasing trends in women as well (5). the per capita alcohol consumption is about 2 litres of absolute alcohol equivalents per adult per year (6). the consumption of alcohol in our country had been increased by about 106 % (4). various health and social problems are directly or indirectly related to alcohol use. it has been implicated in family disorganisation, crime and loss of productivity and thus the economic loss of country (6-7). about one fifth of hospital admissions can be attributable to alcohol use. high association has been found with deliberate self-harm, highrisk sexual behaviour, hiv infection, tuberculosis, oesophageal cancer, liver disease and duodenal ulcer and its use (8). there are numerous studies regarding alcohol use, but there is paucity of studies from central india. scenario of the mental health in central india is changing remarkably. this is considered as a “suicide belt” of india where alcohol addiction is a major determinant. it is worthwhile to know about the psychosocial aspects of alcoholism, for effective planning of interventions. with this back ground in mind present study was carried out to find out various psychosocial factors responsible for alcohol consumption. materials and methods: it was a cross-sectional single interview study carried out in a tertiary care hospital, which caters to needs of people residing in suburban area and having industrial units in the vicinity. study was conducted after permission from institutional ethics committee during january 2013 to june2013. 50 consecutive male alcoholic patients of 18 years or older admitted in psychiatry ward, who fulfilled the diagnostic criteria for alcohol dependence as per diagnostic and statistical manual of mental disorder edition iv ,text revision were included in the study after obtaining written informed consent. the aims of the study were to assess the socio-demographic and psycho-social factors in patients of alcohol dependence and to find the correlations among them. each patient was individually interviewed, by using a semistructured proforma prepared for the study which included socio-demographic profile, family, personal and sociooccupational history, monthly income, amount spent on alcohol per month, presence or absence of stressors, reasons for restarting alcohol, number of admissions for de-addiction treatment, history related to alcohol consumption, motivation, compliance. data thus collected was tabulated and analyzed using non parametric tests under guidance of statistician to draw the conclusions. for analysis chi-square test and fisher exact test were used. results: results of the study were tabulated and analyzed as follows: pjmsvolume 4 : number 2 : july dec. 2014 original article study of socio demographic and psychosocial aspects of male alcoholics with admission in psychiatry ward 1 2 3 3 4 5 6 deshmukh deepanjali , mule sangita , faye abhijeet , gawande sushil , tadke rahul , bhave sudhir , kirpekar vivek 26 table 1: socio-demographic and psychosocial factors of the patients 1)age distribution: out of total participants 42% of the patients were in the age group of 35-45 years of age, 26 %of the participants were of the age more than 45 years age group and only 4% of the participants were of 20-25 years age group. 2) education: maximum participants (66%) were educated up to secondary to higher secondary level. 42% of the patients were doing non-skilled work while only 18 % were professional workers. 3)income: about 42% of the participants had monthly income of less than rs. 5,000, followed by 34% earning rupees between 5,000-10,000 per month (table 1). 4)income spent on alcohol: about 50% of the participants use to spend 500 2000 rupees per month on alcohol whereas around 18 % of the subjects were spending more than 5000 rupees per month on alcohol (table 1). 5)family history and support: in this study 84% of the subjects were married and majority of the participants (62%) were having good family support (supportive family members and friends). family history of alcohol consumption was found in around 44% of the participants whereas 56% reported no such history (table 1). ninety six percent of the subjects gave no family history of any other mental illness. in 40% of the cases, participants were the only earning members of their families and 24% of the subjects were having at least 2 other earning members in the family. 6)distribution by residence: there was no significant difference in the distribution of the subjects according to their residence as 52% belonged to the rural area and an almost equal number that is 48% were from suburban population. 7)comparison between various socio demographic variables: above findings show that 76% of the subjects were earning less than 10000 rupees per month and 42% were spending more than 2000 rupees on alcohol each month. following table illustrates these findings (table 2). table 2: comparison between various socio demographic variables 8) alcohol related details and reasons for relapse and readmission: 40% of the subjects attributed stress as a reason for continued alcohol consumption while majority, 60%, admitted that stressor was not the reason for the continued intake of the same (other reasons like drinking for festival, celebrations, to reduce craving, because of withdrawal symptoms). most of the alcoholics reported more than 5 admissions in the psychiatry ward in the past and comprised of 32% of the total participants, while 22% of them was admitted for the first time (table 1). about 86 % of the participants had history of abstinence periods (multiple times), while 14 % never remained abstinent from the alcohol. alcohol withdrawal related problems (restlessness, anxiety , nausea, weakness, etc.) were the most common reason for the admission in the hospital and constituted 88% of the total subjects and 12% got admitted due to other reason (for de addiction or associated medical problems). most of the patients (92%) were brought by family members and only 4% came by their own for treatment. rest of the patients (4%) were brought by social workers. 90% of the subjects had history of poor compliance to treatment (table 1). a proportionately large number of the subjects (76%) had consumed alcohol 2 days prior to the admission. finally, low motivation level to quit alcohol was found in almost 74% of the subjects (table 1). pjmsvolume 4 : number 2 : july dec. 2014 original article sr. no factors n=50 percentage 1 age in years < 25 02 04 % 25-30 09 18 % 3035 05 10 % 3540 21 42 % >= 45 13 26 % 2 monthly income < 5000 21 42 % in rupees 5000 – 10,000 17 34 % 10,000 – 20,000 04 08 % > 20,000 08 16 % 3 amount in rupees < 500 04 08 % spent of alcohol 500 2000 25 50 % every month 2000 5000 12 24 % > 5000 09 18 % 4 family history of absent 28 56 % alcohol present 22 44 % consumption 5 no. of admissions first 11 22 % in psychiatry ward second 07 14 % third 14 28 % fourth 02 04 % > four 16 32 % 6 h/o stressor present 20 40% absent 30 60% 7 treatment good 05 10 % compliance poor 45 90 % 8 motivation average 13 26 % low 37 74 % patient patients total no. of no. of having spending > patients with positive monthly rs. 2,000 married family history income < on alcohol of alcoholism rs. 10,000 per month 76 % 42% 84% 44% patients 27 pjmsvolume 4 : number 2 : july dec. 2014 original article table 3: association of motivation with various factors those having history of some or the other stress were found to be having more number of admissions for de addiction though this was not significant statistically. we also found that those having more number of admissions had low motivation to quit alcohol and poor compliance to treatment. discussion: in the study conducted by sarkar et al. most of the patients were in the third decade of their age and married which was similar to the finding of present study with similar age group as commonest one and 84 percent of the patients were married (7). this can be due to the fact that most of the indian population marries before or during their thirties. however in this study most of the patients were educated up to secondary or higher secondary as opposed to those in study by sarkar et al where most of the patient had no formal education (7). but this finding was consistent with results of a study by pradeep rj et al (8). most of the patients in this study were non skilled workers and most of the patients (42%) had monthly income of less than 5000 rupees/month. this suggests most of the patients in our study belonged to lower socio-economic strata. this finding is similar to a population based study in bangalore in which 40 % participants had monthly income of 30006000 and 38 % had monthly income of less than 3000 rupees (9). 34% of the patients in our study had monthly income 5000-10,000 rupees. 4% of the patients in this study were divorced as opposed to 1 % in a study by sarkar et al. we did not find any difference between numbers of patients according to their locality which was similar to the finding by girish n et al (3) who also found no significant difference in number of patients from urban or rural area. in present study, 44 % of the patients had family history of alcoholism whereas few studies say that almost 83 % of the patients had positive family history for alcoholism (7). this finding in our study can be explained on the basis of catchment area of the hospital as most of the subject had come from distant places and are away from their families and environmental factors have a major role to play than the genes. in this study, 60 % of the patients continued consuming alcohol for reasons like periodicity of consumption, increased opportunities of consumption, easy availability, etc. whereas 40 % attributed their drinking to financial or family stressors. in the study by girish n et al (3) 58 % of the subjects used to consume alcohol to reduce pain and only 20 % attributed it to financial or family stressors. positive correlation was noted between presence of stressors and number of repeated admissions in present study. this suggests that stress is the major factor for acute increase in alcohol consumption and related complication for which patients seek medical help. it has long been known that stress increases the risk of alcohol relapse. clinical observations, surveys, and epidemiological studies document an association between self-reports of stressors and subsequent return to drinking (10). studies assessing alcohol relapse after treatment completion and discharge also indicate the contribution of highly stressful events independent of alcohol use history that increase the risk of subsequent relapse. furthermore, negative mood and stress are associated with increased craving, and high levels of urges to use alcohol predict relapse (10). most common reason for admission was found to be withdrawal related problems which suggests that most of the patients seek medical help variable motivation chi square p value age average low <35 5 11 0.337 0.562 >35 8 26 family h/o alcoholism present 6 16 0.033 0.856 absent 7 21 stress present 5 15 0.017 0.895 absent 8 22 reason for admission physical 12 32 fisher 1.00 withdrawal 1 5 exact test variable compliance p value age average low <35 4 12 fisher 0.031 >35 1 33 family h/o alcoholism present 2 20 fisher 1.00 absent 3 25 exact test stress present 3 17 fisher 0.377 absent 2 28 exact test reason for admission physical 3 41 fisher 0.103 withdrawal 2 4 exact test exact test table 5: association of number of admissions with various factors variable no. of admission chi square p value age 0ne more than one <35 8 8 2.002 0.157 >35 10 24 family h/o alcoholism present 9 13 0.411 0.522 absent 9 19 stress present 10 10 2.836 0.092 absent 8 22 reason for admission physical 15 29 fisher 0.654 withdrawal 3 3 exact test table 4: association of compliance with various factors 28 only when they have withdrawal symptoms. it was also noted that most of the patients had been brought to hospital due to pressure from their family members and had poor motivation to quite alcohol. the compliance to treatment was poor in most of them. conclusions: most of the participants in our study belonged to lower economic group. majority of the subjects were earning less than 10,000 rupees per month and 42% were spending more than 2,000 rupees per month on alcohol. motivation was low in majority of the participants. this can explain why maximum participants were brought by their family members. around 64% of the subjects had more than 2 admissions in psychiatry ward. compliance to the treatment was poor in 90% of the patients but compared to younger age group compliance was relatively good in those more than 35 years of age. stress also plays major role in relapse and readmissions as evident by the positive correlation between presence of stress and more number of admissions. implications: motivation is a deciding factor with respect to the number of admissions and compliance to the treatment. planning therapies to improve motivation and improving coping skills of the patients may reduce the relapse and number of admissions for alcohol related problems. limitations: 1) sample size was small and this was a cross-sectional study hence findings can't be generalized. 2) most of the participants were selected from suburban industrial area and rural area. 3) all subjects were males. findings can differ with inclusion of female patients. references: 1. global status report on alcohol. geneva: world health organization; 2004. 2. the world health report 2002 – reducing risks, promoting healthy life. geneva: world health organization; 2002. 3. girish n, kavita r, gururaj g, benegal v. alcohol use and implications for public health: patterns of use in four communities. indian j community med 2010; 35:238-44. 4. pal h, kumar a. epidemiology of substance use. in: lal r. substance use disorder manual for physician, new delhi aiims 2005: 8. 5. gururaj g, girish n, benegal v, chandra v, pandav r. public health problems caused by harmful use of alcohol – gaining less or losing more? alcohol control series 2, world health organisation. new delhi: regional office for south east asia; 2006. 6. park k. parks textbook of preventive medicine 21st ed. jabalpur, india: m/s banarsides bhalnot, 2011; 77. 7. sarkar ap, sen s, mondal s, singh op, chakraborty a, swaika b. a study on socio-demographic characteristics of alcoholics attending the de-addiction center at burdwan medical college and hospital in west bengal. indian j public health 2013; 57:33-5. 8. pradeep rj, banu s, ashok mv. severity of alcoholism in indian males: correlation with age of onset and family history of alcoholism. indian j psychiatry 2010; 52:243-9. 9. gururaj g, girish n, benegal v, chandra v, pandav r. burden and socio-economic impact of alcohol: the bangalore study. world health organization new delhi, india 2006. 10. sinha r. how does stress lead to risk of alcohol relapse? alcohol research: current reviews 2011; 34(4): 432-440. pjmsvolume 4 : number 2 : july dec. 2014 original article panacea final 2014 3 antibiotic resistance: antimicrobial resistance is a global pandemic. the worldwide use of antimicrobial compounds to treat infection lead to the evolution of microbes resistant to these compounds. beginning in the 1930s, antibiotics have had a near-miraculous impact on human and animal mortality and morbidity caused by bacterial infections. they have also been exploited for other uses, such as improved yields of meat from animals. the price of these dramatic benefits is that the prevalence of resistant microbes has dramatically increased to the point where, in some cases, antibiotics are no longer effective. the general trend to more widespread antibiotic resistance is relentless and, if it continues unabated, deaths from what were previously treatable infections will occur with increasing frequency. as the world health organization (who) (2004) stated unambiguously, 'today we are witnessing the emergence of drug resistance along with a decline in the discovery of new antibacterials. as a result, we are facing the possibility of a future without effective antibiotics. this would fundamentally change the way modern medicine is practiced.’ evolution of antibiotics: in the late 1920's, the scottish microbiologist alexander fleming returned from a trip to find that one of his petri dishes containing the bacterium, staphylococcus aureus, was contaminated with the mold, penicillium notatum. like a good scientist, he made an observation: there were no bacterial staphylococcal colonies growing directly around the mold. there was a zone that was free of bacterial growth directly surrounding the mold. upon closer inspection, he noticed that the mold was secreting a liquid (now called penicillin) that he later learned was the cause of death to the bacteria growing in close proximity to the mold. what fleming had discovered (actually, re-discovered) was an antibiotic: a chemical that inhibits the growth of or kills microorganisms (e.g. bacteria). antibiotics have evolved in fungi and bacteria as defenses against other microbes. in response to competition, many fungal and bacterial species have evolved chemical weapons to inhibit other species. antibiotics are the chemical weapons of fungi and bacteria. scientist quickly realized that antibiotics could help humanity in wedging war against bacteria, within a few decades; both naturally occurring and synthetic antibiotics were produced in mass quantities and given to people who were sick with infectious diseases and they worked. antibiotics were the miracle cure to all kinds of infectious diseases that had been plaguing humans for hundreds of years. antibiotics worked so well, in fact, that in 1969, the u.s. surgeon general declared: “it is time to close the book on infectious disease.” the war against bacteria was over, and we had won! had we really won? evolution of antibiotic resistance: whenever antibiotics wage war on microorganisms, a few of the enemy are able to survive the drug. being living organisms, these surviving microbes want to protect themselves. microbes are always mutating; some random mutation eventually will develop resistance against the drug. the danger was already recognized by alexander fleming, back in 1945, he had warned that misuse of penicillin could lead to the selection and propagation of mutant forms of bacteria resistant to the drug. the first penicillin-resistant bacteria appeared few years later. their mutant gene encoded for a penicillin-destroying enzyme, penicillinase. penicillin treatment kills non-resistant, but leaves behind resistant bacteria. today, especially in hospitals, there are strains of staphylococcal bacteria that are resistant to nearly all known antibiotics. although most of the multiple-drug resistant staphylococcal strains are only found in hospitals, recently, four children in north dakota and minnesota were killed by staphylococcal infections that they had acquired outside of a hospital. staphylococcus is not the only problem bacterium. more than two-dozen types of bacteria are now resistant to one or more types of antibiotics that had previously been effective against them. people are dying from infections that were easily treated just a few years ago. it has been estimated that infections caused by resistant bacteria kill as many as 77,000 people every year in the united states alone. resistance to antibiotics costs money as well as lives. uneven fight: quoting from the british medical journal “to 395-millionyear-old strains of bacteria, a half-century of antibiotics is like abstract: antibiotic resistance is an alarming health crisis. with the large-scale use of antibiotics a large number of microorganisms (both gram-negative and gram-positive organisms) have acquired resistance or multi resistance to different antimicrobial drugs. this antibiotic resistance is common in hospitals and community. this review article focuses on the molecular mechanism and preventive strategies of antibiotic resistance. keywords: antibacterial, resistance, epidemiology, prevention pjmsvolume 4 number 1: jan june 2014 review article antibiotic resistance : epidemiology, molecular mechanism and preventive strategies 1 kapse ashok 1 consultant pediatrician, surat ashok.kapse@gmail.com 4 microorganisms. in icus in the usa, the proportion of mrsa isolates among s. aureus isolates increased remarkably from 1992 to 2003. a study in the icus in usa showed that resistant staphylococcus aureus isolates accounted for 52% of the icu infections, followed by enterococcus sapprophyties. (28%), pseudomonas aeruginosa (23%) and klebsiella pneumoniae (10%). the overall susceptibility to ciprofloxacin among aerobic gram-negative bacilli declined from 89% in 1990-1993 to 86% in 1994 and 76% in 2000. the most notable reductions in ciprofloxacin susceptibility were seen with p aeruginosa. the decline in activity of ciprofloxacin correlates directly with increase in use of quinolones. evolving problem of antimicrobial resistance in pseudomonas aeruginosa, acinetobacter baumannii and k. pneumoniae is so grave that it has led to the emergence of clinical isolates susceptible to only one class of antimicrobial agent; these isolates are termed as pandrug-resistant isolates. pandrug-resistant strains are associated with significant treatment failures and consequent mortality (2-3). antibiotic resistance in community: antibiotic resistance in the community is an emerging global problem. the normal individual flora, which is important for the maintenance of individual health, can play a critically important role in infectious diseases. carriage of resistant bacteria such as mrsa, entendedspectrombeta lactamase (esbc) enterobacteriaceae and pneumococci may result in infections. in fact, carriage of such pathogens and infections related to them is not rare in the community. in a study performed in saudi arabia, fecal carriage of esbl+ organisms was detected in 26.1% of 272 in-patients, 15.4% of 162 out-patients, and 13.1% of 426 healthy individuals. the esbl rate of community-acquired urinary tract infections related e. coli strains are 7.9% in turkey and 34.4% in india (4). streptococcus pneumoniae which used to be exquisitely sensitive to penicilline has acquired resistance against it; cross-resistance with other frequently used antibiotics is common among these community acquired penicillin resistant organisms. streptococcus pneumoniae have important community reservoirs. yildirim et al reported 8.3% intermediately resistant s. pneumoniae carriage in 484 children (4). mrsa has emerged as a cause of skin infections and, less commonly, invasive infections among otherwise healthy adults and children in the community. a surveillance study was conducted simultaneously at three centers across india. a total of 13,610 test samples from various sites were obtained. antimicrobial susceptibility testing of the isolated strains of staphylococcus aureus and staphylococcus epidermidis to various antimicrobial discs were carried out according to standardized disk diffusion method pjmsvolume 4 number 1: jan june 2014 review article bagatelle! (1), yes, for a bacterium that has existed for million of years without any opposition, a 50-year-old antibiotic may sound a little bit difficult to digest. this could be summarized as war between microbial evolution vs. microevolution. microbes not only have rapid generation time but also posses' efficient means for vertical as well horizontal genetic transfer which in turn swiftly disseminates resistance among different bacteria. bacteria have continued to react to human attempts of controlling them by evading the mechanism of action of antibiotics. growth of new antibiotics has slowed down – resistant microorganisms are increasing at rapid tempo; microbes have clearly outpaced man's ingenuity for antibiotic development. epidemiology: more than 50 years of the large-scale use of antibiotics have resulted in a number of microorganisms which have acquired resistance or multi resistance to different antimicrobial drugs. both gram-negative and gram-positive organisms have demonstrated excellent capability to undermine the effectiveness of one or more antimicrobial agents (2). although problems related to antibiotic resistance differ from unit to unit, hospital to hospital and c o u n t r y t o c o u n t r y h o w e v e r n o t a b l y re s i s t a n t microorganisms do not recognize boundaries between countries; hence, the epidemiology of resistance may be multinational, with some transferable determinants are prevalent worldwide. medical literature on the transfer of resistance from city to city and country to country is widely available. emergence of multidrug resistance among certain strains of gram-negative bacteria such as shigella, klebsiella, enterobacter, acinetobacter, salmonella species and grampositive organisms such as staphylococcus, enterococcus and streptococcus species is extremely troublesome. in recent years there has been a progressive increase in frequency of methicillin-resistant staphylococcus aureus (mrsa), vancomycin-resistant enterococcus species and extended spectrum ß-lactamase producing klebsiella pneumoniae and escherichia coli (2-3). antibiotic resistance in hospitals (abr): resistant nosocomial infections are common in hospital settings. antibiotic usage has been shown to have a critical role in the selection of antibiotic-resistant bacteria as the dominant colonizing flora as well as the nosocomial pathogens of hospitalized patients. resistance acquisition has two mechanisms: firstly antimicrobial-resistant flora may be endemic within the institution and may be transferred to the patient within the hospital setting. second, a small population of antimicrobial-resistant bacteria that are a part of patient's endogenous flora at the time of hospitalization may emerge under the selective pressure of antibiotics and become the dominant flora. icu related infections are c o m m o n a n d o f t e n a s s o c i a t e d w i t h r e s i s t a n t 5 pjmsvolume 4 number 1: jan june 2014 review article recommended by national committee for clinical laboratory standards. of the total 739 cultures of s. aureus, 235 (32%) were found to be multiply resistant with the individual figures for resistance being 27% (mumbai), 42.5% (delhi) and 47% (bangalore). mrsa carriage was reported to be 2.6% in 500 healthy adults and 1.9% in 500 healthcare workers (5). abr: molecular mechanism: microbes are endowed with molecular mechanisms for resistance development, determinants of antibiotic resistance are much older than our antibiotic therapy; nevertheless, unrestrained antibiotic prescribing has fuelled resistance to a very high and level. bacteria acquire resistance by either genetic mutation or horizontal gene transfer from other organisms (6). genetic mutation: under pressure from antibiotic therapy bacteria undergo spontaneous single or multiple changes in bacterial dna, some of these changes code for resistance; resistant survivors may undergo separate mutations over hundreds of generations that favors maintenance of resistance. horizontal gene transfer (hgt): this could be by addition of plasmid or transposons. a) plasmids: a circular, double-stranded unit of dna that replicates within a cell independently of the chromosomal dna. plasmids carry resistant genes which could be easily transferred to other bacteria. b) transposons are short, specialized sequences of dna that can insert into plasmids or bacterial chromosomes. transposon's house genes for resistance determinants, some of these also contain genes for their chromosomal integration and expression. abr: physiological mechanism: bacteria engineer varied physiological mechanisms to protect themselves from antibiotic onslaught. majority of these mechanisms effectively decrease antibiotic efficacy. some of these mechanisms are as below (6): 1.diminishing intracellular drug concentration: i.decreasing outer membrane permeability (b-lactams) ii.d e c r e a s i n g c y t o p l a s m i c m e m b r a n e t r a n s p o r t (quinolones, aminoglycosides) iii.activating antibiotic efflux pumps (multiple drugs, quinolones, macrolides, tetracyclines) by above mechanisms bacteria decrease the intracellular drug to such a low level that the concentration of the drug becomes therapeutically ineffective. 2.drug inactivation (reversible or irreversible) some resistant bacteria inactivate the antibiotic by destroying or modifying the drug itself so that it is no longer toxic. i.modifying enzymes (ß-lactams destroying ß-lactamases) ii.inactivating enzymes (chloramphenicol) 3. altering the antibiotic target: several resistant species have an altered form of the target site of the drug (the place on the cell where the drug binds), so the antibiotics fail to “find” its target. i.target modification (quinolones, ß-lactams, macrolides, linezolid) ii.target bypass (glycopeptides, trimethoprim) abr development: clinico epidemiological settings: antibiotic therapy unintentionally selects resistance, mcgovan and tenovar (7) describe following six basic mechanisms by which resistance is introduced, selected, maintained and spread in health care settings. 1)acquisition of resistance by a few previously susceptible strains through genetic mutation in reservoirs of high organism concentration such as an abscess. 2)acquisition of resistance by a susceptible strain through transfer of genetic material, for example in the gut or on the skin. 3)emergence of inducible resistance that is already present in a few strains in the bacterial population. usually from direct selection by antibiotic prescribing. 4)selection of a small resistance subpopulation of organism, again by antibiotic prescribing. 5)introduction of a few resistant organisms into a population where resistance previously was not present, usually by transfer from another healthcare system but also from community. 6)dissemination of inherently resistant organism locally within the specific setting due to poor infection control procedure. in the want of effective antibiotic policies once selected resistance rapidly grows; there are four interacting variables: patient, organism, drug and environment which need proper understanding for developing effective resistance control strategies (8). patient: large inoculum of organisms as in abscess cavity potentiates the increase in preexistent resistant mutants. presence of foreign body which may lower antibiotic concentration at the site of infection is likely to select resistance; immune compromised patient with slower eradication of infection may also favor resistance development. organism: certain organisms are more capable of producing resistance, staphylococcus, enterococcus, pseudomonas, and many other gram negative bacilli have high potential for 6 pjmsvolume 4 number 1: jan june 2014 review article acquiring antibiotic resistance, conversely antibiotic resistance has not been a problem in among the atypical pulmonary pathogens (e.g., legionella, mycoplasma pneumoniae, chlamydia pneumoniae). rickettsia and spirochetal organisms also have not shown significant resistance development. on removal of selective pressure, reversion to sensitivity may occur, although it may take longer than the initial process of resistance development, however, in certain organisms' genetic compensation for the cost of resistance may well occur, i.e. the resistant survivors can undergo separate mutations over next several generations that would favor maintenance of the resistant gene. mrsa and vre have shown this kind of genetic compensations. generally compensation is more likely outcome than reversion however; adaptive resistance is more likely to revert unless it is mutational. situation is complex where resistance evolves to multiple drugs collectively. the worst scenario is the presence of an integron, a type of transposon, which can accommodate resistant determinants for many drugs in concert. in integron coded resistance it is likely that use of any antibiotic which is represented on that integron will select evolution of resistance to all the antibiotic agents to whom the resistance determinants are coded on that particular integron. transposons can also code for active efflux of many different classes of antibiotics (the 'sumppump' resistance mechanism). the fluoroquinolones possess capability to activate this resistance mechanism. drug: antibacterial resistance development (abrd) potential: not all antibacterial drugs exert analogous resistance selection pressure. some antibacterial drugs possess exceptional resistance development potential, while others lack this character (9). ceftriaxone is an excellent example of a low abr development potential antibiotic; despite high volumes uses over a long period, it has generally remained free of significant resistance problem. conversely resistance against ciprofloxacin and imipenem among pseudomonas was reported even during clinical trials and early after introduction in clinical use (9). knowledge of this particular characteristic of antibacterial agents should be one of the most vital determinants of antibiotic choice. antibiotics with high resistance development potential should have restricted clinical uses, while antibiotics with low resistance development potential could have free clinical uses. collateral damage: human body is studded with lots of bacteria, according to an estimate around 5000 to 10000 different species of bacteria live in the human body. called as commensals these bacteria constitute a significant defense mechanism of our body. when a broad spectrum antibiotic is deployed in a patient, it not only kills offending bacteria but vastly damages commensal flora. many of these commensal under go mutational changes and acquire antibacterial resistance. increasing esbl producing e. coli is a classic example of this kind of collateral damage. practice of using oral third generation cephalosporins for community acquired respiratory infections and fevers is playing a huge havoc world over. cephalosporins have a hand, not only for selecting extended spectrum-lactamase (esbl)-producing enterobacteriaceae and stably depressed mutants of inducible enterobacteriaceae, but also enterococci, methicillin-resistant s. aureus (mrsa), clostridium difficile and yeasts. many studies have shown a reduction in the incidence, if not complete eradication of problem organisms by decreasing cephalosporin uses (8). inappropriate antibiotic therapy: inappropriate antibiotic therapy can be defined as one or more of the following (9): · unnecessary antibiotic prescription for viral diseases · the wrong choice, dose or duration of therapy · ineffective initial empiric treatment of serious bacterial infection. · poor tissue penetration of chosen antibacterial. unnecessary antibiotic prescription for viral diseases: hospitals are the places where lots of antibiotics are supposed to be used, nonetheless; community originated ailments like community originated respiratory infections, fevers, and diarrheas consume a much higher proportion of antibiotics. it is difficult to asses' indications and rational for out patient antibiotic prescriptions, but in 1992 a study using physician surveys revealed that, in the united states, five diagnoses accounted for 76% of all antibiotic prescriptions in community practice: otitis media, upper respiratory infections, bronchitis, pharyngitis, and sinusitis (10). many of these conditions are considered to be of viral etiology and do not benefit from antibiotic therapy, and therefore a substantial proportion of outpatient antibiotic prescriptions can be considered inappropriate or unnecessary. in usa according to a study based extrapolation it is estimated that 6.5 million prescriptions were written for children diagnosed with a uri or the common cold (11). despite knowing too well that antibiotics are unnecessary in upper respiratory infections, physicians tend to prescribe them more out of a habit. except a false sense of security there aren't good reasons for this habitual compulsion. unfortunately ab with high ab with high low resistance potential resistance potential ampicillin amoxicillin carbenicillin pipercillin tetracycline doxycycline, minocycline ciprofloxacin ofloxacin, glevofloxacin gentamicin amikacin ceftazidime ceftriaxone, cefepime imipenem meropenem 7 pjmsvolume 4 number 1: jan june 2014 review article prevalence of this bad habit is equal among junior practioners, among senior practioners, in private practioners and as well in academicians. these scientifically base less prescriptions have a stupendous effect in terms of antibacterial resistance. it is very well known that after a short course of antibiotic like ampicillin, resistant bacteria may persist in faces for as long as three months, these resistant bugs are potentially infectious to other members of the family and community long after the cessation of therapy (9). physician prescribing practices in turn influence their patients' attitudes about the need for antibiotics. in an emergency interview study almost one-fifth of patients had used antibiotics without consulting physician from left over drugs of previous illnesses citing that there physician regularly prescribes antibiotic for common cold. this creates a tremendously dangerous situation in countries where there are no controls over procuring medicines from chemist. patients may start antibiotics by themselves in the case of fever or common cold or to overcome malaise, fatigue or pain. antibiotic leftovers, especially by the point of disappearance of the symptoms, are also common. in a multicenter study performed in ten countries, overall prevalence of possession of leftovers was reported to be 51.9% in 3649 subjects who obtained antibiotics by filing for a new prescription or received them from a medical professional (12). the prevalence ranged between 13.5% (the netherlands) and 90% (china). further use of leftover antibiotics in subsequent infection was also very high (70% in 2252 subjects, ranging between 44.4% in the netherlands and 90.2% in russia) (12). aggressive marketing practices by drug companies greatly fuel these wrong practices. the wrong choice, dose or duration of therapy: in the developing world decision about antibiotic therapy are taken empirically, even in hospitalized patients microbiology support is very meager. many a time's treating physician is in a dilemma about pathogenic microbe, this dilemma invariably induces insecurity; to overcome this predicament physician tends to prescribe a broad spectrum antibiotic. broad spectrum antibiotic inflicts detrimental collateral damage which in turn breeds antibacterial resistance (8).traditional teaching maintains that infections initially should be treated with low doses of mild antibiotics and only a failed treatment should be the contemplation for up scaling the drug doses or consideration of stronger antibiotic. unfortunately these concepts disregard the vital fact that a failed treatment means more chances for mutation and increased odds for antibacterial resistance development. it is the recovering partially damaged bacteria which tend to mutate; antibacterial therapy should brutally kill maximum number of bacteria in a shortest period of time, it must never leave any chances for bacteria for mutation (13). duration of therapy is generally decided empirically. for economic considerations physicians and or patient may try to shorten the course of antibiotic therapy. this may increase the chances for bacterial mutation and a consequent antibacterial resistance development. patient's desire and capability for taking medicines should receive appropriate considerations; a few underlying assumptions about human nature, as highlighted by sanson-fisher et al (11), may ensure that a prescription translates to more than a slip of paper. ·no patients take pills more than 3 times daily. ·no patients take a medication for more than 5 days in a row. ·frequent dosing increases the chances for missed doses. ·no patients take medication that makes them feel worse. delayed appropriate therapy: even at the best of the centers, pending culture sensitivity reports initial antibiotic therapy is selected empirically. a proper selection of antibiotic regimen is vitally important for patient's survival and recovery. a wrong initial choice of antibiotics invariably culminates into poor outcome. starting inappropriate therapy affects not only mortality but also duration of hospitalization; as inappropriate therapy is prolonged, the likelihood of resistant bacteria arising will increase, which sometimes may result in the occurrence of outbreaks. mortality rates are higher among patients with ventilator-associated pneumonia who receive inappropriate empirical treatment (13). poor tissue penetration: microbes are likely to develop resistance if exposed to low antibiotic concentrations; this is particularly true for antibiotic which has a high antibacterial resistance development potential. antibiotic failure and resistance development is more common in body sites where achieving adequate antibiotic concentration is usually difficult. abscess cavities, pyelonephritic kidneys, and csf are some of the places where sub optimal antibiotic concentrations could be anticipated. low antibiotic resistance potential and good tissue penetration should receive due considerations in making antibiotic choice in such conditions (9). environment: hospital or community is the environmental places where bacteria cultivate resistance. hospitals facilitate bacterial resistance development by providing number of opportune circumstances; some of them are listed as below (8): ·greater severity of illness of hospitalized patients. ·more severely immunocompromised patients. ·newer devices and procedures in use. ·increased introduction of resistant organisms from the community. ·ineffective infection control and isolation practices and compliance. ·increased empirical poly microbial antimicrobial therapy. 8 pjmsvolume 4 number 1: jan june 2014 review article ·high antimicrobial usage for geographical area per unit time. however as earlier been stated community offers much greater chance for bacterial resistance development by providing unnecessary antibiotic uses for viral respiratory infections. livestock feed: antibiotics and steroids are commonly added to animal feed, steroids are used to increase the size of animal, while antibiotics are added to chicken and cattle feed to prevent infections. while evidences are lacking that such addition of antibiotics to livestock feed prevents infection; there are enough data that these practices disgustingly increase antibacterial resistance (14). according to burke a. cunha who heads the division of infectious diseases at winthropuniversity hospital in mineola, n.y. animal agriculture is playing a disproportionately large role in induction of antibacterial resistance; the volume of antibiotics used in animal feeds equals or exceeds that used to treat infections in humans; worst is, many of the antibiotics that have been used to supplement animal feeds are the very ones most likely to induce resistance e.g. ciprofloxacin, tetracycline. resistant bacteria developed in livestock can taint the meat or foods exposed to the animals and thereby gain into human gut (13). strategies to prevent antibacterial resistance: antibiotic resistance is a direct consequence of antibiotic use. there is continuous escalation of both, equally in the hospital and in the community despite many calls for moderation in antibiotic use. eradication of resistance is impossible and development of resistance to any particular antibiotic is inevitable yet with proper strategies antibacterial resistance could be decreased and pace of resistance evolution may be stalled. strategies need to address to: contain and/or decrease the already existent resistance, prevent further emergence and spread of resistance (13). control of resistance in the community: ending in-appropriate antibiotic uses: watchful waiting: most of the community acquired fevers, diarrheas, and respiratory infections are viral in origin and aren't much benefited with antibiotic therapy, conversely needless antibiotic therapy provoke unnecessary anti bacterial resistance development. good symptomatic therapy with a watchful waiting is sufficient intervention in majority of such patients (15). timely laboratory help, telephonic counseling, and repeat clinical evaluation are integral to such watchful waiting. use antibiotic with least antibacterial resistance development potential: antibiotic usage is an important contributor to antimicrobial resistance. the ideal is to have all patients treated with the most effective, least toxic and least costly antibiotic for the optimal time. in a particular indication, when the treatment options have similar clinical efficacy; using the antibiotic with the least resistance-inducing capacity is of critical importance (9). unfortunately this particular aspect of antibiotic therapy hasn't been properly addressed and emphasized till far. medical professionals should have adequate information regarding antibacterial resistance development potential of antibiotics which they use in their clinical practice. avoid broad spectrum antibiotic: routine use of broad-spectrum antibiotics for minor infections significantly adds to infection and colonization of the general population with increasingly hardy and difficultto-treat microbes. according to the centers for disease control and prevention (cdc) sources, indiscriminate use of broad-spectrum antibiotics more than doubles an individual's chance of acquiring future infection with resistant organisms. use antibiotics by guidelines/ protocols based on local organisms and drug sensitivity pattern: antibiotic administration guidelines/protocols developed locally or by national societies potentially avoid unnecessary antibiotic administration and increase therapeutic effectiveness. unfortunately, even well-developed guidelines/protocols may not translate into widely accepted t r e a t m e n t a l g o r i t h m s . s o m e d e v i a t i o n f r o m guidelines/protocols is expected because medical decisionmaking should be guided by an individual patient's characteristics and the judgment and experience of the caregivers. locally developed guidelines therefore often have the best chance of being accepted by local health care providers and hence of being better implemented (16). controlling resistance in the hospitals: as has earlier been discussed hospitals particularly icus provide enough opportunities for development of antibacterial resistance. various antibiotic policies: antibiotic cycling, antibiotic rotation, antibiotic combination, restricting broad spectrum antibiotics, restricting hospital formulary etc. have been tried to decrease antibiotic resistance development. none of these barring restricting use of antibiotic with high resistance potential development has given consistently desired results (17). the selection of antibiotic in a hospital formulary must take in to account different factors but resistance potential should be the most important feature in such selection. antibiotic with known resistance problem should be removed from hospital 9 pjmsvolume 4 number 1: jan june 2014 review article formularies. a properly restricted hospital formulary is the best antibiotic resistance measure (17). by substituting a vacuum cleaner antibiotic (e.g., an antibiotic with an equilant spectrum but no or little resistance potential) a hospital environment can be restored to a relatively resistance free atmosphere. replacing ceftazidime, imipenem and gentamycin by drugs like cefepime, meropenem and amikacin respectively could result into significant decrease in resistance among resistant pseudomonas, enterobacter, vre, and mrsa (9). controlling transmission of antibiotic resistance: transmission of antibiotic resistance need following strategies (18): a)techniques for the early recognition of resistant microorganisms via methods such as more rapid diagnostic techniques, surveillance systems and screening of patients and staff: b) reduction of infectivity through the use of antimicrobials and disinfectants. c) reduction of the chance of spread by isolation of the colonized or infected cases and through improvements in hand hygiene (alcohol based hand rubs, universal gloving). d) improvements in the spacing of beds in hospitals. e) screening & isolation decreasing antibiotic supplementation in animal feeds: it is estimated that more than half of all antibiotics produced worldwide are used in animals: there is need to continue developing the evidence base to assess the risks to human health associated with the presence in food and feed of antibacterial-resistant micro-organisms, co-ordination with veterinary bodies and convincing them to stop this kind antibiotic uses is of paramount importance (16). newer antibiotic research: the main expense to the drug industry related to resistance is the money spent on r&d on new antibiotics and, unfortunately, there is an absolute decline in the development of new antibiotics by pharmaceutical companies. aventis, eli lilly, bristol-myers squibb, glaxosmithkline, proctor & gamble, roche and wyeth have greatly curtailed, wholly eliminated or spun off their antibacterial research. “the pipeline for new antibacterial is drying up” says infectious diseases society of america (idsa) (19), since 1998, only 10 new antibiotics have been approved, and only two of those were truly novel defined as having a new mechanism of action with no cross-resistance with other antibiotics and resistance to antibacterial continues to increase; maybe it's time to look at older antibiotics again. critical issues: microorganisms will keep on developing and disseminating resistance as an opposite reaction to anti microbials in accordance with the laws of evolution and natural selection. multidrug-resistant bacterial infections comprise a great problem both in community-acquired and healthcareassociated infections. antibiotic resistance is usually associated with significant morbidity, longer hospitalization, excess costs and mortality. inappropriate antibiotic usage is an important contributor to antimicrobial resistance; unfortunately awareness among medical professionals is lacking about this vital issue; there is an urgent need to heighten consciousness of doctors about this problem. in most of the situations antibiotic choice is made empirically. during residency antibiotherapy, choices regarding several clinical conditions are generally learnt from the seniors. the seniors, in turn, had learnt from their seniors. hence, acceptance of new knowledge into traditional practice needs acceptance first by senior members of this teaching pyramid. unfortunately such an acceptance occurs very rarely (20). proper antibiotic policies vastly improve antibiotic consumption, and this improvement results in less antimicrobial resistance. knowledge about antibiotic resistance development potential and choosing antibiotic with least resistance development problem can solve and prevent lots of problematic issues. antibiotic policies, and implementation of infection control measures (such as hand washing), screening and isolation are the strategies aimed at prevention of emergence and spread of antibiotic resistance. drug industry is shying away from investing in antibiotics research and development. we are dependent on the pharmaceutical industry to provide us with new antimicrobial agents; there is an urgent need for dialogue between stakeholders on how investment in antibiotic development can best be achieved (21). references: (1) richard w, tony h, otto c, marc s, reinen h, pentti h, et al. antimicrobial resistance is a major threat to public health. bmj 1998; 317: 609-610. (2) hooper d. fluoroquinolone resistance among grampositive cocci. lancet infect dis 2002; 2: 530–538. (3) gross r. consequences of antibiotic resistance. clin infect dis 2001; 33:289. (4) goossens h, sprenger mjw. community-acquired infections and bacterial resistance. bmj 1998; 317: 654-7. (5) mehta a, rodrigues c, kumar r, rattan a, sridhar h, mattoo v, ginde v. a pilot program of methicillin-resistant staphylococcus aureus (mrsa) surveillance in india. (mrsa surveillance study group). j postgrad med 1996; 42:1-3. (6) kaye sk. pathogens resistant to antimicrobial agents: epidemiology, molecular mechanism, and clinical management. infect dis clin n am 2004; 18(3): 467-511. 10 pjmsvolume 4 number 1: jan june 2014 review article (7) mcgowan je, tenover fc. control of antimicrobial resistance in the health care system. infectious disease clinics of north america 1997; 11: 297–311. (8) gould im. a review of the role of antibiotic policies in the control of antibiotic resistance. journal of antimicrobial chemotherapy 1999; 43: 459–465. (9) cunha ba. antibiotic resistance. med clin am 2000; 84: 1407-1421. (10) gonzales r, steiner jf, sande ma. antibiotic prescribing for adults with colds, upper respiratory tract infections and bronchitis by ambulatory care physicians. jama 1997; 278: 901-904. (11) nyquist ac, gonzales r, steiner jf, sande ma. antibiotic prescribing for children with colds, upper respiratory tract infections and bronchitis. jama 1998; 279: 875-877. (12) kardas p, pechère jc, hughes da, cornaglia g. a global survey of antibiotic leftovers in the outpatient setting. int j antimicrob agents 2007; 30(6): 530-536. (13) cunha ba. antibiotic resistance: control strategies crit care clin 1996; 8:309. (14) bennish ml. animals, humans, and antibiotics:implications of the veterinary use of antibiotics on human health. adv pediatr infect dis 1999; 14: 269-90. (15) mccaig lf, hughes jm. trends in antimicrobial drug prescribing among office-based physicians in the united states. jama 1995; 273: 214-219. (16) kish ma. guide to development of practice guidelines. clin infect dis 2001; 32: 851-854. (17) cunha ba. factors in antibiotic selection. hosp formulary 1998; 33:558. (18) siegel jd, rhinehart e, jackson m, chiarello l, healthcare infection control practices advisory committee. 2007 guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings. (19) spellberg b, guidos r, gilbert d, bradley j, boucher h, scheld w, et al. the epidemic of antibiotic-resistant infections: a call to action for the medical community from the infectious diseases society of america. clin infect dis 2008; 46: 155-164. (20) buke ac, ermertcan s, hosgor-limoncu m, ciceklioglu m, eren s. rational antibiotic use and academic staff. int j antimicrob agents 2003; 21(1): 63-66. (21) power e. impact of antibiotic restrictions: the pharmaceutical perspective. clin microb infect 2006; 12(5): 25-34. page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 page 1 page 2 page 3 page 4 page 5 page 6 page 7 page 8 page 9 page 10 page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 page 21 page 22 page 23 page 24 page 25 page 26 page 27 page 28 page 29 page 30 page 31 page 32 page 33 page 34 page 35 page 36 page 37 page 38 page 39 page 40 page 41 page 42 page 43 page 44 page 45 page 46 page 47 page 48 page 49 page 50 page 51 page 52 page 53 page 54 page 55 page 56 page 57 page 58 page 59 page 60 page 61 page 62 page 63 page 64 page 65 page 66 page 67 page 68 page 69 page 70 page 71 page 72 page 73 page 74 page 75 page 76 page 77 page 78 page 79 page 80 page 81 page 82 page 83 page 84 page 85 page 86 page 87 page 88 page 89 page 90 page 91 page 92 page 93 page 94 page 95 page 96 page 97 page 98 page 99 page 100 panacea journal of medical sciences 2021;11(2):223–230 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article ultrasonography based imaging criterion to ascertain pancreatic enlargement in pediatric acute pancreatitis dhanraj s raut1,*, shubhangi a desai2, dhananjay v raje2, dinesh singh3, vithalrao p dandge1 1dept. of paediatrics, nkp salve institute of medical sciences, nagpur, maharashtra, india 2mds bio-analytics pvt. ltd., mumbai, maharashtra, india 3spiral ct sacan and diagnostic centre, nagpur, maharashtra, india a r t i c l e i n f o article history: received 22-11-2020 accepted 22-01-2021 available online 25-08-2021 keywords: amylase computed tomography gastroenterology lipase multiple logistic regression radiology and receiver operating characteristics curve. a b s t r a c t introduction: imaging studies have shown enlargement of pancreatic parts in children diagnosed with acute pancreatitis. the purpose here is to develop imaging based diagnostic evaluation criterion for acute pancreatitis in children. materials and methods: this study included 62 children of acute pancreatitis in the age range of 0.33 to 13 years, as reported in a single hospital center (1994-2019). a study was planned including 1116 normal healthy children in the age range of 0.16 to 18 years for pancreatic evaluation during 2016-17. ultrasonography based measurement of three pancreatic parts were obtained for each individual in disease and normal groups. age-adjusted receiver operating characteristics curve analysis was performed on each pancreatic part independently to derive respective cut-offs using a training set. these cut-offs were further referred to dichotomize the measurement data for each individual and was subjected to multiple logistic regression with presence/absence of acute pancreatitis as dependent variable. a probability score and accordingly the cut-off were obtained indicating a collective impression of enlargement of pancreas in disease condition independently for males and females. result: on test data, the accuracy of age-adjusted cut-offs for three parts was near 80% for males, while it ranged between 81-85% for females. roc analysis of probability score resulted into threshold value of 0.024 for males and 0.044 for females, with sensitivity of 94.11% and 90.91% respectively. the classification accuracy of score derived for males and females was nearly same (83%). conclusion: the extent of enlargement of pancreas in acute pancreatitis in children can be determined using the mlr method along with hypoechogenicity. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction acute pancreatitis (ap) is an emerging problem in pediatrics with most cases resolving spontaneously. 1 in the year 1935, dobbs first drew attention to the occurrence of ap in children. 2 pediatric onset of ap is labeled when the first episode of ap occurs before the patient’s 19th * corresponding author. e-mail address: 147dsr@gmail.com (d. s. raut). birthday. 3,4 the disorder spans across pediatric age range, with either focal or diffuse process, and may occur as a single episode, recur or become chronic. 5,6 recent studies estimate the incidence of ap between 3.6 and 13.2 cases per 100,000 children per year. 7 the insppire (international study group of pediatric pancreatitis: in search for a cure) consortium meeting in december 2010 and may 2011 operationally defined the diagnosis of ap as requiring two of the following three criteria:(a) abdominal pain https://doi.org/10.18231/j.pjms.2021.047 2249-8176/© 2021 innovative publication, all rights reserved. 223 224 raut et al. / panacea journal of medical sciences 2021;11(2):223–230 compatible with acute pancreatitis (b) serum amylase or lipase levels greater or equal to three times the upper limits of normal, and (c) imaging findings consistent with ap. 3,4,8,9 as per the first insppire criterion, acute onset of persistent upper abdominal pain, along with nausea and vomiting is the hallmark symptom of ap. 10 measurements of serum lipase had a sensitivity and specificity of 96.6% and 99.4% respectively, whereas serum amylase had a sensitivity and specificity of 78.6% and 99.1% respectively. 11 the urinary amylase excretion is highly sensitive indicator of presence of ap. 12 currently, ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging are the three widely used imaging modalities for evaluating pancreatitis in the pediatric population. 13 abdominal usg is used as the radiologic procedure of choice with symptoms referable to the pancreas. 1,3,7,14–16 usg findings in ap often result in a hypoechoic gland that is focally or diffusely enlarged. 9,15,17 nearly 20% or more with ap initially had normal imaging findings especially in early stages or mild cases. 5 the sensitivity of trans-abdominal ultrasound in detecting pancreatitis was reported as 79.4%.while the sensitivity of ct was reported as 4781%. 1,13 referring to the imaging criterion of insppire as on date, there are no specific guidelines to decide the enlargement of pancreas in ap. therefore, this study aims at determining the extent of enlargement of head, body, and tail of pancreas in ap cases, already diagnosed with clinically and biochemically documented criteria. till date, no study has focused on the entire three parts together and derived criterion for enlargement of pancreas in the disease condition. 2. materials and methods this is a retrospective study in which we reviewed the medical records of total 69 children diagnosed with acute pancreatitis from a single hospital (children) located in a mega town of central india. the age of children ranged between 3.5 months to 13 years as reported during the period of september 1994-july 2019. the completed demographic, clinical, biochemical and radiological details were retrieved from medical records for the children. out of these 69 cases, 63 satisfied two of the three insppire criteria and were considered for downstream analysis. amongst these: a) 61 patients presented with severe epigastric abdominal pain with persistent vomiting b) serum amylase level was more than 375 iu /l (normal: 25 to 125 iu/l by kinetic method) in 41 cases and the urinary amylase was raised more than 48.1 iu/ hr (normal 6 to 48.1 iu/hr by kinetic method) in 25 cases with c) abdominal usg finding with enlarged, bulky and hypoechoic pancreas in 37cases reported by the radiologist. according to insppire criteria 2 out of 3 are required for diagnosis of ap in children, accordingly in present study pain in abdomen was observed in 61 patients and with raised serum amylase in 39 cases, which fulfill the criteria to be labeled as ap in 39 cases. in remaining 22 cases having pain in abdomen with positive abdominal usg and raised urinary amylase constitute the criteria for diagnosis of ap in 22 cases. hence total 61 cases were diagnosed and in remaining 2 cases the pain in abdomen was not presenting feature. out of these two cases, in one case, infant was 3.5-month old had extreme irritability with positive abdominal usg along with raised serum amylase. in other case presented with painless pancreatitis and the diagnosis was made on the basis of two criteria as raised serum amylase and positive abdominal usg. thus, above 63 cases fulfilled the insppire criteria for diagnosing ap. it was observed that the lipase study was not done. from the record it was observed that the urinary amylase was tested in 28 patients and in 25 showed raised levels. urinary amylase testing was done, when the patient presented after 4 days of pain in abdomen (after 4 days, serum amylase level may become normal in ap patients5). all the patients received medical treatment and were followed up for the entire hospital course until clinical recovery. the clinical recovery was judged by disappearance of epigastric tenderness. upon clinical recovery, every patient was subjected to second abdominal usg, and accordingly the scans were available. a sample sonogram at diagnosis and after recovery is shown in figure 1. to establish the imaging-based criterion for enlargement of pancreas in ap, a study to generate normative data on pancreatic dimensions was planned during june 2016-december 2017, in which normal children were enrolled for abdominal usg evaluation. the aim was to establish the age and gender-specific pancreatic dimensions in normal children, so as to ascertain the pancreatic enlargement in the disease condition. till december 2017, at total of 1116 children in the age range of 2 months to 18 years were included in the control group, upon proper consent from parents. the inclusion criteria in control group were: (a) normal healthy siblings of patients attending outpatient department and those visiting for vaccination, and (b) those children without any clinical or laboratory evidence of pancreatic disorder. exclusion criteria from the pancreatitis group were children having protein energy malnutrition (according to indian academy of pediatrics classification), type i diabetes mellitus, cystic fibrosis, premature infants & neonates and clinical or laboratory evidence of hepatic diseases and obesity where echogenicity gets altered, were excluded from the acute pancreatitis category. 16,18–24 the demographic and anthropometric details of these children were obtained using standard protocols. the institutional ethics committee‘s approval was sought before the study. 2.1. abdominal ultrasonography a radiological center with the qualified radiologist performing the ultrasonography remained the same raut et al. / panacea journal of medical sciences 2021;11(2):223–230 225 throughout this study. during the course of study, two duly calibrated machines with 3.5, 5.0, 7.5, mhz sector electronic probes were used. 1. period 1994 to jan 2007, toshiba capasee – japan [ssa-220a] machine was used and 19 cases of ap were studied. 2. period feb 2007 to july 2019, sonoacc x8 medisonkorean [sax8] was used and 44 cases of ap and all the control group children (1116) were studied. 2.2. anatomical landmarks 2.2.1. pancreatic head for measuring head of pancreas, duodenum, which envelops the lateral and caudal contour of the head, was taken as a landmark for measurements,where the pancreatic head was usually directly ventral to the inferior vena cava. 16,25,26 2.2.2. pancreatic body the superior mesenteric artery and splenic vein served as an important landmark for localization of the body of pancreas. 16,25 compression scanning with a “large footprint” curved linear transducer was the key technique in visualizing the body of pancreas. 26 2.2.3. pancreatic tail the splenic artery and vein, facilitated identification of tail of pancreas with the scanning through the spleen and left kidney, as the tail was opposite to the medial margin of left kidney. 16,26 the sonographic examination of pancreas involved assessment of the greatest anteroposterior dimension of head, body and tail regions, as well as the overall texture, when compared with that of liver at a similar depth. the maximum anteroposterior diameter of head, body and tail were measured perpendicular to the long axis of the organ on transverse/oblique images. if pancreas was oriented transversely across the abdomen, the entire gland could be seen in single image. however, the pancreas often had varying degree of obliquity, with the tail lying more cranial than the head and body. in these cases, several images were necessary to demonstrate the entire gland. 16 pancreatic echogenicity was determined by comparison with the adjacent liver at a similar depth on both transverse and longitudinal views, and categorized as less than, equal to, or greater than liver echogenicity. 16,21 2.3. statistical analysis the descriptive statistics for demographic and anthropometric parameters were obtained for normal and ap groups. subjects were classified according to gender and all analyses related to pancreatic parts were performed separately for each gender. a schematic representation of the analysis flow is given in figure 2. in each group, data were partitioned into training and test set. in the normal group, the partitioning ratio was 80:20%, while in the disease group; it was 66:33%. thus, the training set comprised of 894 normal and 40 disease cases, while the test set had 212 normal and 22 disease cases. since age has direct relevance to the size of the pancreas, it was considered as a covariate in the analysis. accordingly, age-adjusted receiver operating characteristics (roc) analysis was performed on each perusing the training data set. the threshold value for each part was determined using youden’s index, and the diagnostic criteria like area under curve (auc), sensitivity, specificity, and accuracy were obtained for the threshold value of each part. the thresholds were used on the test data set to determine their diagnostic strength. the age-adjusted pancreatic dimensions on three parts were dichotomized with 0 indicating value below threshold (no enlargement) and 1 indicating above threshold (enlargement) for each subject. this categorical transformation on three parts was treated as independent variable space, while the ap status was referred as an outcome. to obtain a unified diagnostic criterion based on three parts, a multiple logistic regression (mlr) was performed, which resulted in a probability score for each subject. roc analysis was performed on probability scores to obtain a threshold score and its diagnostic ability was evaluated on the test data set. all the analyses were performed using r-3.4.3 (r core team, vienna, austria). 3. results a total of 1178 children, 1116 control and 62 out of 63 diagnosed with ap, were considered in the study. one patient died during the hospital stay. out of 62 cases, 32 (51.6%) had mild ap, 7 (11.29%) had moderately severe ap, while 23 (37.0%) had severe ap.1 the summary statistics like mean and standard deviation were obtained for demographic and anthropometric characteristics of individuals in both the groups, as shown in table 1. the overall characteristics of the two groups were comparable. the median time between onset of symptoms and admission to hospital was 4 days with a mean of 5.43 (sd: 8.25 days); and about 92% of the cases required hospitalization. the median hospital stay was 8 days and the median duration of illness of patients was 12 days. the mean age-adjusted dimension of each pancreatic part in the disease group was significantly higher than that of the normal group (p value < 0.0001), indicating the tendency of enlargement in ap condition. 226 raut et al. / panacea journal of medical sciences 2021;11(2):223–230 3.1. age-adjusted roc analysis on pancreatic measurements to derive thresholds for each part, age-adjusted roc analysis was performed on the training set according to gender. for males, the thresholds for head, body, and tail were 1.26 cm, 1.10 cm, and 1.20 cm respectively (table 2), with the corresponding aucs 91.8%, 92.7% and 84.2% (figure 4 ). on similar lines, for females, the thresholds for head, body, and tail were 1.30 cm, 1.10 cm, and 1.26 cm respectively, with the corresponding aucs 89.9%, 92.4% and 89.8%. the sensitivity and specificity corresponding to these thresholds showed inconsistency in both gender types. for example, in males, the sensitivity of head was maximum (92.4%), while specificity was maximum for tail (84.2%). similarly, in females, sensitivity was maximum for body (92.12%), while specificity was maximum for head (86%). therefore, for each gender type, an integrated approach involving all three parts was adopted using mlr to obtain probability scores and thereby a classifier. 3.2. roc analysis of probability scores roc analysis on these scores resulted in a threshold value of 0.024 for males and 0.044 for females, such that a value above these thresholds is indicative of pancreatic enlargement with the possible disease condition. the sensitivities were 94.11% for males and 90.91% for females (figure 3). the diagnostic strength of various thresholds was evaluated on the test data set as shown in table 2. as regards individual age-adjusted roc thresholds, the classification accuracy for males was near 80%, while for females, it ranged between 81 to 85%. the classification accuracy of the probability score derived from mlr for males and females was nearly the same (83%). fig. 1: ultrasosnography images showing pancreas at diagnosis and after 6 days upon clinical recovery for a sample patient in 4.5 years male. 4. discussion usg is widely recommended as it can detect the hypoehoic gland that is diffusely or patchily enlarged in such disease condition. the present study targeted the imaging modality to assess pancreatic enlargement, which is one fig. 2: analysis flow to obtain imaging-based diagnostic criterion for acute pancreatitis fig. 3: receiver operating characteristic (roc) curves according to gender for training data using multiple logistic regression (mlr) approach raut et al. / panacea journal of medical sciences 2021;11(2):223–230 227 table 1: descriptive statistics for individual characteristics in two groups characteristics normal (n=1116) pancreatitis (n=62) p-value age in years [mean ± sd] 6.71±4.42 7.78±2.78 0.064a gender [no. (%)] male 626 (56.1) 28 (45.2) 0.120b female 490 (43.9) 34 (54.8) height(cm)[mean ± sd] 113.03±27.28 119.21±14.11 0.082a weight(kg) [mean ± sd] 19.18±11.37 20.05±7.19 0.567a pancreas dimension (age-adjusted) head (cm) [mean ± sd] 0.995±0.333 1.873±0.636 < 0 .0001a (s) body (cm) [mean ± sd] 0.910±0.253 1.702±0.533 < 0.0001a (s) tail (cm) [mean ± sd] 0.972±0.277 1.643±0.554 < 0.0001a (s) a obtained using independentt-test; b obtained using chi square test; s: significant table 2: diagnostic evaluation of different methods on test data set for both gender types method pancreatic part (cut-off) classification accuracy male female age-adjusted roc head (male:1.26 cm; female:1.30 cm) 80.41% 82.11% body (male:1.10 cm; female:1.10 cm) 81.76% 81.05% tail (male:1.20 cm; female: 1.26 cm) 80.01% 85.26% multiple logistic regression (mlr) probability score (male: 0.024; female: 0.044) 83.78% 83.15% table 3: enlargement of pancreas in acute pancreatitis cases at 1st presentation and after clinical recovery using different methods (n=62) method 1st abdominal usg ap a 2nd abdominal usg:after clinical recovery b body > 1.5 cm (khanna et al.) 36 (58.1) 4 (6.5) mean ± 2sd (siegel et al.) head 32 (51.6) 3 (4.8) body 41 (66.1) 5 (8.1) tail 33 (53.2) 12 (19.3) percentile curves (raut et al.) head 33 (53.2) 4 (6.5) body 44 (70.9) 4 (6.5) tail 30 (48.4) 10 (16.1) mlr 55 (88.7) 20 (32.2) ahypo-echogenicity was observed in 61 patients and hyper echogenicity in 1 patient; b all 62 patients showed iso-echogenicity of the insppire diagnostic criterion. earlier, khanna et al.proposed a criterion of body dimension more than 1.5 cm as indicative of enlargement. later, siegel et al.suggested a criterion: dimension of any part exceeding 2sd above the mean as indicative of ap. 16,17 recently, raut et al.developed percentile curves for each part based on data of normal children. 27 in the present study, the threshold measurements were obtained for each part using the ageadjusted roc analysis. subsequently, the probability score based classifier, as indicator of enlargement, was obtained using mlr. table 3 provides the number of cases showing enlargement at presentation and after clinical recovery. as per the criterion by khanna et al., 36(58.1%) had enlargement on day 1, while 4(6.5%) showed enlargement even after clinical recovery. 17 the criterion by siegel et al. detected 41(66.1%) cases based on body dimension, followed by 33(53.2%) using tail and 32(51.6%) using head. after clinical recovery, tail showed maximum i.e. 12(19.3%) cases as still enlarged. the percentile curves proposed by raut et al. detected 44(70.9%) cases with body dimension above 95% percentile, followed by 33(53.2%) on head and 30(48.4%) on tail. 27 a visual representation of the shift in dimensions on percentile plots is shown in figure s2. the multiple regression models detected 55(88.7%) cases with enlargement at first presentation, while 20(32.2%) cases continued to show enlargement after clinical recovery. the severity of ap in children as defined by the consensus committee was referred. 1 the maximum i.e. 32 (51.6%) cases had mild, 7(11.29%) moderate, while 228 raut et al. / panacea journal of medical sciences 2021;11(2):223–230 table 4: description of various parameter according to severity of pancreatitis mild ap moderate ap severe ap total total number of cases 32 (51.6%) 7 (11.29%) 23 (37%) 62 time interval between pain in abdomen and admission in daysa [mean±sd] (median) 3.35±2.48 (3) 3.71±2.43 (3) 6.35±6.22 (5) time interval between pain in abdomen and 1st abdomen usg in daysb 4.35±2.81(4) 4.14±2.48(3) 7.17±6.51(5) [mean±sd](median) first abdominal usg within 48 hours 14 (73.7%) 2 (10.5%) 3 (15.8%) 19 after 48 hours 18 (41.9%) 5 (11.6%) 20 (46.5%) 43 enlargement by mlr 25 (45.5%) 7 (12.7%) 23 (41.8%) 55 enlargement type: global 18 (43.9%) 5 (12.1%) 18 (43.9%) 41 enlargement type: patchy 7 (50 %) 2 (14.3%) 5 (35.7%) 14 [h & b: 5; b & t:2] [h & b:2] [h & b:4 & b:1] no enlargement by mlr 7 (usg within 48 hr) 0 0 7 second abdominal usg on clinical recovery enlargement by mlr 0 5 (25%) 15 (75%) 20 [h&b: 2; h&t: 3] [gobal: 8; h&t: 3; h&b:2; h:2] echogenicity hypoechogenicityhypoechogenicityhypoechogenicity62 on 1st abdominal usg 32 (51.6%) 7 (11.29%) 22 (35.5%) hyperechogenicity1 (1.6%) on 2nd abdominal usg iso-echogenicity iso-echogenicity iso-echogenicity 32 (51.16%) 7 (11.29%) 23 (37%) h: head; b: body and t: tail; a significant p-value: 0.042; b insignificant p-value: 0.068 obtained using one-way anova. 23(37%) had severe ap (table 4). the time interval between pain in abdomen and hospital admission showed statistically significant difference of mean days across three severity categories (p value 0.042), while the mean time interval between pain in abdomen and first abdominal usg was insignificantly different across categories (p value 0.068). for 19(30.6%) cases, the first abdominal usg was performed within 48 hours of pain in abdomen, in which 14(73.8%) had mild and 2(3.2%) cases had moderate and 3(4.8%) had severe ap. in 43, the first usg was done after 48 hours, out of which 18 (29.0%) had mild, 5(11.6%) had moderate and 20(46.5%) had severe ap. the enlargement in pancreatic size was detected by mlr method in 55 cases, out of which 25(45.5%) were mild ap, 7(12.7%) were moderately severe and 23(41.8%) were severe. no enlargement by mlr was seen in 7 mild cases with first usg done within 48 hr. however, the cases had hypoechogenicity. similar observation was made by previous workers stating that nearly 20% or more of the children in early or mild ap stage had normal imaging. 5 the sensitivity of transabdominal ultrasound in detecting pancreatitis was reported as 79.4%. 13 in such cases, it is proposed that further usg study may be undertaken after 24 to 48 hours to demonstrate the enlargement of pancreas. this method also revealed that global enlargement of pancreas was observed in 41(66.1%) and patchy enlargement in 14(22.5%) cases. patchy enlargement predominantly involved head and body parts of pancreas. mlr method further demonstrated that 20(32.2%) cases continued to show enlargement after clinical recovery in moderately severe and severe ap groups and none in mild ap group. fleischer ac et al. stated that this may be due to residual effects of edema, hemorrhage and fibrosis that occur as a result of pancreatic inflammation. 24 this study also demonstrates that all cases of ap do not have enlargement on presentation and may remain within normal limits with hypoechogenicity. however, on clinical recovery, there could be a marginal change in size with iso-echogenicity. similar observation was made by siegel et al. and showed that in 54% of the cases pancreatic measurements were normal. 16 in the present study, it was observed that the mean measurements of normal children and diagnosed cases on clinical recovery raut et al. / panacea journal of medical sciences 2021;11(2):223–230 229 fig. 4: roc curves for three pancreatic parts using training data according to gender showed statistically insignificant difference indicating the reduction in size of pancreas from the stage of presentation of ap. in this study, hypoechogenicity in 61(98%) and hyperechogenicity in 1(2%) were observed at presentation, while iso-echogenicity was observed in all the cases after clinical recovery. fleischer et al. reported hypoechogenicity in 79% cases during ap stage. 24 further, they stated that decreased echogenicity of pancreas was a reliable indicator of the presence of pancreatitis in children. clinical recovery was noticed within 6 days in mild, 8 days in moderately severe and 11 days in severe ap groups. werlin et al.reported clinical recovery within 4-5 days in mild ap cases. 5 there are some limitations of the present study. the number of diagnosed cases of ap was low due to low prevalence and being a single centric study. prospectively, we plan to involve multiple such hospital centers and strengthen the thresholds to comment on the pancreatic enlargement in disease condition. mlr provides the fig. 5: scatter plot showing pancreatic dimensions for males and females with reference to age in disease condition and after clinical recovery on the respective percentile plots. overall enlargement of the pancreas in a disease condition. however, one of the limitations of this criterion is its practical utility in clinical and radiological settings. accordingly, we have developed a web-based application to determine the enlargement by using the mlr method. users can access the site www.acrs-edc.com and log in by using pancreas.ps as both username and password. the patient‘s details and dimensions can be entered to obtain the possible enlargement of the pancreas. the enlargement criterion in conjunction with the clinical and biochemical test can be used for strengthening the diagnosis of ap. 5. conclusion the study demonstrates the enlargement of pancreas in patients diagnosed with ap based on clinical and biochemical criteria. the raw measurements on each part showed reasonably good enlargement in cases along with hypoechogenicity; however, the part specific diagnostic strength differed between males and females. hence, a multivariate approach, integrating the information from all the three parts was used, which proved to be a reliable indicator of enlargement in the disease condition. 6. author’s contribution rds was involved in conceptualizing, data generation of manuscript writing. dsa was involved in the statistical 230 raut et al. / panacea journal of medical sciences 2021;11(2):223–230 programming and analysis of data, rdv was involved in statistical and machine learning approach design, sd was involved in generating radiographic data and dvp was involved in overall supervision and interpretation of the findings of the study. 7. abbreviations ap-acute pancreatitis, usg-ultrasonography, rocreceiver operating characteristic, arp-acute recurrent pancreatitis, mlr-multiple logistic regression, pepancreatic echogenicity. 8. conflict of interest the authors declare that there are no conflicts of interest in this paper. 9. source of funding none. references 1. abu-el-haija m, kumar s, szavo f, werlin s, conwell d. classification of acute pancreatitis in pediatric population: clinical report from the naspghan pancreas committee. j pediatr gastroenterol nutr. 2017;64(6):984–90. 2. gupta sp, tewari gn, shukla pk. acute pancreatitis. indian pediatr. 1970;7:294–5. 3. morinville vd, husain sz, bai h. definition of pediatric pancreatitis and survey of present clinical practices. j pediatr gastroenterol nutr. 2012;55(3):261–5. 4. sonawane bd, titare pu, rathod pb, tembhekar ng, anand a. ultrasound assessment of pancreatitis in paediatric adolescent population. sch j app med sci. 2014;2(6d):3140–4. 5. werlin sl, wilschanski m. acute pancreatitis. in: in nelson textbook of pediatrics. 1st edn.. vol. 2016. elsevier india private limited;. p. 1913–5. 6. werlin sl. acute pancreatitis. in: in rudolph‘s pediatrics. 22nd edn.. vol. 2011. mcgraw hillmedical;. p. 1487–8. 7. aliye u, fishman ds. pancreatic disorders. pediatr clin north am. 2017;64(3):685–706. 8. chlebowczyk ug, jasielska m, wancerz af, weiceck s, gruszczynska k, chlebowczyk w, et al. acute pancreatitis in children. prz gastroenterol. 2018;13(1):69–75. 9. kramer c, jeffery a. pancreatitis in children. crit care nurse. 2014;34(4):43–52. 10. carroll j, herrick b, gipson t. acute pancreatitis: diagnosis, prognosis and treatment. am fam physician. 2007;75(10):1513–20. 11. abu-el-haiza m, lin tk, palermo j. update to the management of pediatric acute pancreatitis: highlighting areas in need of research. j pediatr gastroenterol nutr. 2014;58(6):689–93. doi:10.1097/mpg.0000000000000360. 12. wani md, chalkaoo m, ahmad z, yousuf am, arafat y, arsalan ss, et al. clinical significance of urinary amylase in acute pancreatitis. arch surg clin res. 2017;1:21–31. doi:10.29328/journal.ascr.1001004. 13. restrepo r, hagerott he, kulkarni s, yasrebi m, edward yl. acute pancreatitis in pediatric patients: demographics, etiology, and diagnostic imagining. am j roentgenology. 2016;206(3):632–44. 14. suzuki m, sai jk, shimizu t. acute pancreatitis in children and adolescents. world j gastrointest pathophysiol. 2014;5(4):416–6. 15. darge k, anupindi s. pancreatitis and the role of us, mrcp and ercp. pediatr radiol. 2009;39(2):153–7. doi:10.1007/s00247-0091145-5. 16. siegel mj, martin kw, worthington jl. normal and abnormal pancreas in children: us studies. radiology. 1987;165(1):15–8. 17. khanna pc, pruthi s. the pancreas. in: and others, editor. caffey’s pediatric dignostic imaging. 12th edn. philadelphia elsevier saunders; 2013. p. 988–96. 18. el-hodhod ma, nassar mf, hetta oa, gomaa sm. pancreatic size in protein energy malnutrition: a predictor of nutritional recovery. eur j clin nutr. 2005;59(4):467–73. 19. chiarelli f, altobelli e, verrotti a, morgese g. 241 size of pancreas in children and adolescents with type i diabetes mellitus: a study based on ultrasonographic evaluation. pediatr res. 1994;36:43. doi:10.1203/00006450-199407000-00241. 20. swobodnik w, wolf a, wechsler jg, kleihauer e, ditschuneit h. ultrasound characteristics of pancreas in children with cystic fibrosis. j clin ultrasound. 1985;13(7):469–74. 21. walsh e, cramer b, pushpanathan c. ultrasound characteristics of pancreas in children with cystic fibrosis. pediatr radiol. 1990;20(5):323–5. 22. giandomenico vd, filippone a, basilico r, spinazzi a, capani f, bonomo l, et al. reproducibility of ultrasound measurement of pancreatic size with new advanced high-resolution dynamic image scanners. j clin ultrasound. 1993;21(2):77–86. 23. pezzilli r, calculli l. pancreatic steatosis: is it related to either obesity or diabetes mellitus? world j diabetes. 2014;5(4):415–9. 24. fleischer ac, parker p, kirchner sg, james ae. sonographic finding of pancreatitis in children. radiology. 1983;146(1):151–5. doi:10.1148/radiology.146.1.6849038. 25. ueda d. sonographic measurement of the pancreas in children. j clin ultrasound. 1989;17(6):417–23. 26. winter t, maryellen. maryellen: the pancreas. in: and others, editor. diagnostic ultrasound. 5th edn. elsevier; 2018. p. 210–28. 27. raut ds, raje dv, dandge vp, singh d. percentile reference curves for normal pancreatic dimensions in indian children. indian j radiol imaging. 2018;28:442–7. author biography dhanraj s raut, former professor shubhangi a desai, biostantistician dhananjay v raje, head, data analysis group dinesh singh, consultant vithalrao p dandge, retired hod cite this article: raut ds, desai sa, raje dv, singh d, dandge vp. ultrasonography based imaging criterion to ascertain pancreatic enlargement in pediatric acute pancreatitis. panacea j med sci 2021;11(2):223-230. http://dx.doi.org/10.1097/mpg.0000000000000360 http://dx.doi.org/10.29328/journal.ascr.1001004 http://dx.doi.org/10.1007/s00247-009-1145-5 http://dx.doi.org/10.1007/s00247-009-1145-5 http://dx.doi.org/10.1203/00006450-199407000-00241 http://dx.doi.org/10.1148/radiology.146.1.6849038 original research article doi: 10.18231/2348-7682.2018.0018 panacea journal of medical sciences, may-august, 2018;8(2):79-82 79 clinico-bacteriological profile of community acquired pneumonia in a tertiary care hospital (rural based) saurabh kose1, neelam jaitly2,* 1mbbs student, 2professor, dept. of microbiology, nkp salve institute of medical sciences and research centre and lata mangeshkar hospital, nagpur, maharashtra, india *corresponding author: email: neelam.jaitly2014@gmail.com abstract respiratory tract infections are the most frequent of all the infections. pneumonia is the commonest disease with a high prevalence in the community. the knowledge and identification of organisms causing community acquired pneumonia helps in early start of empirical treatment. the study was carried out to know the bacterial etiology of community acquired pneumonia and to find out the antibiotic sensitivity pattern of isolated bacteria. this study was a prospective cross sectional time based study of 174 patients carried out at tertiary care hospital. sputum sample was collected and screened by gram’s staining and inoculated on blood agar, macconkey’s agar. antibiotic sensitivity was performed as per clsi guidelines by modified kirby bauer method. out of total 174 patients micro-organisms were identified in 102 patients (60%). micro-organisms isolated in sputum were klebsiella pneumoniae (46.22%) followed by pseudomonas aeruginosa (21.69%). organisms were found to be sensitive to ceftriaxone plus sulbactum, imipenem, piperacillin plus tazobactum, piperacillin and ceftazidime. most of the patients showed good response to third generation cephalosporin’s, macrolides or in a combination. bacteriological profile of cap varies geographically. there is a need to conduct regular prevalence and antibiogram studies to develop empirical guidelines for treatment of cap.’ keywords: pneumonia, bacteriological profile, klebsiella pneumoniae. introduction respiratory tract infections are the most frequent of all the infections and accounts for the number of work days lost in the general population. among them, pneumonia is the commonest disease with a high prevalence in the community and a cause of significant mortality and morbidity.1 pneumonia is broadly defined as any infection of lung parenchyma. pneumonia is clinically divided into community acquired pneumonia (cap) and nosocomial pneumonia. infectious diseases society of america defines cap as “an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, accompanied by the presence of an acute infiltrate on a chest radiogram or auscultatory findings consistent with pneumonia in a patient not hospitalized or residing in a long-term care facility for more than 14 days before onset of symptoms.1-4 etiology of community acquired pneumonia is generally bacterial but the microbial pattern varies from place to place and so does the antimicrobial sensitivity and emerging resistant pattern. cap is leading cause of death in the world. but the seriousness of cap despite a reasonably common and potentially lethal disease, often is underestimated by physician and patient alike. the treatment of cap is complicated by growing threat of antimicrobial resistance and the tendency to rely on empirical therapy. the resistant strains of bacteria can quickly multiply and spread within the community. recent years have witnessed the emergence of new pathogens and newer antibiotics designed to combat them.1 in the indian scenario, studies on bacteriological profile are few and far between, and are mostly confined to limited geographical areas. our study is a sincere attempt to look into various causative bacterial agents of cap, predisposing factors and sensitivity pattern of bacteria in this geographical area. this will help to plan therapy among patients in limited facility setting. aims and objectives 1. to know the bacterial aetiology of community acquired pneumonia (cap). 2. to find out the antibiotic sensitivity pattern of isolated bacteria. materials and methods this study is a prospective cross sectional time based study from august 2016 to september 2016 (2 months) carried out at tertiary care hospital in central india. study population: all patients with clinically and radiologically diagnosed pneumonia attending our hospital between above period were enrolled in study. a detailed history, clinical examination & investigation were carried out in all the cases as per proforma attached. prior to the study the protocol was approved by the institutional ethics committee. inclusion criteria: all patients of either sex over 15yrs of age presenting to paediatrics, medicine or pulmonary medicine department with cap who have not resided in hospital in last 14 days. saurabh kose et al. clinico-bacteriological profile of community acquired pneumonia…. panacea journal of medical sciences, may-august, 2018;8(2):79-82 80 cap was defined as new or progressive infiltrates on chest radiograph together with at least two of the following: fever, cough, production of purulent sputum or leucocytosis > 10,000/mm3. exclusion criteria: patients with radiographic or laboratory evidence suggestive of aids, leukaemia and tb, those with chest infiltrate due to other causes such as congestive heart failure, pulmonary infarction or lung cancer, patients receiving immunosuppressive treatment. collection of specimen: all samples were collected preferably before start of antibiotics. if patient was already on antibiotics, samples were collected just prior to next dose of antibiotics. sputum was collected. sputum collection: patient was advised to rinse mouth several times with water and to cough deeply to produce sputum from depth of lung. spontaneously expectorated sputum specimen was collected in sterile specimen container and transported and processed immediately in hospital microbiology laboratory. patient who could not expectorate sputum, bal (broncho-alveolar) fluid was collected. processing of specimens: all sputum samples were screened by gram’s staining. all specimens were inoculated on blood agar, macconkey’s agar and incubated at 370 c. the plates were examined for growth after 24 hrs. the bacteria were identified by standard bacteriological tests.5 antimicrobial sensitivity was performed as per clsi guidelines by modified kirby bauer method. mrsa was reported by the growth and morphology on blood agar plate, gram staining, catalase test, coagulase test and resistance to 30 microgram cefoxitin disc on mueller-hintton agar.5,6 results among 174 patients 104 were males (59.77%) and 70 (40.22%) were females. maximum patients were in age group 51-60yrs in males (18.96%) and in females (16.09%). symptoms on presentation in decreasing order of frequency were cough, fever, crepitations, expectoration and bronchial breath sound (table 1). table 1: symptoms and sign of patients (n=174) symptoms and signs no. % cough 165 94.82 fever 156 89.65 crepitation 141 81.03 bronchial breath sound 123 70.68 expectoration 130 74.71 pleuritic chest pain 87 50 dyspnoea 62 35.63 pallor 45 25.86 cyanosis 34 19.54 haemoptysis 3 1.72 in our study the culture was positive in 60 cases in males (n=104) (57.69%) and 42 in females (n= 70) (60%). in our study the most frequent pathogen was klebsiella pneumoniae (46.22%) followed by pseudomonas (21.69%). (n=106) * out of 104 plates, 2 plates showed 2 different organisms grown on culture (table 2). table 2: organisms grown on culture organisms no. percentage klebsiella pneumoniae 49 46.22 pseudomonas aeruginosa 23 21.69 candida 3 2.83 staphylococcus aureus 6 5.66 streptococcus pyogenes 11 10.37 mrsa 7 6.6 enterobacter 1 0.94 acinetobacter 1 0.94 non-fermenter 5 4.71 total 106 100 antimicrobial sensitivity pattern: fig. 1: klebsiella sensitivity pattern klebsiella pneumoniae showed sensitivity to ceftriaxone sulbactum (73.46%) followed by imipenem (67.34%) and ciprofloxacin (44.89%) (fig. 1). saurabh kose et al. clinico-bacteriological profile of community acquired pneumonia…. panacea journal of medical sciences, may-august, 2018;8(2):79-82 81 fig. 2: pseudomonas sensitivity pattern pseudomonas showed sensitivity for piperacillin + tazobactum (73.91%), piperacillin and ceftazidime (69.56% each) (fig. 2). fig. 3: streptococcus pyogenes sensitivity pattern streptococcus showed sensitivity for vancomycin (100%), linezolid (90.90%), ciprofloxacin (63.63%) and gentamycin (63.63%) (fig. 3). fig. 4: staphylococcus aureus sensitivity pattern staphylococcus (c –ve) showed sensitivity for vancomycin (100%), ciprofloxacin and penicillin (83.33% each) (fig. 4). saurabh kose et al. clinico-bacteriological profile of community acquired pneumonia…. panacea journal of medical sciences, may-august, 2018;8(2):79-82 82 fig. 5: mrsa sensitivity pattern methicillin resistant staphylococcus aureus (mrsa) showed sensitivity for linezolid and vancomycin (85.71% each) (fig. 5). non fermental growth showed sensitivity for cephalexin (80%) and imipenem (60%). enterobacter showed sensitivity for amikacin, cotrimoxazole, imipenem, ceftriaxone, gentamicin, pi, p+t (100%) acinobacter showed sensitivity for amikacin, ciprofloxacin, cephalexine and ceftriaxone (100%). discussion the role of microbiology lab in diagnosis of cap remains very important. the common age group affected in the present study was 51-60 years. other studies have also reported similar findings i.e. acharya vk et al1 in our study, bacterial growth was found positive in 60%. it correlates with study of gupta et al.7 in present study, the most frequent pathogen was klebsiella pneumoniae followed by pseudomonas aeruginosa. similar reports were reported by other studies.1,4,8 in our study, most of the patients showed good response to third generation cephalosporin’s, macrolides or in a combination. it correlates well with study of acharya vk et al.1 limitations in present study, only bacterial causes of community acquired pneumonia were included. further studies can include tests for viral & atypical pathogens. relevant outcomes such as speed of response, subsequent relapse rates, and harmful antibiotic effects and health economic burden of different antibiotic treatment regimens, were not assessed. as per the standard operating protocols of the microbiology laboratory here sensitivity was done only to a group of relevant antibiotics once a specific organism was cultured, based on spectrum of antibiotics as per the literature and local practice. conclusion bacteriological profile of cap varies geographically. there is a need to conduct regular prevalence and antibiogram studies to develop empirical guidelines for treatment of cap. references 1. acharya vk, padyana m, unnikrishnan b, anand r, acharya pr, juneja dj. microbiological profile and drug sensitivity pattern among community acquired pneumonia patients in tertiary care centre in mangalore, coastal karnataka. indian j clin diagn res. 2014;8(6):mc04–mc06. 2. giriraj b, manthale d. clinico-microbiological profile of community acquired pneumonia in a tertiary care hospital. journal of biomedical and pharmaceutical research. 2015;4(4):65-68. 3. community-acquired pneumonia: bacterial profile and microbiological investigations. supplement to journal of association of physicians of india. 2013;61:9-11. 4. bansal s, kashyap s. a clinical and bacteriological profile of community acquired pneumonia in shimla, himachal pradesh. indian journal of chest diseases and allied sciences. 2004;46:17-22. 5. collee jg, fraser ag. mackie and mccartney practical medical microbiology 14 edition, 2006 churchill livingstone. 6. ananthnarayan r, paniker ck. textbook of microbiology, 10th edition, university press, hyderabad india 2017;207. 7. gupta d, agarwal r, aggarwal an, singh n, mishra n, khilnani gc, et al. guidelines for diagnosis and management of community – and hospital –acquired pneumonia in adults: joint ics/nccp(i) recommendations. lung india. 2012;29(6):27-62. 8. oberoi a, agarwal a. bacteriological profile, serology & antibiotic sensitivity pattern of microorganism causing community acquired pneumonia. jk scien. 2006;8:79-82. https://www.ncbi.nlm.nih.gov/pubmed/?term=acharya%20vk%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pubmed/?term=padyana%20m%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pubmed/?term=b%20u%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pubmed/?term=r%20a%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pubmed/?term=acharya%20pr%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pubmed/?term=acharya%20pr%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pubmed/?term=juneja%20dj%5bauthor%5d&cauthor=true&cauthor_uid=25121014 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4129319/ review article panacea journal of medical sciences, january-april,2016;6(1): 3-7 3 wake up call to halt the evolving epidemic of sexual offence in india: urgent need to find out the solutions padhy gouri kumari1,*, mishra abhishek2, pal anjali3, dash shreemanta kumar4 1associate professor, 2senior resident, 3assistant professor, department of community and family medicine, 4associate professor, department of forensic medicine & toxicology, aiims, raipur *corresponding author: email: gouripadhy@gmail.com abstract violence against women is a global public health problem of epidemic proportion, requiring urgent action and india ranks 4th in the world as per recent statistics of rapes. an increasing trend in the incidence of rape has been observed during the periods 2010 2014. the reported figures are only the tip of the iceberg. only 1% of sexual violence victims in india report the crime. the victims of sexual violence experience a wide range of physical and psychological problems. the number of disabilityadjusted life years (daly) lost by women for this is comparable to diseases such as tuberculosis, hiv, cardiovascular diseases or cancer. it contributed about 5% of the total global disease burden. the causes for this problem are multifaceted, so are the solutions. fear of punishment cannot be the sole solution, as it may lead to increased rate of murder of victim to destroy evidence. considering the rising incidences of sexual assaults in the society an attempt is made in this article to suggest some measures which can bring down these incidences. the role of yoga, meditation and moral education in different stages of life becomes very crucial in this context. but all these are long term interventions. hence along with these measures some urgent steps need to be taken to tackle this problem. measures like decriminalizing/ legalizing prostitution, cuddle cafe and phone sex are being used in some countries as newer approaches to satiate the desire for sex. keywords: sexual assault, rape, prostitution, cuddle sex, phone sex. introduction violence against women is a global public health problem of epidemic proportion, requiring urgent action(1) and india ranks 4th in world as per recent statistics of rapes. the increasing trend from 1 per lakh to 2 per lakh population in a decade is an area of concern(2). image of india in the world is being negatively affected by this rising trend of sexual assault against females. recent sexual attacks against female visitors in tourist areas and cities show that foreign tourists are also equally vulnerable(3). according to the latest statistics of national crime records bureau (ncrb), every day 93 women are being raped in india(4). an increasing trend in the incidence of rape has been observed during the periods 2010 2014. these cases have shown an increase of 35.2% in the year 2013 in comparison to 2012 and 9% in 2014 in comparison to 2013(5). a total of 36,739 cases were registered for 36,968 victims under ‘other than incest rapes’ during 2014 (including custodial rape and gang rape cases)(4). there were 197 victims of custodial rapes and 2,346 cases were reported as gang rape(4). there were 674 incest rape cases registered for 713 victims. a total of 13,766 cases were registered for 13,833 victims of child rape during 2014, as per posco act 2012 (the protection of children from sexual offences act)(4). so, the total number of rape victim was 51,514. average age of rapist and other demographic profile of accused is not reported or displayed in the data published by ncrb. incidents of incest rape (rape by blood relation like father, brother) in the country have increased by 25.7% and incidence of child rape has increased by 11.3% during the year 2014 over the previous year(4). ncbr for the first time reported separate data for custodial rape, gang rape, incest rape and other rapes. there is no separate data regarding rape by defense personnel. there have been no studies to find out the prevalence of female sexual assault in india. national crime records bureau (ncbr) is the only data source, which is mainly based on first hand information report. national family health survey (nfhs) 3 collected some data related to sexual violence(6). there is an urgent need to device a proper system to collect population data regarding this. sexual violence against women could be a feasible post-mdg (millennium development goal) gender indicator(7). recently john hopkins university has started an online course “confronting gender based violence: global lessons with case studies from india”(8). the lancet has also indicated that it could commission a landmark paper to actually gauge the burden of such acts of violence in india in the near future(9). the reported figures are only the tip of the iceberg, as many incidents remain unreported. only 1% of sexual violence victims in india report the crime(10). many cases remain unreported due fear or stigma or family honor. sometimes crime is reported to the police but the victim faces difficulty in getting the case registered or recorded(6). the police response varies according to the position the perpetrators hold in the society. inconsistent police response is also influenced by the societal patriarchal mindset(11). padhy gouri kumari et al. wake up call to halt the evolving epidemic of sexual offence in india: urgent…. panacea journal of medical sciences, january-april,2016;6(1): 3-7 4 sexual assault against women in the society is widespread amongst all groups of age, social class, income and culture. especially vulnerable are refugees, migrants, destitute, females living in institutions and in areas of armed conflict(6). according to ncrb 2014, nearly 1.1% (547) of the total victims of rape were girls younger than six years, 55% (28,368) were below 18 years. about 0.2% of victims (90 cases) were women older than 60 years(4). the victims of sexual violence experience a wide range of physical and psychological problem. the rape victims are at high risk of developing reproductive health problems including hiv/aids or stis(12). psychologically, the victim may experience fear, anxiety, low esteem which can also result in social adjustment problems. the most common long term issues are depression and posttraumatic stress disorder (ptsd). rape may also result in unwanted pregnancy(11-12). some of the victims even end their life by committing suicide and some are murdered(13-14). the number of disability-adjusted life years (daly) lost by women for this is comparable to other diseases such as tuberculosis, hiv, cardiovascular diseases or cancer. it contributed about 5% of total global disease burden(1). report of sexual abuse from mass media in india ring an alarm necessitating some corrective actions. there is no doubt that reporting in mass media helps in sensitizing public regarding this issue but at times it seems that it also gives some provoking thought to those with perverted mentality. solutions: the causes for this problem are multifaceted, so are the solutions. role of legislation: the increasing instances of gang rape, rape by minors and, rape associated with brutality and murder points towards deteriorating moral values, delinquent mental behavior, and lack of fear of punishment. no doubt strict punishment and fast justice can deter the perpetrator, but with the abysmal conviction rate (about 16%), even strict legislations may not achieve the necessary deterrence(15). the punishment given to the convicted involved in nirbhaya case of 2012 is yet to be executed. this reflects negligible impact of reframing of existing laws and introduction of new laws after mass protest in nirbhaya case. fear of punishment cannot be the sole solution, as it may lead to increased rate of murder of victim to destroy all evidence (as observed these days). involvement at young age as accused and also as victim highlights the need for some social reforms(16). recent media reports of children committing rape are worrisome. role of moral value and parenting skill: today indian society faces the consequences of psychological instability caused by increasing proportion of working women, disintegration of joint family system, and preference for one child norm. many a times parents are not able to spend quality time with children, hence they try to compensate it by fulfilling the undue desire and demands of the child. the materialistic outlook of the population has lead to disintegration of human values. proper parenting skills need to be developed with emphasis on instilling human values among children. for this the parents need to spend quality time with their children. training regarding parenting skill can be organized for the couple while the woman is pregnant. parenting skill can even be offered as a course. they need to teach their son to respect females. it is essential for the girl children to be trained to differentiate mischievous touch from affectionate touch, as 86 to 98 % of rapes are caused by known persons(17,4). repeated instructions not to get lured by the accused have to be given. witnessing or experiencing violence as a child was found to be the foremost contributing factor influencing the behavior of accused leading to rape(18). hence parents need to be aware of negative impact of domestic violence and abuse on the children. role of alcohol: alcohol abuse was cited as the second leading factor influencing the accused to commit the crime(18). alcohol operates by dropping inhibitions and impairing judgment between right and wrong(19). generating awareness and creating a mass movement amongst the people against the sale and consumption of alcohol will definitely help in curbing the problem. role of education system and spirituality: for creation of a healthy and wholesome environment in the society, we need to reform our education system. the sole purpose of today’s education is to acquire knowledge to earn livelihood. minimal emphasis is given to spiritual, moral and intellectual development. indian mythological texts mention that all kinds of crime in the world are basically outcome of three fires: fire of hunger, sex and anger. if one can control these three things, most of the crimes in the world will automatically get reduced. our old texts including upanishads also mention the methods to control these fires. yoga, devotion to divine power and meditation are the some of those methods. this devotion to god (either by god loving attitude or by god fearing attitude) is gradually disappearing from the society. there is no emphasis on building self discipline and discrimination between right and wrong. hence there is an urgent need to focus on revising the study curriculum giving due emphasis to mental and spiritual dimensions of health at all levels of education. role of mental health: antisocial personality is usually found to be associated with person committing such crimes. many a times parents are aware of deviant padhy gouri kumari et al. wake up call to halt the evolving epidemic of sexual offence in india: urgent…. panacea journal of medical sciences, january-april,2016;6(1): 3-7 5 behavior of the person since his childhood, but they never seek any medical care because of stigma attached to mental illnesses. timely diagnosis and treatment of deviant mental health status may help in prevention of occurrence of such cases. psychological assessment of a child should be a part of medical checkup carried out in school health program. the same can be conducted for college students for early detection of any deviant behavior (especially in aggressive and delinquent children). community need to be sensitized regarding social acceptance of abnormal mental status by doing intensive campaign using mass media. the role of yoga, meditation and moral education in different stages of life becomes very crucial in this context. but all these are long term interventions, if we start working on these issues today; we will get the result after many years or decades. hence along with these measures some urgent steps need to be taken to tackle this problem. role of women empowerment: the increased mobility of women for education and employment has made them especially vulnerable to such crimes. the need of the hour is training of females for self-defense and awareness regarding use of mobile applications / phone call using toll free no (like 182 ) to contact the police control room and seek help when they face such threatening situations. role of media and other recreational facilities: rapid pace of urbanization with increasing trend of nuclear family and single child norm forces children to spend more time in watching tv and browsing internet and thereby giving them premature exposure to visual material having sexual overtones. portrayal of erotic and sexually explicit material in cinema and television for cheap popularity has made negative impact on young minds. it is high time for censor board to restrict erotic scenes and item songs in movie and television. mentally healthy adults having better judgment power can differentiate wrong and right, they realize that real life is different from reel life. whereas young adolescent and people with sexually perverted mentality lack that judgment, they get easily swayed by the reel life and try to emulate the same in personal life (incomplete awareness regarding sexuality makes them more vulnerable). there is a need to raise a voice to regulate broadcasting of shows in tv and scenes in movie. the timing for adult scenes can be restricted to late night. by the time there is a control over broadcasting; parents can try to have a control over the remote of their tv in order to choose the program to be watched by the children. the parent needs to sit with the child to monitor his activities when he makes a search in internet. appropriate use of modern technology for benefit of society will definitely help in controlling the problem to a large extent. lack of recreation facilities like playground and parks prevents the young adolescents from getting engaged in healthy life style including sports and physical exercise. hence their energy may get directed towards undesirable and antisocial activities. emphasis should be given to provide facilities for physical exercise for all ages. role of measures to decrease vulnerability: globalization has caused a significant change in the indian culture. there is increased social acceptance of late night party, dj, dating in the past few yrs. the youngsters need to be sensitized regarding the limitations of relationship between opposite sexes. females need to maintain decency, take proper care of their attire and avoid late night outings to decrease their vulnerability. role of age of marriage: late marriage is stated to play some role; early marriage in early 20s to satisfy sexual need is suggested as a solution by some people(19), but early marriage will invite problems related to population explosion, so it can’t be a feasible option. role of some other alternatives: in earlier times people had better control over their physical desires, exposure to media was limited, still there existed a system, the system of prostitution which means there always existed some need. prostitution in india can be traced back to ancient times(20). prostitution has been present in societies across the world for thousands of years(21). during twentieth century, emergence of problems like std, hiv, and child trafficking gained prominence. hence various countries wanted to take some action for its control; they had adopted one of the two broad approaches to control it: either ‘abolition’ or ‘regulation’ of prostitution(22). there are pros and cons attached to each approach. countries like japan, latvia, australia, spain, germany, denmark and netherland where prostitution is either legal or of limited legality, show a declining trend of sexual violence(23-24). more recently another possibility has been explored – legalization or decriminalization and some countries have shown a declining trend after decriminalizing it. as prostitution has demerits like hiv, child trafficking, forced entry from very early age attached to it, one needs to give a serious thought before decriminalizing prostitution in india. but even after enforcement of strict laws like prevention of immoral traffic act (pita), suppression of immoral traffic act (sita), immoral traffic prevention act 2006 (itpa) prostitution still persists in the society. if a sex worker consistently uses barrier method or tries to have one to one relationship preferentially, then it may be of some help, provided the sex workers are adults and have not been forced into the trade (which is very difficult to ensure). padhy gouri kumari et al. wake up call to halt the evolving epidemic of sexual offence in india: urgent…. panacea journal of medical sciences, january-april,2016;6(1): 3-7 6 there is a need to find some other alternatives to prostitution. developed countries like japan, usa, singapore, and london came up with cuddle cafe as an alternative(25). recently sex over phone (phone sex or telephone sex) has become popular(26). phone sex is a conversation between two people on the phone where one or more of the individuals are describing the act of sex. phone sex takes imagination on both parties' part(27). phone sex service providers typically advertise their services in men's magazines, in pornographic magazines and videos, on late-night cable television, and online(27-28). phone sex appears to be much safe in comparison to prostitution. unlike prostitution, phone sex has no hazard of hiv/sti, child trafficking and unwanted pregnancy. the amount of money spent is also quite less. it has nothing to do with age and look of phone sex operator(29). it is still uncertain if such alternative to physical sex are going to impact the incidence of rape in the society. for this we need to monitor the trend of sexual offences in countries like japan, china, korea, and thailand where these facilities are available and widely used. the current statistics show a declining trend in all these countries(24). legalization of phone sex would bring economic benefit for governments by imposing suitable taxes on such services. the use of pornography and sex toys for masturbation is not new. indians reacted to recent ban of pornography stating pornography is somehow helpful in decreasing crime because it provides some means to channelize sexual desire. so the ban was imposed on child porn sites only. some people may find phone sex a better option to pornography because of the two way interaction and added effects of moaning sounds of a feminine voice (it makes the sexual act more realistic), some use it along with pornography. use of phone sex is not a solution to the sexual crimes against women nor is it an alternative for those who rape an infant or toddler or commit incest rape. however it may have some role in providing sexual gratification for those in need. it can add a new dimension to the life of people living with hiv, disabled persons, couples staying apart, unmarried adults, divorced, vulnerable groups like truck drivers, migrant laborers, military personnel and transgender. conclusion strengthening implementation of existing laws, improvement in mental health, inculcation of moral values, better education of children, improved policy with accountability (administration, police, judiciary and other departments of government) and awareness among parents are the need of the hour. last but not the least, improved literacy with better employment facility and control over population growth will no doubt help the nation in solving many problems including sexual violence. references 1. who, department of reproductive health and research, london school of hygiene and tropical medicine, south african medical research council. global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and nonpartner sexual violence 2013. available from: http://apps.who.int/iris/bitstream/10665/85239/1/9789241 564625_eng.pdf. cited on 28 june 2015. 2. ejaz khan. top 10 countries with highest rape crime. available from: http://www.wonderslist.com/10countries-highest-rape-crime/. cited 28 october 2015. 3. india tourism fears after latest rape – telegraph. available from: http://www.telegraph.co.uk/travel/destinations/asia/india/ 11327948/india-tourism-fears-after-latest-rape.html. cited 21 november 2015. 4. welcome to national crime records bureau. available from: http://ncrb.gov.in/. cited 28 october 2015. 5. 93 women are being raped in india every day, ncrb data show the times of india. available from: http://timesofindia.indiatimes.com/india/93-women-arebeing-raped-in-india-every-day-ncrb-datashow/articleshow/37566815.cms. cited 28 october 2015. 6. base paper on availability of data and data gaps for situation analysis of well-being of children and women. available from: http://mospi.nic.in/mospi_new/upload/base_paper_on_da ta_gaps_child_women11sept14.pd. cited 25 july 2015. 7. the global burden of violence against women. available from: http://www.who.int/violence_injury_prevention/violence/ 6th_milestones_meeting/watts_ipv.pdf. cited 2 august 2015. 8. confronting gender based violence: global lessons with case studies from india johns hopkins university, coursera. available from: https://www.coursera.org/course/gbv. cited 30 october 2015. 9. british medical journal lancet now pulls up indian government for failing to stop rapes the times of india. available from: http://timesofindia.indiatimes.com/india/british-medicaljournal-lancet-now-pulls-up-indian-government-forfailing-to-stop-rapes/articleshow/49528470.cms. cited 29 october 2015. 10. raj anita, mcdougal lotus. sexual violence and rape in india. the lancet 2014; 383(9920): 865. 11. ignatius arun. sexual violence in india. thesis (unpublished). available from: https://dspace.mah.se/bitstream/handle/2043/16733/arun %20ignatius%20hr%20iii%20c-thesis%20pdf.pdf. cited on 12 august 2015. 12. who. violence against women. available from: http://www.who.int/mediacentre/factsheets/fs239/en/. cited on 28 october 2015. 13. day after rape, murder, mob beats man to death in eluru the new indian express. available from: http://www.newindianexpress.com/states/andhra_pradesh /day-after-rape-murder-mob-beats-man-to-death-ineluru/2015/06/20/article2875990.ece. cited on 5 november 2015. 14. j&k: four get death for rape-murder of minor-the indian express. available from: http://indianexpress.com/article/india/crime/foursentenced-to-death-for-rape-murder-of-13-year-old-girl/. cited on 5 november 2015. javascript:void(0); padhy gouri kumari et al. wake up call to halt the evolving epidemic of sexual offence in india: urgent…. panacea journal of medical sciences, january-april,2016;6(1): 3-7 7 15. himabindu bl, arora radhika, prashanth ns. whose problem is it anyway? crimes against women in india. glob health action 2014; 7: 23718. 16. child sexual abuse: top 5 countries with the highest rates – international business times. available from: http://www.ibtimes.co.uk/child-sexual-abuse-top-5countries-highest-rates-1436162. cited on 28 october 2015. 17. rape in india wikipedia, the free encyclopedia. available from: https://en.wikipedia.org/wiki/rape_in_india. cited on 28 october 2015. 18. sexual aggression high among indian youth, finds research the times of india. available from: http://timesofindia.indiatimes.com/india/sexualaggression-high-among-indian-youth-findsresearch/articleshow/49590089.cms. cited on 5 november 2015. 19. sharma i. violence against women: where are the solutions? indian j psychiatry 2015;57(2):131-139. 20. critically examine the consequences of legalization of prostitution in india. available from: http://iasbaba.com/2015/09/3-critically-examine-theconsequences-of-legalization-of-prostitution-in-india. cited on 28 october 2015. 21. should prostitution be legalized? do the benefits of legalization or decriminalization outweigh the possible dangers? available from: http://debatewise.org/debates/2509-prostitution. cited on 28 october 2015. 22. a critical examination of responses to prostitution in four countries: victoria-australia, ireland, the netherlands and sweden. available from: https://www.glasgow.gov.uk/chttphandler.ashx?id=884 3&p=0. cited 16 august 2015. 23. 100 countries and their prostitution policies legal prostitution procon.org. available from: http://prostitution.procon.org/view.resource.php?resource id=000772. cited on 4 november 2015. 24. crime > rape rate: countries compared. international statistics at nationmaster.com. available from: http://www.nationmaster.com/countryinfo/stats/crime/rape-rate. cited on 28 october 2015. 25. cuddle up to me: 10,000 people rush to us woman who opened up a professional cuddling shop! latest news and gossip on popular trends at india.com. available from: http://www.india.com/whatever/cuddle-up-to-me10000-people-rush-to-us-woman-who-opened-up-aprofessional-cuddling-shop-200835/. cited on 21 november 2015. 26. how to have phone sex: 7 steps (with pictures) wiki how. available from: http://www.wikihow.com/havephone-sex. cited on 5 november 2015. 27. phone sex wikipedia, the free encyclopedia. available from: https://en.wikipedia.org/wiki/phone_sex. cited on 28 october 2015. 28. the joy of phone sex work in mefimag. available from: http://mefimag.com/issuepdfs/mefimag-008-nov-2011web.pdf. cited on 28 october 2015. 29. older women prove to be better at phone sex – times of india. available from: http://epaperbeta.timesofindia.com//article.aspx?eid=318 04&articlexml=older-women-prove-to-be-better-atphone-30082015022029. cited on 28 october 2015. panacea journal of medical sciences 2022;12(2):260–266 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article outcome and complications of open reduction and internal fixation in ankle fractures at a tertiary care center ritesh jaiswal1, venkata sivaram g v1,*, s.v.l. narasimha reddy1, daruru venkata srinath1 1dept. of orthopaedics, malla reddy institute of medical sciences, suraram, hyderabad, telangana, india a r t i c l e i n f o article history: received 22-02-2022 accepted 03-06-2022 available online 17-08-2022 keywords: outcome complications open reduction internal fixation ankle fractures a b s t r a c t background: closed reduction used for management of ankle fractures usually result into delayed healing. it inhibits the healing of the ankle fractures. on the contrary, open reduction and internal fixation helps to preserve the supply of blood not only to soft tissues but also bones. this way it helps in proper and timely healing. objective: to study outcome and complications of open reduction and internal fixation in ankle fractures materials and methods: a hospital based prospective study was carried out among 40 cases of ankle fractures. detailed history, general examination were carried out as per the pre-tested, pre-designed study questionnaire. once patient was found to be eligible for present study, surgical profile and pre-anesthetic check-up was done as per standard guidelines. all patients were treated with open reduction and internal fixation method. results: most commonly affected age group was 31-40 years (40%). males were affected more than females (4:1). vehicular accident was most common cause (65%) of ankle fracture. 95% had closed fracture. most common injury pattern (57.5%) was pronation external rotation. k-wire was most commonly used (40%) operative technique. among the variables, open type of fracture and other mode of injury were significantly associated with painful gait. there were no other complications recorded. 70% had excellent outcome and 25% had good outcome. among all factors studied, only open type of fracture was found associated with functional outcome that is not excellent. conclusion: thus open reduction and internal fixation is the treatment of choice in case of fracture ankle joint, with very less change of complications this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction in the united states, most commonly treated fracture is the ankle fracture by the orthopedic surgeons. 1 population based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s 2 as well as there is increase in the severity of fractures, especially in elderly individuals. * corresponding author. e-mail address: gvvvsiva@gmail.com (venkata sivaram g v). ankle is the most congruous joint in the lower extremity, bearing up to five times the body weight. it was demonstrated by ramsey and hamilton that there can be 42% reduction in the articulation of tibiotalar if there is even one millimeter lateral displacement. this will be enhanced with further lateral displacement. in all fractures through the articular surface of a major weight bearing joint, restoration of the normal anatomy is required to prevent development of secondary arthritis and ankle joint is no exception. 3 despite the general perception that operative treatment of ankle fracture yields better clinical results than closed https://doi.org/10.18231/j.pjms.2022.050 2249-8176/© 2022 innovative publication, all rights reserved. 260 jaiswal et al. / panacea journal of medical sciences 2022;12(2):260–266 261 treatment, this advantage has not been demonstrated scientifically in most studies. 4 the primary difficulty in evaluation of the literature in this regard is that, in most clinical studies, the fractures have not been stratified by type but, rather, have been evaluated as a heterogeneous group. after 1970, ankle fractures are usually managed by operative methods. 5 the goal of treatment is to restore biomechanical stability to the ankle, therefore it is imperative to have a clear definition of the altered biomechanical status caused by a specific injury. 2 many clinical studies of ankle fractures have proven that good results depend upon an anatomic reduction of the fracture, and there is a direct correlation between displaced fractures and the occurrence of degenerative arthritis. 5 in ancient times injuries of the ankle were diagnosed chiefly as “luxation.” not until the middle of the eighteenth century were there attempts in the literature to clarify the position of malleolar fractures in relation to “luxation” of the ankle. among the earliest observations on the pathomechanics of ankle injuries were those by sir percival pott, who in an article entitled “some few general remarks on fractures and dislocation” published in 1768, attempted to relate the clinical findings in a given case to the injuries that caused them. after that most experimental studies on the production of ankle fractures were done by the french. 6 the next significant advance in our understanding of ankle fractures had to wait nearly 50 years before baron guillaume dupuytren’s describeddupuytren’s fracture dislocation of ankle in 1819 and commended pott on his powers of acute observation. both pott and dupuytren were the first to point out the type of ankle injury in which the fracture of fibula occurs proximal to level of syndesmosis. they indicated that mechanism of injury was abduction of the foot in relation to the tibia, but they failed to recognize that rupture of the ligaments of syndesmosis accompanied the fracture. 6 considering the fact that the original description was in english, it is surprising how little has been written in english language on the subject. the french on the other hand have written extensively, beginning with baron dupuytren’s description in 1819 of the fracture that eponymous bears his name. according to boning, the period 18151872 was dominated first by dupuytren and then by one of his pupil maisonneuve, who described a fracture dislocation after his name, experimentally produced in 1840, but clinically described for the first time by hundred an eight years later. 6 the most significant contribution was made by lauge hansen in 1950 when based upon his cadaver experiments and a careful study of both clinical and radiological points of view a new classification was proposed – ‘genetic classification of ankle injuries. 7 by this time – the 1960s – the concept of internal fixation in ankle fractures was fast gaining grounds. r.a. denham & c.l. colton advocated internal fixation for unstable ankle fractures and fracture dislocations. this was based on the concept that perfect anatomical reduction was the crux of the issue and absolutely essential for optimum functional results. yet, the concept of early mobilization had not gained great popularity due to lack of sufficiently rigid fixation. 8 management of ankle fractures by internal fixation became popular after the work of “muller, allgower and willenegger (1970)”. 2 the motto was “life is movement, movement is life”. however they utilized the classifications introduced by weber in 1964 –66, for analysis of ankle fracture and making decision as to choice of implants. 3 hughes (1980) reported a comparative study of ankle fractures from three major centers. they reported that “open reduction and internal fixation” of ankle fractures was superior to closed method. 8,9 closed reduction used for management of ankle fractures usually result into delayed healing. it inhibits the healing of the ankle fractures. on the contrary, open reduction and internal fixation helps to preserve the supply of blood not only to soft tissues but also bones. this way it helps in proper and timely healing. hence, present study was carried out to analyze the outcomes & complications among patients treated for ankle fractures with open reduction and internal fixation method 2. materials and methods a hospital based prospective study was carried out from aug 2016 to aug 2018 among 40 cases of ankle fractures at a tertiary care hospital. institutional ethics committee permission was taken and informed consent was taken from all study participants. during the study period, it was possible to include 40 cases of ankle fracture. patients with ankle fracture belonging to age group of 20 years and above of either gender or consenting were included in the present study. those with complicated fracture and with severe comorbidities were excluded from the present study. detailed history, general examination were carried out as per the pre tested, pre designed study questionnaire. once the patient was found to be eligible for the present study, surgical profile and pre-anesthetic check-up was done as per the standard guidelines. in the present study we have taken three radiographs anteroposterior, lateral & mortise view of all clinically diagnosed ankle fractures. all patients were treated with open reduction and internal fixation method. first to start with, giving the priority to fibula, we first fixed lateral malleolus followed by fixing the medial malleolus. after every anatomical reduction, it is necessary to carry out temporary stabilization. for provisional stabilization of the lateral malleolus k wires are used and similarly the medial malleolus is also provisionally fixed. the internal fixation is then carried out, using a 4 mm cannulated cancellous screw, or a four – hole plate 262 jaiswal et al. / panacea journal of medical sciences 2022;12(2):260–266 with/without interfragmentary screw. all kirschner wires are removed at the end, except when they provide additional fixation. the ideal time for the procedure is within the first 6 to 8 hours before any true swelling or fracture blisters develop. the leg is then kept elevated to reduce the swelling before the open reduction is undertaken. standard post-operative care was taken. all patients were followed up for six months to study the functional outcome. regarding post-operative protocol in present study, all patient were given below knee cast for at least 2 weeks and then mobilized with physiotherapy along with partial weight bearing followed by full weight bearing after 6 weeks. period of immobilization recommended in below knee cast is for 2 weeks in monomalleolar, bimalleolar and trimalleolar fractures with additive and its 2 more weeks in partial or complete diastasis fractures. non-weight bearing was however started two weeks after operation. functional results were assessed and graded at the end of plaster immobilization and patient sent for partial weight bearing and physiotherapy. at this time patient was also assessed for painful gait, infection, instability and persistent subluxation. 2.1. statistical analysis the data was expressed as proportions. chi square test was applied to study the factors related to the outcome. p value <0.05 was taken as statistically significant. 3. results most commonly affected age group was 31-40 years (40%) followed by 20-30 years (25%). males were affected more than females in the ratio of 4:1. vehicular accident was the most common cause of ankle fracture in 65% of the cases. 95% of the cases had closed fracture. most common injury pattern was pronation external rotation in 57.5% of the cases. k wire was most commonly used operative technique in 40% cases (table 1) among the variables, open type of fracture and other mode of injury were significantly associated with the painful gait. (table 2) only one case (2.5%) had painful gait at the end of six months follow-up period. there were no other complications recorded (table 3) 70% of the cases had excellent outcome and 25% had good outcome. fair outcome was recorded in only two cases (table 4) among all the factors studied, only open type of fracture was found to be associated with functional outcome that is not excellent (table 5) 4. discussion following the operation, a good or excellent result was obtained in 95% of patients in the present study. majority of cases fall in age group of 31-40 years. males were more in number compared to females. as far as ankle fractures are concerned sexual variation has no clinical significance. the higher proportion of male cases could be because cases were more of vehicular accidents and males are usually at the wheel in most instances. most common mode of injury is vehicular accidents with closed type of fractures which are diagnosed as mono, bi, or trimalleolar fractures with having pronation external rotation type of injury pattern in among more than 50% of cases. in the present study we have taken three radiographs anteroposterior, lateral & mortise view of all clinically diagnosed ankle fractures. anteroposterior, lateral view & anteroposterior with slight medial rotation views are essential for appropriate classification of fracture and their management. several investigators have studied the necessity for the use of three radiographsanteroposterior, lateral & mortise view for classification of fracture and their management. 10,11 lauge hansen pointed out that little reliance can be placed on patient’s interpretation of how ankle was injured because he usually has little idea of the forces involved. it is more satisfactory to take account only of information obtained from radiology and clinical examination. 12 in our study the accurate anatomical reduction with stable internal fixation preferably rigid is responsible for superior result and early functional recovery with minimum possibility of mal-union or non-union as compared to results after conservative treatment. we found that “open reduction and internal fixation using the ao–asif method” gave very good results. previous studies also found the same., 11,12 that sometimes anatomical reduction can give rise to fair/poor functional result but fair / poor reduction always give poor functional result. it requires serial manipulation and further immobilization in cast which leads to further increase in duration in hospital stay and delayed physiotherapy for the joint and delay in rehabilitation. in any case, results from closed treatment frequently reveal that the fractures were inadequately reduced or inadequately maintained after an original adequate reduction and, as would be expected, had comparatively poor results. 13 in the study reported by brounstein and wade (1959) of 57 patients whose ankle injuries had been treated by close reduction, 28 required a second manipulation and 8 a third or fourth manipulation. 14 these authors comment on difficulty in maintaining the position by plaster splintage during the first few weeks as the edema subsides. extent of immobilization is necessary after closed reduction but that lead to osteoporosis, with more risk in elderly females. 3 there is always risk of mal-union and residual subluxation and non-union if there is soft tissue interposition between fragments of medial malleolus. 15 jaiswal et al. / panacea journal of medical sciences 2022;12(2):260–266 263 table 1: socio-demographic and clinicalcharacteristics variable number % age (years) 20-30 10 25 31-40 16 40 41-50 7 17.5 51-60 4 10 > 60 3 7.5 sex male 32 80 female 8 20 mode of injury fall from height 3 7.5 vehicular accident 26 65 other 11 27.5 type of fracture open 2 5 closed 38 95 injury pattern supination adduction 8 20 supination external rotation 2 5 pronation abduction 4 10 pronation external rotation 23 57.5 pronation dorsiflexion 1 2.5 other 2 5 diagnosis monomalleolar 12 30 bimalleolar 12 30 trimalleolar 16 40 operative technique k wire as well 16 40 only tp and cortical screw 12 30 malleolar screw as well 10 25 cc screw as well 2 5 table 2: association betweensocio-demographic, clinical variables with painful gait variables painful gait chi square p yes no sex female 0 8 (100%) 0.256 0.613 male 1 (3.1%) 31 (96.9%) mode of injury fall from height 0 3 (100%) 0.552 0.759vehicular accident 1 (3.8%) 25 (96.2%) other 0 11 (100%) type of fracture open 1 (50%) 1 (50%) 19.487 < 0.0001 closed 0 38 (100%) injury pattern supination adduction 0 8 (100%) 16.932 < 0.0001 supination external rotation 0 2 (100%) pronation abduction 0 4 (100%) pronation external rotation 0 23 (100%) pronation dorsiflexion 0 1 (100%) other 1 (50%) 1 (50%) diagnosis monomalleolar 0 12 (100%) 1.538 0.463bimalleolar 0 12 (100%) trimalleolar 1 (6.3%) 15 (93.8%) table 3: complications among the cases at the end of six months complications number % painful gait 1 2.5 no wound infection 40 100 no implant failure 40 100 264 jaiswal et al. / panacea journal of medical sciences 2022;12(2):260–266 table 4: functional outcome at the end of six months functional outcome number % excellent 28 70 good 10 25 fair 2 5 total 40 100 table 5: association between socio-demographic, clinical variables with functional outcome at the end of six months. variable functional outcome at six months x 2 p excellent good fair sex female 5 (62.5%) 3 (37.5%) 0 1.205 0.547 male 23 (71.9%) 7 (21.9%) 2 (6.3%) mode of injury fall from height 3 (100%) 0 0 2.740 0.602vehicular accident 19 (73.1%) 6 (23.1%) 1 (3.8%) other 6 (54.5%) 4 (36.4%) 1 (9.1%) type of fracture open 0 1 (50%) 1 (50%) 10.526 0.005 closed 28 (73.7%) 9 (23.7%) 1 (2.6%) injury pattern supination adduction 6 (75%) 2 (25%) 0 17.848 0.058 supination external rotation 2 (100%) 0 0 pronation abduction 1 (25%) 3 (75%) 0 pronation external rotation 18 (78.3%) 4 (17.4%) 1 (4.3%) pronation dorsiflexion 1 (100%) 0 0 other 0 1 (50%) 1 (50%) diagnosis monomalleolar 10 (83.3%) 2 (16.7%) 0 4.119 0.390bimalleolar 8 (66.7%) 4 (33.3%) 0 trimalleolar 10 (62.5%) 4 (25%) 2 (5%) by doing open reduction and internal fixation one can achieve anatomical reduction by removing soft tissue interposition if that is causing problems in reduction and end result are likely to be excellent. in the present study, no any soft tissue interposition interfering the reduction was found or probably orif of medial and lateral malleolus caused a fall of the soft tissues to their original anatomical positions. in our study 2 cases came within 6-12 hour of injury and got operated immediately. one case was 45 year old male having compound grade ii fracture of ankle joint. irrigation, debridement and orif with a malleolar screw was performed for medial malleolus and one third tubular plate with 3.5 mm cortical screws was used for fracture of lateral malleolus. tag sutures were taken in view of compound wound. later on stsg was performed. patient was initially maintained in bk slab. bk cast was given after stsg took over for 8 weeks and mobilize thereafter. final outcome was fair functional end result in view of painful gait, restricted movement and edema of foot. timothy j. bray, in his study of 31 compound ankle fractures treated with orif, concluded that it is better than conservative management in view of speedy recovery and rehabilitation. 16 in present study standard medial approach used for fixation of medial malleolus. in some cases, 4mm cannulated cancellous screws of proper length were used. large fragment required two screws. all patients had complete union of medial malleolus. the lateral malleolus is fixed by standard lateral approach. the lateral malleolus has a key role to play in achieving reduction and stability of ankle fractures. yablon ig et al from boston university medical center produced an important and interesting paper in 1976. till then it had been wrongly believed for a long time that if the medial malleolus was reduced and fixed, the fibular fracture fell into place. they provided evidence that in patients with bimalleolar fracture cases, first it is necessary to reduce the lateral malleolus so that we can reposition the talus. 17 in present study, the same principal described by yablon ig et al 17 was followed and lateral malleolus fixed first in each bi-malleolar and tri-malleolar fracture and anatomical reduction with excellent functional end results was achieved. fixation of posterior malleolus is not always required. posterior malleolus fracture is first describe by destol 1911 occurs primarily as a consequence of avulsion by the posterior–inferior tibio–fibular ligament of because of pressure from the externally rotating talus when associated with medial and lateral malleolar fracture called as trimalleolar fracture. intra-articular fragment that are big allowed to heal in the displaced position lead to intra articular incongruity lead to post traumatic arthritis. in our present study, 16 cases of posterior malleolus fractures were found and orif was not done. all of these cases had jaiswal et al. / panacea journal of medical sciences 2022;12(2):260–266 265 excellent functional result. mcdaniel wj et al in their paper concluded that when posterior fragment involved 25% of the articular surface or more operative treatment of the posterior malleolus was associated with better functional result than of close treatment. 18 harper mc et al concluded that fracture of posterior malleolus is not at all required to fix by orif if both malleoli reduced anatomically and fixed with rigid internal fixation, the posterior malleolus got reduced by its own and remain stable. 11 finsen v et al in their study of 56 patients of fracture ankle conclude that there is no added advantage of postop. mobilization with or without bk cast, if the fixation is stable. 19 in this study, patients were asked to use crape bandage for 6 weeks after removal of the cast to prevent rebound edema. patients were assessed every two weeks in general. the following criteria were adopted for rehabilitation. if the patient is light and sedentary worker early rehabilitation at about two weeks after the expected period of union. heavy manual worker requires walking and standing, had to wait for two weeks to eight weeks after the period of union. in present study there were no complications like infection and implant failure except painful gait in one patient till after end of one year. in our study there is a significant association of painful gait complication with open type of fractures. a compound fractures of ankle joint which resulted in fair function end result was found comparable with the study published by burwell hn et al. 14 wilson fc in his paper on fracture of the ankle jointpathogenesis and treatment, concludes that, bimalleolar fracture and posterior malleolar fracture with fracture fragment more than 25% of the tibial plafond should be fixed with orif for better result. 20 5. conclusion maximum period required by majority of the patient after operation to return back to work was 12-14 weeks; however some were able to go back to work as early as 8 weeks. successful results were seen in 95% of cases and complications were observed only in 5% patients. the main complication found was painful gait. surgical intervention with anatomical reduction and stable internal fixation yields superior results with minimal complications and earlier rehabilitation. it is essential to treat all ankle fractures by accurate anatomical reduction and stable internal fixation. thus open reduction and internal fixation is the treatment of choice in case of fracture ankle joint, with very less change of complications. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. ahl t, dalen n, selvik g. mobilization after operation of ankle fractures. good results of early motion and weight hearing. acta orthop scan. 1988;59(3):302–6. doi:10.3109/17453678809149368. 2. ahl t, dalen n, selvik g. ankle fractures. a clinical and roentgenographic stereophotogrammetric study. clin orthop. 1989;(245):246–55. 3. ahl t, dalen n, lundberg a, bylund c. early mobilization of operated on ankle fractures. prospective, controlled study of 40 bimalleolar cases. acta orthop scand. 1993;64(1):95–9. doi:10.3109/17453679308994541. 4. ali ms, mclaren ca, rouholamin e, o’connor bt. ankle fractures in the elderly: non-operative or operative treatment. j orthop trauma. 1987;1(4):275–80. doi:10.1097/00005131-198701040-00002. 5. bauer m, jonsson k, nilsson b. thirty-year follow-up of ankle fractures. acta orthop scand. 1985;56(2):103–6. doi:10.3109/17453678508994329. 6. amendola a. controversies in diagnosis and management of syndesmosis injuries of the ankle. foot and ankle. 1992;13(1):44–50. doi:10.1177/107110079201300108. 7. baird ra, jackson s. fractures of the distal part of the fibula with associated disruption of the deltoid ligament. treatment without repair of the deltoid ligament. j bone joint surg. 1987;69(9):1346–52. 8. bauer m, bengnér u, johnell o, redlund-johnell i. supination-eversion fractures of the ankle joint: changes in incidence over 30 years. foot ankle. 1987;8(1):26–8. doi:10.1177/107110078700800107. 9. bauer m, bergstrom b, hemborg a, sandegard j. malleolar fractures: non-operative versus operative treatment. a controlled study. clin orthop. 1985;(199):17–27. 10. goergen tg, danzig la, resnick d, owen ca. roentgenographic evaluation of the tibiotalar joint. j bone joint surg. 1977;59(7):874– 7. 11. harper mc. the deltoid ligament. an evaluation of need for surgical repair. clin orthop relat res. 1988;(226):156–68. 12. lauge-hansen n. combined experimental-surgical and experimentalroentgenologic investigations. arch surg (1920). 1950;605:957–85. 13. joy g, patzakis mj, harvey jp. precise evaluation of the reduction of severe ankle fractures. j bone and joint surg. 1974;56(5):979–93. 14. burwell hn, charnley ad. the treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. j bone and joint surg. 1965;47(4):634–60. 15. boden sd, labropoulos pa, mccowin p, lestini wf, hurwitz sr. mechanical considerations for the syndesniosis screw. a cadaver study. j bone joint surg am. 1989;71(10):1548–55. 16. bray tj, endicott m, capra se. treatment of open ankle fractures. immediate internal fixation versus closed immobilization and delayed fixation. clin orthop relat res. 1989;(240):47–52. 17. yablon ig. the key role of the lateral malleolus in displaced fractures of the ankle. j bone joint surg. 1977;59(2):169–73. 18. mcdaniel wj, wilson fc. trimalleolar fractures of the ankle. an end result study. clin orthop. 1977;(122):37–45. 19. finsen v, saetermo r, kibsgaard l, farran k, engebretsen l, bolz kd, et al. early postoperative weight-bearing and muscle activity in patients who have a fracture of the ankle. j bone joint surg. 1989;71(1):23–7. 20. wilson fc. the pathogenesis and treatment of ankle fractures : historical studies. instr course lect. 1990;39:73–7. author biography ritesh jaiswal, assistant professor http://dx.doi.org/10.3109/17453678809149368 http://dx.doi.org/10.3109/17453679308994541 http://dx.doi.org/10.1097/00005131-198701040-00002 http://dx.doi.org/10.3109/17453678508994329 http://dx.doi.org/10.1177/107110079201300108 http://dx.doi.org/10.1177/107110078700800107 266 jaiswal et al. / panacea journal of medical sciences 2022;12(2):260–266 venkata sivaram g v, associate professor s.v.l. narasimha reddy, associate professor daruru venkata srinath, assistant professor cite this article: jaiswal r, venkata sivaram g v, reddy svln, srinath dv. outcome and complications of open reduction and internal fixation in ankle fractures at a tertiary care center. panacea j med sci 2022;12(2):260-266. panacea journal of medical sciences 2022;12(2):335–339 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a clinical study of primary open angle glaucoma (poag) in myopia-an observational study sumita mohapatra1, suresh chandra swain1,*, debasmita jena1 1dept. of ophthalmology, s.c.b. medical college & hospital, cuttack, odisha, india a r t i c l e i n f o article history: received 11-07-2021 accepted 24-08-2021 available online 17-08-2022 keywords: myopia primary open-angle glaucoma spectral domain optical coherence tomography a b s t r a c t background: the primary open-angle glaucoma is the most common type of glaucoma causing irreversible blindness. myopia is one of the risk factor responsible for pathogenesis of glaucoma. the association between myopia and primary open angle glaucoma has been found in numerous case studies. the aim of the study to evaluate the relationship of myopia in primary open-angle glaucoma by classifying the eyes into low, moderate and high myopia. materials and methods: this prospective study was performed on 1414 axial myopic patients more > 18 years. clinical examination included, slit-lamp biomicriscopy, goldman applanation tonometry, refraction, dilated optic disc assessment, central corneal thickness, visual field analysis and optical coherence tonography. results: out of 1414 patients, 769(54.38%) were male and 645(45.62%) were female. low myopia (<3d) cases are 938(66.32%), moderate myopia (-3d to -d) 309(21.88%), high myopia (>-6d), 107(11.8%). maximum number of cases were in younger age group (20-30 years). intraoccular pressure > 21mmhg in 143 cases of low myopia, 78 cases in moderate myopia, 72 cases in high myopia. there were 138 cases with glaucomatous field changes. out of 138 cases 86(62.32%) were high myopia, 35(25.36%) were moderate myopia and 17(10.8%) cases were low myopia. the cup-disc ratio <0.5 in 75.95% cases, 0.5-<0.9 in 20.37% cases, >0.9 in 3.68% cases. the average values of circumpapilary nerve fiber layer thickness in micrometer of low myopia, moderate myopia, high myopia, with non-glaucomatous cases were 98.9, 97.3, 93.5 and with glaucomatous cases, 74.4, 73.7 and 73.3 respectively. the average values of ganglion cell complex thickness in micrometer in low, moderate and high myopia without glaucoma were 94.9, 93.5, 92.7 and with glaucoma 77.3, 74.6, 70.2 respectively. conclusion: this study shows there is strong relationship between myopia and primary open-angle glaucoma. early detection of glaucoma in myopic patients is necessary in delaying blindness. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. background myopia or short-sightedness is a refractive condition of the eye that makes distant objects to be blurry while close object appears normal. among different etiological types myopia, axial myopia is commonest, in which their occurs axial elongation of eyeball. axial elongation affect the * corresponding author. e-mail address: suresh211167@gmail.com (s. c. swain). eye’s intraocular structure (optic disc or macula), where glaucomatous damage can occur. glaucoma, a progressive optic neuropathy causes irreversible blindness. 1 it is characterized by the loss of retinal nerve fiber tissues, recognized clinically as visual field defect and loss of the neuro retinal rim of the optic nerve head. the primary open-angle glaucoma (poag) is the most common type of glaucoma. https://doi.org/10.18231/j.pjms.2022.063 2249-8176/© 2022 innovative publication, all rights reserved. 335 336 mohapatra, swain and jena / panacea journal of medical sciences 2022;12(2):335–339 elevated intraocular pressure (iop) is a measure risk factor for poag. 2 other risk factors like age, gender, race, refractive errors, heredity and systemic factors may play a role in glaucoma pathogenesis. 3 most of the studies have suggested that moderate to high myopia is associated with increased risk of poag. 4,5 mechanical theory explains the association between myopia and primary open-angle glaucoma (poag), which describes that damage to optic nerve head at lamina cribosa leads to retinal ganglion cell atrophy and glaucomatous optic neuropathy, induced by increased iop and a tensile sclera or by exacerbated shearing forces due to longer axial eye length. 2. materials and methods this is a prospective study, was conducted during the period of october 2018september 2020 at ophthalmology department, s.c.b. medical college, cuttack, odisha. ethical committee clearance was taken. subjects with axial myopia >=-1d identified by a standardized subjective refraction and categorized into low myopia (<=-1d to >-3d), moderate (>-3d<-6d) or high myopia (>-6d) according to sihota’s classification and taken for the study. primary open-angle glaucoma diagnosed taking into account characteristic visual field loss combined with optic disc cupping and neuro retinal rim thinning with or without raised iop. 2.1. inclusion criteria all the myopic patients (>=-1d) of age >18 years who had given consent for study. 2.2. exclusion criteria 1. known case of any form of secondary glaucoma. 2. angle closer glaucoma. 3. lenticular opacity. 4. keratoconus. 5. history of trauma. 6. history of surgery. a total of 1414 axial myopia patients included in this study. the examination included, medical history, best corrected of visual acuity, refraction by auto refractometer and subjective refraction, slit-lamp biomicroscopy, goldmann applanation tonometry for intra ocular pressure (iop), central corneal thickness (cct) measurement by ultrasound pachymeter, post dilation optic disc (od) and retina evaluation with +90d fundus noncontact lens, visual field analysis by humphrey perimeter, optical coherence tomography (oct) for optic nerve head (onh), ganglion cell complex (gcc) and circum papillary retinal nerve fiber (cp rnfl) evaluation. 3. results the above table shows 769 (54.38%) patients were male and 645 (45.62%) were female. maximum number of myopic patients were younger age group, between 20-30 years. 438 cases were low myopics, 127 cases were moderate myopics and 68 cases were high myopics. less number of patients were more than 40 years.table 1 according to sihota myopia is classified as low (<-3d), medium (-3d to -6d) and high (>-6d). low myopia cases were 938 (66.34%), moderate myopia and high myopia patients were 309 (21.85%), 167 (11.81%) respectively. bcva of patients varied from 6/6 to <6/60. it could improve up to >6/60 in all the low myopics, 98.7% (305) of the moderate myopics, 97.01% (162) of high myopics and rest with bcva <=6/60.table 2 normal intraocular pressure is taken to be between 11mmhg and 21mmhg with mean iop as 16+-2.5mmhg. measurement of iop was done by goldmann applanation tonometer. 143 cases with low myopia, 78 cases with moderate myopia and 72 cases of high myopia had iop>21mmhg. 1074 (75.95%) patients had c/d ratio <0.5, 288 (20.37%) patients had 0.5-<0.9 and 52 (3.68%) patients had c/d ratio >0.9.table 3 mean cct in 938 cases low myopic group was 536.6, 309 cases of moderate myopic group was 531 and 167 cases that of high myopic group was 540.9 micrometer.table 4 1405 patients with bcva >6/60 were advised for 242 visual field test done by humphrey’s perimeter. out of these 138 patients had glaucomatous field changes and 48 patients had non-glaucomatous changes. 1219 patients had no perimetry changes. out of 138 patients with perimetric glaucoma 86 (62.32%) cases were high myopics, 38 (25.36%) cases were moderate myopics and 17 (12.32%) cases were low myopics.table 5 the patients were subjected for sd-oct scan. the average cp rnfl thickness was 98.9 micrometer in low myopic non-glaucomatous patients, 74.4 micrometer in glaucomatous cases. 97.3 micrometer in moderate myopic non-glaucomatous patients, 73.7 micrometer in glaucomatous cases. 93.5 micrometer in high myopic nonglaucomatous patients, 73.3 micrometer in glaucomatous cases. the superior and inferior cprnfl thickness in micrometer were found to be less in glaucomatous group than non glaucomatous group like average cp rnfl thickness.table 6 the average gcc parameters in micrometer measured by sdoct scan was 94.9 micrometer in low myopic nonglaucomatous patients, 77.3 micrometer in glaucomatous patients. 93.5 micrometer in moderate myopic nonglaucomatous patients, 74.6 micrometer in glaucomatous cases. 92.7 micrometer in high myopic non-glaucomatous patients, 70.2 micrometer in glaucomatous cases. the superior and inferior gcc parameter were found to be less in glaucomatous group than non glaucomatous group like mohapatra, swain and jena / panacea journal of medical sciences 2022;12(2):335–339 337 table 1: a. sex prevalence of myopia category no. of patients percentage male 769 54.38 female 645 45.62 total 1414 100 b. age group in years age group low myopia moderate high myopia <20 206 78 35 20-30 438 127 68 30-40 197 76 48 >40 97 28 16 total 938 309 167 table 2: a. degree of myopia degree of myopia nunber % low (< -3d) 938 66.34 moderate (-3 to -6d) 309 21.85 high (> -6d) 167 11.81 total 1414 100 b. classification of patients on the basis of bcva degree of myopia bcva >6/60 percentage bcva <=6/60 percentage low 938 100 0 moderate 305 98.7 4 1.3 high 162 97.01 5 2.99 table 3: a. iop by goldmann applanation tonometry in the patients degree of myopia iop range <10mmhg 10-21mmhg >21mmhg total low 233 562 143 938 moderate 87 144 78 309 high 32 63 72 167 b. cup-disc ratio (c/d ratio) cup-disc ratio number of myopes % <0.5 1074 75.95 0.5-<0.9 288 20.37 >0.9 52 3.68 table 4: cct in micrometer in the patients myopia groups number mean cct range 0 to -3d 938 536.6 305-684 >-3 to -6d 309 531 417-613 >-6d 167 540.9 417-614 table 5: a. perimetric changes no of patients done perimetry perimetry suggestive of glaucomatous changes perimetry suggestive of non-glaucomatous changes perimetry having no changes 1405 138 48 1219 b.grading of poag on the basis of perimetric findings (hodappparrishanderson criteria) no of poag patients with perimetric glaucoma no of patients with high myopia and perimetric glaucoma no of patients with moderate myopia & perimetric glaucoma no of patients with low myopia and perimetric glaucoma 138 86(62.32%) 35(25.36%) 17(12.32%) 338 mohapatra, swain and jena / panacea journal of medical sciences 2022;12(2):335–339 table 6: cp rnfl parameters in different grades of myopia (with and without glaucoma) cp rnfl thickness (µm) low myopia moderate myopia high ng myopia ng g ng g g average cprnfl 98.9 74.4 97.3 73.7 93.5 73.3 superior cprnfl 99.5 76.5 96.8 75.6 92.9 74.3 inferior cprnfl 101.8 74.2 98.5 74.3 94.8 75.0 ng= no glaucoma g= glaucoma table 7: gcc parameters in different grades of myopia (with or without glaucoma) gcc parameters (µm) low myopia moderate myopia high myopia ng g ng g ng g average gcc 94.9 77.3 93.5 74.6 92.7 70.2 superior gcc 96.9 80.3 95.4 77.3 94.8 74.1 inferior gcc 95.1 71.4 94.6 70.6 94.4 68.1 average gcc thickness.table 7 3.1. statistical analysis the statistical analysis was formed using commercially available software (spss, version 15, spss ink, chicago, illinois) including chi-square test. 4. discussion out of 1414 patients in our study, 769(54.38%) were male and 645(45.62%) were female (table 1a). male to female ratio 1.19:1. maximum number of myopic patients were in younger age group. (table 1b). holden et al suggest variability in gender difference is owing to environmental influences, such as inequitable access to education, participation in physical activity and closed work. 6 in many of the study it is reported that gender prevalence exhibits a particular pattern with a greater prevalence of myopia in girls starting to appear at around the age of 9 years, continuing through teenage years and early adulthood and diminishing to no or minimal gender difference around the age of 50 to 60 years. out of 1414 patients there were 938(66.34%) low myopia (<3d), 309(21.85%) moderate myopia (-3d to -6d) and 167(11.81%) of high myopia cases (>-6d) (table 2a). optic nerve head of myopic eyes are more susceptible to glaucomatous damage due to some structural changes. increasing degree of myopia is a risk factor for glaucoma. blue mountains eye study, they found a strong relationship between glaucoma and myopia after adjusting for age, sex and other risk factors (odds ratio 2.3 for eyes with low myopia, 3.3 for moderate to high myopia). 7 myopic subjects had a two three-fold increase risk of glaucoma compared with that of non myopic subjects. the singapore malays eye study showed persons with moderate or high myopia had almost 3 times higher risk of poag compared with those emmetropia. 8 143 cases with low myopia, 78 cases with moderate myopia and 72 cases of high myopia had iop>21mmhg. conversely 17(12.32%) patients of low with low myopia, 35(25.36%) patients with moderate myopia and 86(62.32%) with high myopia had perimetric glaucoma (tables 3 and 5 ). there is increase in number patients with perimetric glaucoma as severity of myopia increases. edgar and rudnika found that low myopia was associated with doubling of the risk of glaucoma at any age and a threefold increase with medium and high myopia compared to that emmetropia. 9 in our study the number of patients with cup-disc ratio 0.5-<0.9 were 288 (20.37%), and c/d ratio>0.9 were 52 (3.68%) patients. study of ocular hypertention and glaucoma patients 10 found that the incidence of visual field defects increased markedly with cdr greater than 0.7. the mean cct in low myopic group was 536.6 micrometer, moderate myopic group was 531 micrometer and high myopic group was 540.9 micrometer (table 4). cct difference is not statistically significant. cp rnfl and gcc parameters detected by sd-oct is essential for glaucoma diagnosis and progression. all the average values were found to be less in glaucomatous group than the non glaucomatous group (tables 6 and 7 ). kim et al found similar results comparing glaucomatous group with non-glaucomatous group by sd-oct measurements. 11 assessment of gcc parameters is a useful technique complimentary to cprnfl thickness assessment, for evaluating patients with glaucoma and high myopia by shoji t et al. 12 5. conclusion this study shows myopia is a risk factor for poag as observed by many studies. but it is a proven fact that mohapatra, swain and jena / panacea journal of medical sciences 2022;12(2):335–339 339 prevalence of poag is more in moderate and high myopics. myopia is relatively common in younger age group. so early detection of glaucoma in these patients will be helpful in delaying the blindness. especially for moderate and high myopia. 6. conflict of interest the authors declare that they have no conflict of interest. 7. source of funding none. references 1. loyo-berrios ni, blustein jn. primary-open glaucoma and myopia: a narrative review. wmj. 2007;106(2):95–9. 2. mcmonnies cw. intraocular pressure spikes in keratectasia, axial myopia, and glaucoma. optom vis sci. 2008;85(10):1018–26. doi:10.1097/opx.0b013e3181890e91. 3. ohana eb, blumen mb, bluwol e, derri m, chabolle f, nordmann jp, et al. primary open angle glaucoma and snoring: prevalence of osas. eur ann otorhinolaryngol head neck dis. 2010;127(5):159– 64. doi:10.1016/j.anorl.2010.07.003. 4. knapp a. glaucoma in myopic eyes. trans am ophthalmol soc. 1925;23:61–70. 5. podos sm, becker b, morton wr. high myopia and primary openangle glaucoma. am j ophthalmol. 1966;62(6):1038–43. 6. holden ba, fricke tr, wilson da. global prevalence of myopia and high myopia and temporal trends from. othphalmology. 2000;123(5):1036–42. doi:10.1016/j.ophtha.2016.01.006. 7. mitchell p, hourihan f, sandbach j, wang jj. the relationship between glaucoma and myopia: the blue mountains eye study. ophthalmology. 1999;106(10):2010–5. doi:10.1016/s01616420(99)90416-5. 8. perera sa, wong ty, tay wt, foster pj, saw sm, aung t, et al. refractive error, axial dimensions, and primary open angle glaucoma: the singapore malayeyestudy. arch ophthalmol. 2010;128(7):900–5. doi:10.1001/archophthalmol.2010.125. 9. edgar fd, rudnika ra. glaucoma identification and co-management. vol. 7. edinburgh: butterworth heinemann elsevier; 2007. 10. gloster j. quantitative relationship between coping of the optic disc and visual field loss in chronic simple glaucoma. br j ophthalmol. 1978;62(10):665–9. doi:10.1136/bjo.62.10.665. 11. kim nr, lee es, seong gj, kang sy, kim jh, hong s, et al. comparing the ganglion cell complex and retinal nerve fibre layer measurements by fourier domain oct to detect glaucoma in high myopia. br j ophthalmol. 2011;95(8):1115–21. 12. shoji t, nagaoka y, sato h, chihara e. impact of high myopia on the performance of sd-oct parameters to detect glaucoma. graefes arch chin exp ophthalmol. 2012;250(12):1843–9. author biography sumita mohapatra, professor suresh chandra swain, associate professor debasmita jena, senior resident cite this article: mohapatra s, swain sc, jena d. a clinical study of primary open angle glaucoma (poag) in myopia-an observational study. panacea j med sci 2022;12(2):335-339. http://dx.doi.org/10.1097/opx.0b013e3181890e91 http://dx.doi.org/10.1016/j.anorl.2010.07.003 http://dx.doi.org/10.1016/j.ophtha.2016.01.006 http://dx.doi.org/10.1016/s0161-6420(99)90416-5 http://dx.doi.org/10.1016/s0161-6420(99)90416-5 http://dx.doi.org/10.1001/archophthalmol.2010.125 http://dx.doi.org/10.1136/bjo.62.10.665 original research article doi: 10.18231/2348-7682.2017.0005 panacea journal of medical sciences, january-april,2017;7(1): 15-18 15 inhibitory effect of alternariol on nitric oxide synthase in different parts of rat brain hassan my osman assistant professor, dept. of biochemistry, medical research institute, alexandria university, alexandria, egypt email: hassanyousry12@yahoo.com abstract alternariol (3,4,5 trihydroxy 6-methyl dibenzoxy-a –pyrone) is a metabolite result of various strains of alternariatenuis organism. its structure has closeness to cannabinol subordinates. the impact of the alternariol on nitric oxide snythase (nos) extracted from distinct parts of rat brain; particularly: frontal cortex, basal ganglia, cerebellum, pons, medulla oblongata was considered. kinetic studies were done to decide the sort of inhibition of nos and the inhibitor dissociation constants (ki) by alternariol. the outcomes showed that alternariol inhibited nos of the cortex, medulla oblongata and cerebellum more than that of alternate parts of the brain. these parts are in-charge of observation, tactile, psychic exercises and reflex focuses of breath. the inhibition of these enzymes increased with increasing the dose of alternariol added to the examined blend, i.e., the inhibition was dose dependent and of the competitive type. the estimations of ki for alternariol –nos complexes shifted from 1.8 to 5.6 mm. the distinction in the level of inhibition of the extracts of these brain parts could be ascribed to the slight contrast in the structure, i.e. course of action of their amino acids (isozyme phenomenon) and to their particular gene loci. keywords: alternariol, nitric oxide synthase, brain parts, inhibition. introduction alternariolis, a metabolite created by distinctive strains of alternariatenuis.(1) its structure was built up as 3,4,5 trihydroxy 6-methyl dibenzoxy pyrone c14 h10 o5 (i). it has striking likeness to cannabinol subordinates (ii). common events of alternaria toxins have been accounted for in different natural products, handled organic product items, for example, squeezed apple, tomato items, wheat and different grains, sunflower seeds and pecans.(2-3) pre-cancerous changes were observed in the esophageal mucosa of alternariol fed mice for 10months.(4) nitric oxide (no) is an administrative organic substance and an essential intracellular errand person that goes about as a particular middle person of different neuropathological disorders.(5)no is incorporated by nitric oxide synthase (nos), and increased in an assortment of tumor cells. no controls various cell reactions by s-nitrosylation.(6) nitric oxide synthase (nos) was initially recognized and depicted in 1989. the development of no by nos in vascular endothelial cells opened up what can be viewed as another territory of organic research. brain nos is a constitutive compound, the capacity of which is to deliver no on interest for various neurophysiological exercises.(7) nos intercedes the development of the neurotransmitter no in addition to citrulline from l-arginine. no plays an important role as a neurotransmitter in the nervous system, as a vasodilator in the cardiovascular system and as a cytotoxin in the host defence mechanism of macrophages.(8) the present review was led to research the inhibitory impact of alternariol on nos extracted from entire and five sections of rat brain, to be specific; frontal cortex, basal ganglia, cerebellum, pons and medulla oblongata. compound kinetic studies were done to decide the sort of inhibition and enzymeinhibitor dissociation constant (ki) of nos by alternariol, and to know which of these parts was repressed by alternariol more than different parts. material and methods alternariol was prepared by growing a strain of alternariatenuis, catalogue number s.m.108, on czepek-doxmedium using either glucose or molasses, as a carbon source.(1)the metabolite was extracted from the dried defatted mycellian with ether, then purified by repeated crystallization from dioxane giving colorless needles m.p. 350° (decomp). chemicals: naphthyl ethelenediamine dihydrochloride, sigma (deisonhofen germany), sulfanylamide, sigma hassan my osman inhibitory effect of alternariol on nitric oxide synthase in different parts of rat brain panacea journal of medical sciences, january-april,2017;7(1): 15-18 16 deisonhofen germany, phosphoric acid (h3po4): deisonhofen germany and buffer: phosphate (kh2po4 and na2hpo4) 0.1 m, ph 8.0 bdh. animals: thirty male albino rats (125-150 gram body weight) age 2 months were used in the experiments. rats were supplied from medical research institute animal house, alexandria university (egypt) and were housed in group cages (five in each) and given free access of food and tap water (ad libitum). the brains of these rats were used as a source for nos. the rats were profoundly anesthetized and slaughtered by beheading after an overnight fast, with free access of water. each brain weighed about 1.6 gm. assay of nitric oxide synthase (nos) activity: brain nitric oxide synthase (nos) is a constitutive compound and the capacity of which is to create nitric oxide (no): l-arginine nos  l-citrulline + no nos was controlled by evaluating nitrite (no2) (being the most stable metabolite). it is utilized as a file for nos.(9-10) because of the transient and unpredictable nature of no which makes it precarious, continually oxidized to the steady forms nitrite (no2) and nitrate (no3), the most advantageous discovery technique for no was to be measured as far as no2 which can be identified by photometric strategy utilizing griess reagent(9)at 546 nm. griess reagent consists of one part of naphthyl ethelenediamine dihydrochloride (ned) in distilled water and one part of 1% sulfanilamide in 5% concentrated phosphoric acid (h3po4). the two parts being mixed together within 12 hours of use and kept chilled. each part may be stored separately refrigerated up to 2 months. the mixture of the two parts incubate with a no2-continaing sample (ratio 1:1) to form purple azo dye and its absorbance is measured at a wave length of 546 nm.(9,10) to decide no2 in brain tissue; 150 μl brain homogenate containing 20mg tissue were blended with 1.5 ml of griess reagent and the blend incubated for 5 min at room temperature. the color formed was measured at absorbance 546 nm. nitrite was computed from no2 standard curve. for the assurance of the binding constant (kb), bimolecular rate constant (ka) and the inhibition rate (ki), (11)alternariol was added to the previously mentioned blend in the following concentrations: 140, 280, or 420 or 560 µm while keeping the substrate at a steady fixation (166 µm), then the catalyst was examined after various interims (0, 15, 30, 45 and 60 sec). the experimental design and interpretation of the results were based on the following equation:(11) where [i] is the inhibitor fixation , and (△ t/2.3 △ log v) is the first order rate constant at steady [i]. for the assurance of the kind of inhibition and the enzyme-inhibitor dissociation constant (ki), the substrate fixation was differed: 111, 166, 222 and 333 µm while the inhibitor (alternariol) was kept constant for every investigation: 140, 280 or 560µm.the inhibitor and substrate were added all the while simultaneously to the previously mentioned blend. results graphical representation of the inhibition of nos by alternariol at various concentrations (140, 280, 420 or 560 µm) got by plotting log v (the speed of reaction) against time (t) gave straight lines (fig. 1a). the slopes were processed and gave the esteem 2.3∆ log v/∆t. these results were utilized to develop the chart of [i].∆t/2.3∆ log v plotted against [i] (fig 1b). the slope of the straight line gave 1/ki(ki is the rate of inhibition), the catch on the [i] pivot gave kb (binding constant) and the capture on the ordinate gave 1/ka(ka is the bimolecular rate constant).the estimations of ki, kb and ka are given in table 1. as regards the kind of inhibition of nos by alternariol; figure 2 demonstrates that the double reciprocal curves of 1/v (v is the speed of the reaction) versus 1/[s] (s is the substrate concentration in µmol/l), keeping the inhibitor [i] constant for every analysis and changing the substrate concentration as mentioned by dixon and webb.(12) the slopereplots(inset of fig.2) demonstrate that alternariol is a linear competitive inhibitor (after cleland nomenclature).(13) the subsequent estimations ofki (enzyme inhibitor dissociation constant), km (michaelis' constant) and ki/km (affinity constant) for the distinctive parts under analysis, are recorded in table 1. table 1: kinetic constants characterizing the inhibition of nos of whole and different parts of rat brain by alternariol. values represent mean of 3 repeated experiments. s.d. was 10% part of the brain ki(a) (min-1) kb(b) (mm) ka (c) (µm.min)-1 ki(d) (mm) km(e) (µm) ki/km(f) whole brain 3.25 1.1 3.0 3.5 325 10.7 basal ganglia 1.7 0.8 2.2 1.8 333 5.4 frontal cortex 5.4 0.4 14 5.6 290 19.3 medulla oblongata 5.6 0.8 7.0 5 400 12.5 hassan my osman inhibitory effect of alternariol on nitric oxide synthase in different parts of rat brain panacea journal of medical sciences, january-april,2017;7(1): 15-18 17 pons 1.75 0.4 4.5 4.5 460 9.8 cerebellum 3.67 0.6 6.1 4.7 415 11.3 (a) inhibition constant (d) enzyme-inhibitor dissociation constant (b) binding constant (e) michaelis’ constant (c) bimolecular rate constant (f) affinity constant fig. 1(a): the time course of inhibition of cerebellum fig 1(b): main plot of the data of the inhibition of nos by alternariol in vitro at constant substrate cerebellum nos by alternariol. the slope of the concentration (0.3mm), concentrations of straight line gave 1/ki (ki: rate of inhibition), the alternariol: 140( (∆), 560 (○) µm. intercept on [i] axis gave kb (binding constant) and the intercept on the ordinate gave 1/ka(ka: bimolecular rate constant) inset: cleland replot of the slopes obtained from fig. 2 against the inhibitor concentration [i]. fig. 2: competitive inhibition obtained from line weaver-burk plot of 1/v versus 1/s, under the effect of alternariol on activity of basal ganglia nos. () control, () 4.0, () 7.0 & () 10 mmol/l discussion the preliminary experiments showed considerable difference in nos activity in the various parts of rat brain. the highest activity was detected in the medulla oblongata, frontal cortex and cerebellum, lower in basal ganglia and pons. the high nos activity in the cerebellum is in agreement with the results described by other authors(14) who found that nos activity was significantly decreased by 75% in the cerebellum. decreased nos activity in the nervous tissue was associated with decreased motor activities and spontaneous behavior of rats. in the present work, the in vitro study of the effect of alternariolon nos activity showed that alternariol had an inhibitory power on nos of the cerebellum, pons and medulla oblongata more than that on the other parts which was in agreement with other authors(15) who found that the vmax and km values of the enzyme in cortex and cerebellum of rats were higher than in other brain parts. these studies show differential distribution and higher activity of nos in rat brain regions and spinal cord compared to mouse tissues. alternariol possessed higher affinity and binding to the enzyme extracts of medulla oblongata (responsible for neural control on heart rate, respiration and blood pressure) than to the extracts of the other parts. this indicated that it resembled serine(16) that was introduced as a nos inhibitor which was time and dose-dependent. it also resembles carbaryl (sevin)(a carbamate analogue of eserine which was introduced as a cholinesterase and nos inhibitor).(17) 1.4 1.6 1.8 2 0 20 40 60 time (sec) lo g a c t iv it y % 0.0 5.0 10.0 1/ka 20.0 25.0 30.0 35.0 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 [i] mm [i].  t / (2.3  log v) µm.min 1/ki kb hassan my osman inhibitory effect of alternariol on nitric oxide synthase in different parts of rat brain panacea journal of medical sciences, january-april,2017;7(1): 15-18 18 carbaryl (sevin) alternariol was introduced in this work as a nos inhibitor as it was previously postulated(18)that nos inhibitor agents play crucial roles in neurodegeneration and neuropathic pain, as it is known that no levels rise after neurological insults causing the previously – mentioned malfunctions. alternariol was previously introduced as having a dual inhibitory effect on cholinesterase (che) and monoamine oxidase (mao).(19) finally; it is note-worthy to mention that the difference in the rate of nos inhibition by alternariolin different parts of rat brain could be due to: a. the inhibition of nos in the various regions of the brain is dependent on the concentration or the form of the enzyme i.e., isoenzyme phenomenon.(20) b. the high effect of alternariolon nos activity may be due to the solubility of this compound in the lipid layer in the brain exactly as eserine behaved and also affecting the parts containing white matter (e.g. medulla oblongata) more than the parts containing gray matter, as previously proved by osman et al.(21) c. the difference in isozyme inhibition could be due to distinctly different gene loci(22) and the amino acid sequence(23) leading to substrate specificity of the isozymes. d. the difference in inhibition could be due to nos content in each part of the brain. so, it is recommended that further studies are to be done to produce medications from alternariol as a triple inhibitory agent on che, mao and nos to overcome neurodegenerative disorders and accompanying pain. references 1. raistrick h, stickings c.e, thomas, r. biochemistry of microorganisms: alternariol and alternariolmonomethyl ether, metabolic products of alternariatenuis. biochem j. 1953;55:421. 2. ostry v. alternaria mycotoxins: an overview of chemical characterization, producers, toxicity, analysis and occurrence in foodstuffs. world mycotox j.2008;1(2):175–188. 3. logrieco a, moretti a, solfrizzo m. alternaria toxins and plant diseases: an overview of origin and occurrence. world mycotox j. 2009;2(2):129–140. 4. yekeler h, bitmis k, özcelik n, doymaz m, calta m .analysis of toxic effects of alternaria toxins on esophagus of mice by light and electron microscopy. toxicologic pathology.2001;29(4):492–7. 5. rodrigo j, fernández ap, alonso d, serrano j, fernández-vizarra p, martínez-murillo r et al. nitric oxide in the rat cerebellum after hypoxia/ischemia. the cerebellum. 2004;3(4),194-203. 6. zhu w, yang b, fu h, ma l, liu t. flavone inhibits nitric oxide synthase (nos) activity, nitric oxide production and protein s-nitrosylation in breast cancer cells. biochemical and biophysical research community. 2015;458(3):590-5. 7. robbins pa, hamel fg, floreani aa. bovine bronchial epithelial cells metabolize l-arginine to u-citrulline. possible role of nos. life science.1993;52(8):709-16. 8. bredt ds, snyder sh. nitric oxide mediated glutamated glutamate-linked enhancement of cgmp levels in the cerebellum. procnatlacadsciusa.1989;86(22):9030-3. 9. marzinzing m, nussler ak, stadler j, marzinzing e, barthlen w, nussler nc et al. improved method to measure end product of no in biological fluid. nitric oxide: biology and chemistry 1997;1(2):177-89. 10. ayub s, verma j, das n. effect of endosulfan and malathion on lipid peroxidation, nitrite and tnf α release by rat peritoneal macrophages. international immunopharmacology. 2003;3(13):1819–28. 11. main ar. affinity and phosphorylation constants for the inhibitions of esterases by organophosphates. science, 1964;144(3621):992-3. 12. dixon m, webb ec. enzymes (2nd edn). green and co, london. 1964:328-30. 13. cleland ww. mechanisms of catalysis. in: the enzymes. boyer pd, editor. new york: academic press. 1970;3(2):1-65. 14. halcak l, pechanova o, zigova z, klemova l, novacký m, bernatova i. inhibition of no synthase activity in nervous tissue leads to decreased motor activity in the rat. physiological research/ academia scientiarum bohemoslovaca. 1999;49(1):143-9. 15. barjavel mj, bhargava hn. nitric oxide synthase activity in brain regions and spinal cord of mice and rats: kinetic analysis. pharmacology. 1995;50(3):168-74. 16. osman hmy. effect of the carbamate (physostigmine) on the activity of nitricoxide synthase in different parts of rat brain (invivo studies). bulletin of high institute of public health. 2007;37(2):41523. 17. osman my and osman hmy. effect of carbaryl (sevin) on the activities of acetylcholinesterase and nitric oxide synthase in different parts of rat brain. the faseb j.2013;27:563.1. 18. mukherjee p, cinelli ma, kang s, silverman rb. development of nitric oxide synthase inhibitors for neurodegeneration and neuropathic pain. chemical society reviews. 2014;43(19):6814-38. 19. osman my, osman hm. dual effect of alternariol on acetylcholinestrase and monoamine oxidase extracted from different parts of rat brain. the faseb journal. 2009 apr 1;23(1 supplement):676-2. 20. stenesh j. foundation of biochemistry. plenum press. new york &london.1998;(1):67. 21. osman my, abdel tawab s, sharaf ia. effect of physostigmine on cholinesterase activity in different parts of rat brain. arzeneimittel-forsch drug research. 1995;45(1):663-5. 22. shih jc. molecular basis of human mao-a and mao-b. neuropsychopharmacology. 1991;4:1-3. 23. veselovsky av, ivanov as, medvedev ae. is one amino acid responsible for substrate specificity. biochemistry (moscow).1998;63(12). http://www.ncbi.nlm.nih.gov/pubmed/?term=zhu%20w%5bauthor%5d&cauthor=true&cauthor_uid=25680459 http://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20b%5bauthor%5d&cauthor=true&cauthor_uid=25680459 http://www.ncbi.nlm.nih.gov/pubmed/?term=fu%20h%5bauthor%5d&cauthor=true&cauthor_uid=25680459 http://www.ncbi.nlm.nih.gov/pubmed/?term=ma%20l%5bauthor%5d&cauthor=true&cauthor_uid=25680459 http://www.ncbi.nlm.nih.gov/pubmed/?term=liu%20t%5bauthor%5d&cauthor=true&cauthor_uid=25680459 http://www.ncbi.nlm.nih.gov/pubmed/25680459 http://www.ncbi.nlm.nih.gov/pubmed/25680459 case report panacea journal of medical sciences, may-august,2016;6(2): 107-109 107 a case of primary eyelid tuberculosis : a r are entity sudipta chakrabarti1,*, senjuti dasgupta2, supriya sarkar3 1associate professor, esi pgimsr, kolkata, 2assistant professor, dept. of pathology, medical college, kolkata, 3professor, dept. of chest medicine, nrs medical college & hospital, kolkata, west bengal *corresponding author: email: sudiptach@gmail.com abstract ocular tuberculosis may affect virtually any intraocular tissue and ocular adnexa and usually manifest in the form of conjunctivitis, scleritis, episcleritis, corneal phlycten, interstitial keratitis, granulomatous uveitis, orbital granuloma, panophthalmitis, and optic nerve involvement. however, primary eyelid tuberculosis is an extremely rare condition with only sporadic cases having been previously reported. such a rare case identified in a 65 year old female is being reported here. prompt diagnosis and institution of therapy are required in case of eyelid tuberculosis to avoid the serious consequences that occur in untreated cases. keywords: eyelid tuberculosis, clinical features, cytology. access this article online website: www.innovativepublication.com doi: 10.5958/2348-7682.2016.00016.6 introduction tuberculosis is one of the most common infectious diseases causing mortality and morbidity in developing countries like india. the disease primarily affects lungs, but the kidneys, lymph nodes, brain, bowels, skin, are other common sites(1). ocular involvement by tuberculosis usually manifest as conjunctivitis, scleritis, episcleritis, corneal phlycten, interstitial keratitis, granulomatous uveitis, orbital granuloma, panophthalmitis, and optic nerve involvement(2). however, tuberculosis affecting the eyelid alone is very rare. only few sporadic cases of primary lid tuberculosis have been reported in literature(3). common lesions that may mimic tuberculosis of eyelid include psoriasis and eyelid dermatitis(4). sometimes the clinical presentation may resemble that of basal cell carcinoma(5). a case of primary tuberculosis of the left upper eyelid in an elderly female patient is being presented. case history a 65-year-old female patient presented with a red colored painless swelling on the left upper eyelid for the last one and a half years. she stated that the lesion was initially small, but had gradually increased in size over a period of six months. there was no history of trauma to the region. she had no fever, cough or any other tuberculosis related symptoms. she also did not have any significant past medical history. on examination, the patient was found to be in good general health. local examination showed that the reddish to grey colored nodular plaque was 2.5 cm × 1.5 cm in size and a part of it was covered with crusted secretions (fig. 1). no regional lymphadenopathy was detected. fig. 1: reddish to grey colored nodular plaque on the left upper eyelid complete haemogram showed that the patient had microcytic hypochromic anemia. her hemoglobin level was found to be 7 g/dl and the differential count was within normal limits. erythrocyte sedimentation rate (esr) was 28 mm in the first hour. scrapings were taken from the lesion and aspiration was performed. the smears were stained with leishmangiemsa (lg) stain and ziehl-neelsen (z-n) stain. the lg stained smears showed squamous epithelial cells, lymphocytes and neutrophils in a necrotic background. z-n stained smears revealed presence of acid fast bacilli (afb) (fig. 2). chakrabarti sudipta et al. a case of primary eyelid tuberculosis: a rare entity panacea journal of medical sciences, may-august,2016;6(2): 107-109 108 fig. 2: cytologic smear showing squamous epithelial and inflammatory cells in a necrotic background (lg stain, ×400) thorough clinical examinations did not reveal any other focus of tubercular infection. mantoux test was then advised for corroboration. it yielded positive results with an induration measuring 20 × 18 mm. chest radiograph of the patient was within normal limits (fig. 3). abdominal ultrasonography did not reveal any suspected tubercular lesion. a diagnosis of primary eyelid tuberculosis was therefore rendered. fig. 3: chest radiograph showing features within normal limits the patient was prescribed anti-tubercular drugs for a period of six months. the patient was lost in follow up. discussion tuberculosis is still a dominant health problem in developing countries. in industrialized nations, there has been a resurgence of tuberculosis due to a combination of factors which include immigration from endemic regions, the human immunodeficiency virus (hiv) pandemic and poverty(6). ocular tuberculosis results from the haematogenous dissemination of mycobacteria and may affect virtually any intraocular tissue and ocular adnexa(7). most common manifestation of ocular tuberculosis is anterior uveitis or choroiditis. primary lid tuberculosis is a very rare condition and maybe acquired following minor trauma or contact with infected material. despite the rarity of the disease, the requirement for early diagnosis and institution of therapy cannot be overemphasized because prolonged untreated eyelid tuberculosis leads to eyelid and tarsal plate destruction, formation of abscess, skin fistula and cicatrical ectropion(8). clinically, the differential diagnoses of eyelid tuberculosis include psoriasis and eyelid dermatitis(4). wyrwicka a et al reported a case of eyelid tuberculosis, in which the lesion clinically resembled basal cell carcinoma(5). eyelid tuberculosis may present as a papule, plaque, swelling or abscess(3,4,9). in our case, the patient presented with an erythematous, painless plaque. thorough examination did not reveal any other focus of infection in the patient. this disease can affect any age group. no definite sex predilection has been identified(4). our patient was a 65 year old female who had no significant past medical history. the diagnosis of ocular tuberculosis is difficult, especially in cases of intraocular disease. this is because intraocular biopsy is risky in the face of active inflammation. however, in case of eyelid lesions, scrapings and aspirations maybe performed easily. definitive diagnosis is based on demonstration of afb (tubercle bacilli)(3,10). in this case, cytological examination of the scrapings and aspiration material revealed squamous epithelial cells, lymphocytes and neutrophils in a necrotic background. z-n stained smears showed presence of afb. conclusion we conclude that tuberculosis of the eyelid is an extremely rare but curable condition. prompt diagnosis and early institution of therapy are required to prevent the serious ocular complications that inevitably occur in neglected and untreated cases. references 1. longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j. tuberculosis. in: longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j, editors. harrison s principles of internal medicine.18th ed. usa: mc graw hill; 2013.p. 2252-80. 2. oluleye ts. tuberculous uveitis. j multidiscip healthc 2013;6:41 3. 3. agrawal r, agarwal s. isolated right upper eyelid tuberculosis: a case report with review of the literature. j clin diagn res 2012;6:1068-9. http://www.ncbi.nlm.nih.gov/pubmed/?term=oluleye%20ts%5bauth%5d 429 too many requests you have sent too many requests in a given amount of time. pjmsvolume 3 number 1: january-june 2013 editorial 1 research in medical education began just over three decades ago with a small group of clinicians and educational researchers at the medical school in buffalo, new york. since then it is rapidly expanding all over the world with india being no exception, though we are still in a stage of infancy. during the last ten years medical educationists in india have slowly made their presence felt and today they are there where they should bein the national medical education policy making forums. the goal of medical education has always been directed to provide competent physicians who could ultimately deliver high quality heath care. to achieve this, the system uses diverse and need based processes. in spite of the fact that lot of emphasis is being given today to health care and improving the quality of life of the patient, reports of multiple medical errors, variation in quality of care and prescribing habits is also being documented. hence more attention needs to be given to the source of these issues which could largely be due to the health providers attitude, skill and knowledge. therein lies the huge scope to examine the role of medical education in health care outcomes and only concerned efforts in structuring good educational research protocols could give answers to such questions. influence of medical education on individual knowledge, performance, skill or sensitivity to patient care while working in a health care system cannot be undermined. quality medical education provides quality improvement in patient safety in medical care. clinical outcomes are directly related to quality in medical education and hence better health care is the responsibility of the medical education community. moreover, there is a cry to improve health care and a call for accountability. only an elaborate medical education research effort will help develop research in medical education chari suresh* *chief editor panacea, jms professor biochemistry and director research and medical education technology nkpsims and rc, digdoh hills, hingna road, nagpur440019 sureshchari2@gmail.com a sound evaluation and outcome measure that will influence curriculum changes with the sole purpose of improving health care. medical educational research should be directed towards creating studies that investigate the effect of medical education and has the strength to measure the outcome of medical education. there are challenges in medical education research in india which are unique in nature. among the fundamental difficulties in doing meaningful medical education research are anaemic funding, lack of incentive, paucity of readily available data set to examine the performance of medical graduates at workplace, biases about the subjectivity of the research, individual variations, difficulties in measuring the outcomes and the variable support from management. medical universities in india are responsible for providing medical education, research and health care services. they have to constantly respond to the health needs of the society and modify their educational policies. thus proper planning for educational research in line with the objectives of the vision and mission of the medical education will go long way in improving the overall health care system in india. panacea, journal of medical sciences publishes papers describing original research in all areas of medical field. in the last few issues we have been inviting medical educational research papers, since research in medical education has contributed substantially to the understanding of learning process, educational decision making and generation of educational policy documents. this section in the journal encourages original work in educational research in medical science that will foster understanding and development of medical education that will ultimately help quality health care. “when medicine can be evidence based why should medical education and educational decision making not demand evidence!” 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2022;12(2):289–295 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article prevalence of depression and suicidal ideation in trauma patients in western rajasthan surender kumar1, kamala verma2, girish chandra baniya3,* 1dept. of orthopaedics, government medical college and attached hospital, barmer, rajasthan, india 2dept. of obstetrics & gynaecology, government medical college and attached hospital, barmer, rajasthan, india 3dept. of psychiatry, government medical college and attached hospital, barmer, rajasthan, india a r t i c l e i n f o article history: received 09-08-2021 accepted 27-10-2021 available online 17-08-2022 keywords: prevalence depression trauma accident suicidal idea a b s t r a c t background: depression is a common psychiatric disorder in trauma patients. early detection of depression in a traumatized patients can help alleviate long-term symptoms and adverse effects associated with depression. this study aimed to determine the prevalence of depression and suicidal ideation in trauma patients after one month of injury. materials and methods: hospital-based cross-sectional study was carried out among 120 individuals with a history of trauma from march 2020 to may 2020. purposive sampling was used to recruit participants over a specified period. the beck’s depression inventory-ii (bdi-ii) was used to measure depression intensity and suicidal ideation. the statistical analysis was carried out using spss version 20. results: the study included a total of 120 participants. the prevalence of depression was 30% in study participants. in our study, 8 (44.44%) of 18 participants over the age of 60, 30 (36.59%) of 82 male participants, 9 (64.29%) of 14 separated or divorced participants, 17 (45.95%) of 37 illiterate participants, 25 (43.86%) of 57 participants from low socioeconomic backgrounds, and 23 (42.59%) of 54 participants from rural backgrounds had more depression. twenty (46.51%) out of 43 polytrauma participants, 5 (45.45%) out of 11 participants injured due to violence, 31 (33.70%) out of 92 participants who had a history of more than 48 hrs hospitalization, and 17 (48.57%) out of 35 participants had a history of icu admission had more depression. twenty-one participants (58.33%) of the 36 who suffered from depression had suicidal thoughts or intentions. conclusion: suicidal ideation and depression were more common in traumatic patients. physicians’ treatment should not be limited to early physical rehabilitation. they must also prioritise early mental rehabilitation in order to avoid long-term issues with mental and physical disabilities. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction traumatic injuries account for 11% of worldwide deaths. 1 they cause significant psychological and physical morbidity across all ages. traumatic injury patients report a marked decrease in quality of life, as well as longterm mental and physical disabilities. traumatic injuries * corresponding author. e-mail address: girishdrbaniya@gmail.com (g. c. baniya). can have a psychological effect on patients. this can lead to long-term mental health problems such as depression or post-traumatic stress. 2 the survival rate for multiple trauma patients has increased to 85-88% in the past decade due to pre-hospital treatment has improved, with shorter rescue times and more intensive care. special trauma centres are also available, providing better surgical care. 3 the long-term effects of multiple trauma injuries are important for quality control as https://doi.org/10.18231/j.pjms.2022.055 2249-8176/© 2022 innovative publication, all rights reserved. 289 290 kumar, verma and baniya / panacea journal of medical sciences 2022;12(2):289–295 well as economic interests. full-time employment can result in large amounts of productivity loss. the average age of poly traumatized victims is between 20-60. 4 male to female ratios averages around 3.5:1. also more serious injuries are often sustained by men. 5 apart from the treatment costs for patients, economic burdens are caused by loss of work, working disability, and subsequent rehabilitation or disability costs. 6 an increased return to work rate is linked to a good functional status after discharge. this is not just a term for physical impairment, but it can also refer to psychological impairment. 7 after severe trauma, depression is the most common psychiatric complication. a permanent disability can lead to severe depression in patients who have suffered trauma. 8 this condition can lead to suicidal ideas or intent in patients who are more likely than the general population. 9 while this information gives a clear picture of mental impairment in trauma victims, there are still many things to be learned about the impact of time. that is why this study was conducted to determine the incidence of depression and suicide ideation in adults after major trauma. 2. material and methods 2.1. study setting this was a descriptive quantitative study. data were taken from patients who had been injured and came to follow up after one month at the department of orthopaedic from march 2020 to june 2020 at government medical college barmer. all patients 18 years or older admitted to the study site and meeting trauma admission criteria and came after one month for follow-up treatment were evaluated for inclusion, regardless of injury mechanism severity or background. trauma admission criteria are determined by injury mechanism, physiologic and injury criteria. for example, motor vehicle collisions, assaults, or falls from heights above 3 meters. patients who had pre-existing cognitive impairments such as dementia, traumatic brain injury resulting from cognitive impairment were excluded. all patients who participated in the study signed a written consent before any data were collected. to confirm that neither of the participants was intellectually disabled, the montreal cognitive assessment (moca) was used. 10 to ensure that patients did not have any severe psychotic disorders or substance abuse issues, the mini international neuropsychiatric interview (mini) based on the diagnostic and statistical manual of mental disorders 4th edition (dsm-iv) was administered. 11 2.2. instruments and methods for collecting data face-to-face interviews were used to collect data using a semi-structured questionnaire. it included clinical and sociodemographic variables. beck’s depression inventoryii (bdi-ii] was used for evaluating depression. 12 the bdi-ii, a self-report tool for depression, is frequently used. it measures depression across multiple cultural groups. it has been validated in both psychiatric and non-psychiatric populations. the bdi-ii is used to screen traumatic individuals for depressive symptoms within the last two weeks. the tool contains 21 items. each item is a description of a particular symptom. each statement has a rating from 0 to 3, and the total score can then be calculated by adding all of the scores. according to the bdi-ii, depression has a cut-off level of 10. a score of zero to nine is normal. a score from 10 to 18 indicates mild depression. scores between 19 and 29 indicate moderate depression. scores of 30 and higher signify severe depression. cronbach’s indices of alpha 0.856 were used to measure the internal consistency. question 9 of bdi-ii was used to assess suicidal thoughts. 2.3. data processing and analysis all questionnaire data were pre-coded to simplify the analysis, ensure accuracy, and avoid any translation errors. after entering the data into microsoft excel 365, they were exported to spss v.20 windows. spss v.20 is statistical software for social science. continuous data were described using descriptive statistics such as mean and standard deviation, while categorical variables were described using percentages or numbers. an independent student t-test or chi-square test was used to distinguish between variations among variables. 2.4. ethical approval the institution’s ethics committee approved the research. all ethical issues related to the research were addressed. participants were required to sign an informed consent form before they could begin the interview. participants signed this form to indicate their willingness to participate in the study. participants signed consent forms, which gave them the right to withdraw and disclose personal information. participants were assured that any data collected would be kept confidential. 3. results in total, 120 participants were enrolled in the study. the age range of the respondents was 18–70 years, with a mean (sd) of 38.43 (10.24) years. forty-two participants (35.0%) were between the ages of 46 and 60 years, while 32 participants (26.67%) were between the ages of 31 and 45 years. eighty-two (68.33%) participants were male, while 38 (31.67%) were female. eighty-eight participants (73.33%) were married, while 18 participants (15.00%) were unmarried. in terms of education, 37 participants (30.83%) were illiterate, while 36 participants (30.00%) had completed secondary school. lower socioeconomic status was represented by 57 individuals (47.50%), followed by kumar, verma and baniya / panacea journal of medical sciences 2022;12(2):289–295 291 middle socioeconomic status (30.83%). regarding location, 54 participants (47.50%) came from rural areas, whereas 41 participants (34.17%) came from semiurban areas. (table 1) the depression was found in 36 traumatic participants (30.00%) using the bdi-ii. of the 36 participants, 21 participants (58.33%) were mildly depressed, 12 participants (33.33%) were moderately depressed, and 3 participants (8.33%) were severely depressed. (figure 1) in our study, 8 (44.44%) of 18 participants over the age of 60, 30 (36.59%) of 82 male participants, 9 (64.29%) of 14 participants who were divorced or separated, 17 (45.95%) of 37 illiterate participants, 25 (43.86%) of 57 participants from low socioeconomic backgrounds, and 23 (42.59%) of 54 participants from rural backgrounds had more depression as compared to their counterparts. a statistically significant difference was found between gender, marital status, education, socioeconomic status, and locality (p-value <0.05). (table 2) regarding clinical characteristics of participants, 43 participants (35.83%) had a history of polytrauma, 78 (65.00%) had been injured due to road traffic accidents, followed by 23 (19.17%) fall from height. ninety-two participants (76.67%) required hospitalization more than 48 hours, while 35 (29.17%) had a history of icu admission. (table 3 ) twenty (46.51%) out of 43 polytrauma participants, 5 (45.45%) out of 11 participants injured due to violence, 31 (33.70%) out of 92 participants of more than 48 hrs hospitalization, and 17 (48.57%) out of 35 participants had a history of icu admission had more depression than their counterparts. a statistically significant difference was found between polytrauma patients, more than 48 hours of hospitalization and icu admission (p-value <0.05). (table 4) figure 2 depicted the suicidal thoughts of the bdiii rating scale in traumatic patients with depression. twenty-one participants (58.33%) of the 36 who suffered from depression had suicidal thoughts or intentions. two participants (5.56%) had thoughts of killing themselves if they had the chance. seven participants (19.44%) wished to kill themselves, while 12 participants (33.33%) merely considered killing themselves but did not carry out their plans. 4. discussion this study aimed to determine the prevalence and severity of depression and suicidal ideation among trauma patients in western rajasthan. in this study, the prevalence of depression among patients with trauma was 30%. it was significantly correlated with males, divorced or separated, low education, poor socioeconomic status, and rural background. psychiatric sequelae can be a burden for both the individual and their family after an injury. 13 our findings table 1: sociodemographic characteristic of trauma patients. variable number (n=120) percentage age mean (sd) 38.43 10.24 age group 18 to 30 28 23.33 31 to 45 32 26.67 46 to 60 42 35.00 more than 60 18 15.00 gender male 82 68.33 female 38 31.67 marital status married 88 73.33 unmarried 18 15.00 separated/divorced 14 11.67 education illiterate 37 30.83 up to primary 35 29.17 up to secondary 36 30.00 up to graduation 12 10.00 socioeconomic status low 57 47.50 middle 37 30.83 high 26 21.67 locality rural 54 45.00 semiurban 41 34.17 urban 25 20.83 fig. 1: severity of depression among trauma patients. indicate that there was no statistically significant difference in age between our two groups. a study by maes m in 2000 corroborated our conclusion that age is irrelevant. similar findings have been reported in studies of flood and burn victims. 14 in contrast to our findings, zhang and ho found that depression among earthquake survivors was more common in the elderly after two months. 15 additionally, an epidemiological study conducted in germany revealed a higher prevalence of depression in older age groups, which is presumed to be due to participants being homeless and residing in shelter homes. 16 because results vary according 292 kumar, verma and baniya / panacea journal of medical sciences 2022;12(2):289–295 table 2: showing the presence of depression according tosociodemographic characteristics. variable presence of depression n (%) chisquare, p-value yes (n=36) no (n=84) age group 18 to 30 5 (17.86) 23 (82.14) 4.788 31 to 45 8 (25.00) 24 (75.00) 0.18746 to 60 15 (35.71) 27 (64.29) more than 60 8 (44.44) 10 (55.56) gender male 30 (36.59) 52 (63.41) 5.348 female 6 (15.79) 32 (84.21) 0.020* marital status married 23 (26.14) 65 (73.86) 8.981 unmarried 4 (22.22) 14 (77.78) 0.011* separated/ divorced 9 (64.29) 5 (35.71) education illiterate 17 (45.95) 20 (54.05) 10.252 up to primary 12 (34.29) 23 (65.71) 0.016*up to secondary 5 (13.89) 31 (86.11) up to graduation 2 (16.67) 10 (83.33) socioeconomic status low 25 (43.86) 32 (56.14) 10.67 middle 8 (21.62) 29 (78.38) 0.004* high 3 (11.54) 23 (88.46) locality rural 23 (42.59) 31 (57.41) 7.676 semiurban 9 (21.95) 32 (78.05) 0.021* urban 4 (16.00) 21 (84.00) *significant <0.05 table 3: clinical characteristics of trauma patients. variable number (n=120) percentage poly trauma yes 43 35.83 no 77 64.17 mechanism of injury road traffic accident 78 65.00 fall from height 23 19.17 violence 11 9.17 sports and other injury 8 6.67 hospitalization (more than 48 hrs.) yes 92 76.67 no 28 23.33 icu admission yes 35 29.17 no 85 70.83 table 4: showing the presence of depression according to clinical characteristics. variable presence of depression n (%) chi-square, p-value yes (n=36) no (n=84) poly trauma yes 20 (46.51) 23 (53.49) 8.7 no 16 (20.78) 61 (79.22) 0.003* mechanism of injury road traffic accident 22 (28.21) 56 (71.79) 2.788 fall from height 8 (34.78) 15 (65.22) 0.425 violence 5 (45.45) 6 (54.55) sports and other injury 1 (12.50) 7 (87.50) hospitalization (more than 48 hrs.) 31 (33.70) 61 (66.30) 2.564 yes 5 (17.86) 23 (82.14) 0.109 no icu admission yes 17 (48.57) 18 (51.43) 8.115 no 19 (22.35) 66 (77.65) 0.004* *significant <0.05 fig. 2: suicidal thoughts in bdi-ii rating scale (question 9) in trauma patients. to the type of trauma and study population, it is difficult to compare studies. in our study, men were more likely than women to experience depression. several studies found similar results. 1,17 men are more susceptible to developing mental illness following trauma in the indian scenario because they are the family’s primary earner. our research demonstrates that participants were involved in both traffic accidents and non-aggressive activities. 18 this could explain why our findings differ from those of other research. researchers concluded from a review of the available literature that women are not at a greater risk of developing depression kumar, verma and baniya / panacea journal of medical sciences 2022;12(2):289–295 293 following a motor vehicle accident (mva) than men. 19 individual coping strategies and psychological resources may have a role in either maintaining or recovering from depression. 20 our study discovered a significant link between marital status and depression in traumatic patients, suggesting that divorced or separated trauma patients are more likely to develop depression than married patients. 17 this could be because a divorced or separated individual already feels lonely, and any trauma stresses exacerbate mental illness. they also lack the support of a life partner, making it harder for them to cope with physical disability assistance. the study found that participants from lower social backgrounds had a higher risk of depression than those from higher socioeconomic backgrounds. the findings were consistent with those of research conducted in kumar s. 21 additionally, individuals with low socioeconomic status, a limited educational experience, or a rural background have a limited source of income and limited knowledge, which impedes the timely management of trauma patients, increasing the risk of morbidity and mortality. this also increases the likelihood of depression. additionally, the patient’s poor socioeconomic status resulted in financial, social, and emotional costs, worsening the patient’s illness, and a measure of depression. 22 additionally, recent research indicates that the longer an illness goes untreated, the greater the likelihood of depression. 23 however, another study found no significant link between education, socioeconomic status, and depression. 24 the disparity may be explained by the use of disparate diagnostic criteria for depression, sample sizes, and selection of traumatic patients, as well as by the use of disparate study locales and participant cultures. in our study, depression was significantly associated with polytrauma patients, hospitalization for more than 48 hours, and icu admission. in contrast to violence or sports-related injuries, men are more susceptible to road traffic accidents because they must go outside to work. according to soberg et al., individuals who have experienced multiple severe traumas are more likely to develop depression. 25 multiple traumas raise the possibility of physical incapacity, which increases the likelihood of becoming reliant on others and causing further agony. 26 feeling helpless can intensify the impact of a lack of hope, and helplessness can lead to sentiments of hopelessness and pessimism. 6,27 so, it is crucial to think about the observation time and the type of trauma and the demographic. many studies have shown a positive correlation between injury severity, such as length of hospitalization and need for icu admission, and depression. 3,25,28 according to min et al., head trauma requiring icu admission was a robust predictor of the onset of post-injury depression in trauma victims. 29 patients on ventilator support had twice the rate of depressive symptoms as patients with mild injuries. according to davydow et al., following a motor vehicle accident, the rate of developing psychiatric illness was similar between patients who required icu admission and those who did not. 30 different methodologies could explain the disparities in study results. there are numerous methods for evaluating diagnoses, recruiting subjects, and implementing management strategies. this implies that more long-term longitudinal research on the topic is required. we found a significant difference in suicidal ideation scores on the beck depression inventory’s suicidal ideation questionnaire (in question 9: "suicide thoughts and wishes"). some studies have revealed that those who have experienced multiple traumas are more likely to commit suicide. 31 studies by mackelprang et al. identified that patients with physical disabilities want to commit suicide because their lives were rendered meaningless due to multiple traumas and a lack of earning potential. 32 people with diagnosed physical disability due to trauma with mental disorders experience financial and relationship problems at a greater frequency. 16 there are numerous ways to interpret the relationship between an accidental or traumatic outcome and potentially suicidal behaviour. unsatisfactory rehabilitation is believed to increase the risk of developing a mental illness. 25 this is due to the fact that patients are constantly reminded of the trauma that resulted in their dysfunction or disability. these reminders can have a detrimental effect on an individual’s emotional state, resulting in immobility. a mental illness can also impair physical functioning, resulting in psychosomatic diseases and impaired functional outcomes. 28 psychological and physical health are inextricably linked. occasionally, frustrated patients commit suicide in order to alleviate their disability-related pain. 33 it is critical to pay closer attention to potentially selfharming behaviours such as refusing to participate in any activity, failing to return for routine follow-up, and engaging in activities that may pose a risk to people with multiple deformities. both functional rehabilitation and psychosocial support are critical during the recovery process following severe trauma. 5. limitation and strength of the study the study was a cross-sectional study carried out in an outpatient setting. as a result, causal links between depression and trauma are difficult to establish. this study was done after one month of the traumatic event so, this study was susceptible to recall bias. small sample size is a serious constraint on prevalence studies. due to the study’s limitation to a single centre, it is possible that these findings do not apply to all patient groups. the study excluded other psychiatric disorders such as anxiety disorders and 294 kumar, verma and baniya / panacea journal of medical sciences 2022;12(2):289–295 psychotic disorders. this would be an interesting study to conduct a longitudinal analysis of the outcome using a multicentre design. the main strength of our study was its use of structured diagnostic tools to assess depressive symptoms. it is possible that the prevalence estimated for this condition was more accurate. 6. conclusions depression was found to be 30% prevalent in this study. it was associated significantly with male gender, divorced or separated status, low education and socioeconomic status, rural origin, polytrauma patients, hospitalisation for more than 48 hours, and icu admission. this study emphasises the critical importance of identifying and treating comorbid depression in trauma patients. suicidal ideation was increased in patients who had experienced major trauma and were depressed. thus, it is critical that patients who have experienced multiple traumas receive early psychosocial counselling. clinicians must therefore assess and treat depression and suicidal ideation thoughts in trauma patients in order to improve the treatment outcomes of their patients. 7. conflict of interest the authors declare that they have no conflict of interest. 8. source of funding none. references 1. mahran dg, farouk o, qayed mh, berraud a. pattern and trend of injuries among trauma unit attendants in upper egypt. trauma mon. 2016;21(2):20967. doi:10.5812/traumamon.20967. 2. mcfarlane ac. the long-term costs of traumatic stress: intertwined physical and psychological consequences. world psychiatry. 2010;9(1):3–10. 3. yucel n, demir to, derya s, oguzturk h, bicakcioglu m, yetkin f, et al. potential risk factors for in-hospital mortality in patients with moderate-to-severe blunt multiple trauma who survive initial resuscitation. emerg med int. 2018;p. 6461072. doi:10.1155/2018/6461072. 4. perkonigg a, kessler rc, storz s, wittchen hu. traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. acta psychiatr scand. 2000;101(1):46–59. 5. wilson l, stewart w, dams-o’connor k, diaz-arrastia r, horton l, menon dk, et al. the chronic and evolving neurological consequences of traumatic brain injury. lancet neurol. 2017;16(10):813–25. 6. lo j, chan l, flynn s. a systematic review of the incidence, prevalence, costs, and activity and work limitations of amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury in the united states: a 2019 update. arch phys med rehabil. 2021;102(1):115–31. 7. pike j, grosse sd. friction cost estimates of productivity costs in cost-of-illness studies in comparison with human capital estimates: a review. appl health econ health policy. 2018;16(6):765–78. 8. schultebraucks k, yadav v, shalev ay, bonanno ga, galatzer-levy i. deep learning-based classification of post-traumatic stress disorder and depression following trauma utilizing visual and auditory markers of arousal and mood. psychol med. 2020;8(1):1–11. 9. lindsey ma, xiao y. depression, trauma, and suicide among adolescent and young adult males. in: griffith d, bruce m, thorpe r, editors. men’s health equity: a handbook. 1st edn. routledge/taylor & francis group; 2019. p. 288–303. 10. julayanont p, nasreddine zs. montreal cognitive assessment (moca): concept and clinical review. in: larner a, editor. cognitive screening instruments. 1st edn. springer, cham; 2017. p. 139–95. 11. sheehan dv, lecrubier y, sheehan kh, amorim p, janavs j, weiller e, et al. the mini-international neuropsychiatric interview (mini): the development and validation of a structured diagnostic psychiatric interview for dsm-iv and icd-10. j clin psychiatry. 1998;59(20):22–33. 12. dozois dj, dobson ks, ahnberg jl. a psychometric evaluation of the beck depression inventory-ii. psychol asses. 1998;10(2):83–9. 13. pine ds, cohen ja. trauma in children and adolescents: risk and treatment of psychiatric sequelae. biol psychiatry. 2002;51(7):519– 31. 14. maes m, mylle j, delmeire l, altamura c. psychiatric morbidity and comorbidity following accidental man-made traumatic events: incidence and risk factors. eur arch psychiatry clin neurosci. 2000;250(3):156–62. 15. zhang y, ho sm. risk factors of post-traumatic stress disorder among survivors after the 512 wenchuan earthquake in china. plos one. 2011;6(7):e22371. doi:10.1371/journal.pone.0022371. 16. wafaisade a, lefering r, bouillon b, sakka sg, thamm oc, paffrath t, et al. epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the trauma registry of the german society for trauma surgery. crit care med. 2011;39(4):621–8. 17. hauffa r, rief w, brähler e, martin a, mewes r, glaesmer h, et al. lifetime traumatic experiences and post-traumatic stress disorder in the german population: results of a representative population survey. j nerv ment dis. 2011;199(12):934–9. 18. misra p, majumdar a, misra mc, kant s, gupta sk, gupta a, et al. epidemiological study of patients of road traffic injuries attending emergency department of a trauma center in new delhi. indian j crit care med. 2017;21(10):678–83. 19. dsouza c, rao vv, kumar a, diaz e. epidemiological trends of trauma in tertiary care centre in dakshina kannada district of karnataka, india. j clin diagn res. 2014;8(3):66–8. 20. peele pb, tollerud dj. depression and occupational injury: results of a pilot investigation. j occup environ med. 2005;47(4):424–7. 21. kumar s, verma v, kushwaha u, hynes ejc, arya a, agarwal a, et al. prevalence and association of depression in in-patient orthopaedic trauma patients: a single centre study in india. j clin orthop trauma. 2020;11(4):573–7. doi:10.1016/j.jcot.2019.12.010. 22. jenewein j, moergeli h, wittmann l, büchi s, kraemer b, schnyder u, et al. development of chronic pain following severe accidental injury. results of a 3-year follow-up study. j psychosom res. 2009;66(2):119–26. 23. qin z, jiang z, yang q. evaluation of the psychological characters of normal children and children with accidental injury. chinese j tissue eng res. 2005;9(16):223–5. 24. jain m, khadilkar n, de sousa a. burn-related factors affecting anxiety, depression and self-esteem in burn patients: an exploratory study. ann burns fire disasters. 2017;30(1):30–4. 25. soberg hl, bautz-holter e, roise o, finset a. long-term multidimensional functional consequences of severe multiple injuries two years after trauma: a prospective longitudinal cohort study. j trauma. 2007;62(2):461–70. 26. soberg hl, finset a, roise o, bautz-holter e. the trajectory of physical and mental health from injury to 5 years after multiple trauma: a prospective, longitudinal cohort study. arch phys med rehabil. 2012;93(5):765–74. 27. hellstrøm t, kaufmann t, andelic n, soberg hl, sigurdardottir s, helseth e, et al. predicting outcome 12 months after mild traumatic brain injury in patients admitted to a neurosurgery service. front http://dx.doi.org/10.5812/traumamon.20967 http://dx.doi.org/10.1155/2018/6461072 http://dx.doi.org/10.1371/journal.pone.0022371 http://dx.doi.org/10.1016/j.jcot.2019.12.010 kumar, verma and baniya / panacea journal of medical sciences 2022;12(2):289–295 295 neurol. 2017;8:125. doi:10.3389/fneur.2017.00125. 28. soberg hl, bautz-holter e, roise o, finset a. mental health and post-traumatic stress symptoms 2 years after severe multiple trauma: self-reported disability and psychosocial functioning. arch phys med rehabil. 2010;91(3):481–8. 29. min ja, lee cu, hwang si, shin ji, lee bs, han sh, et al. the moderation of resilience on the negative effect of pain on depression and post-traumatic growth in individuals with spinal cord injury. disabil rehabil. 2014;36(14):1196–202. 30. davydow ds, katon wj, zatzick df. psychiatric morbidity and functional impairments in survivors of burns, traumatic injuries, and icu stays for other critical illnesses: a review of the literature. int rev psychiatry. 2009;21(6):531–8. 31. tsaousides t, cantor jb, gordon wa. suicidal ideation following traumatic brain injury: prevalence rates and correlates in adults living in the community. j head trauma rehabil. 2011;26(4):265–75. 32. mackelprang jl, bombardier ch, fann jr, temkin nr, barber jk, dikmen ss, et al. rates and predictors of suicidal ideation during the first year after traumatic brain injury. am j public health. 2014;104(7):100–e7. 33. awan n, disanto d, juengst sb, kumar rg, bertisch h, niemeier j, et al. evaluating the cross-sectional and longitudinal relationships predicting suicidal ideation following traumatic brain injury. j head trauma rehabil. 2021;36(1):18–29. author biography surender kumar, senior resident kamala verma, associate professor girish chandra baniya, assistant professor cite this article: kumar s, verma k, baniya gc. prevalence of depression and suicidal ideation in trauma patients in western rajasthan. panacea j med sci 2022;12(2):289-295. http://dx.doi.org/10.3389/fneur.2017.00125 julydecember 2012 pdf for website pjmsvolume 2 number 2: julydecember 2012 review article oxygen therapy: a panacea for the critically ill 1 girish meenakshi 1 associate professor, dept of pediatrics, nkp salve institute of medical sciences and research centre, digdoh hills, hingna road, nagpur, 440019 min_gir@rediffmail.com abstract 'oxygen is so toxic that if it was discovered today fda would not have approved its use’. we started using oxygen for resuscitation because it seemed like a good idea. now we use it because we always have. majority of healthcare professionals including doctors use oxygen like freely available water without understanding the science behind its use. while nature always knew that living things do not require more than 21% oxygen, scientist are just figuring out that to resuscitate a full term asphyxiated baby we need only 21% oxygen and that anything more than that can actually be harmful particularly in premature babies. the following article describes oxygen as a drug with all the advantages and pitfalls of using oxygen. introduction: nature has provided us with an abundance of oxygen around us, 21% of the atmospheric gases, to be precise, but what has always been puzzling the philosophical mind is that our body does not contain any storage of oxygen. ever since this element was discovered in 1774, by joseph priestly, the use of oxygen in illnesses has been taken for granted. we started using oxygen for resuscitation because it seemed like a good idea. now we use it because we always have. oxygen therapy is not simply an act of attaching a mask to the patient's face, turning on the oxygen cylinder and attaching the pulse oximeter probe. two common case scenarios will illustrate this point. 1. 3 year old child is admitted in picu with an acute illness. child's oxygenation status: spo2 100% and pao2 100 mmhg. 6 hours later, child died of hypoxia. 2. 2 year old baby admitted with diarrhea and moderate dehydration. her oxygenation status seems adequate, spo2 100%, pao2 100 mmhg. she is later found to have lactic acidosis suggesting tissue hypoxia, despite a normal oxygenation value! oxygen therapyphysiology: the above cited cases illustrate the need to shift our focus from just giving oxygen to a patient to ensuring proper delivery of oxygen to the tissues for optimum benefit. two terminologies need to be understood before discussing oxygen therapy viz hypoxemia and hypoxia. hypoxemia is defined as inadequate oxygenation of blood and is indicated by sao2 <94% and pao2 <60 mmhg. hypoxia is inadequate delivery of oxygen to the tissues (do2) (1). delivery of oxygen (do2) to the tissues is determined by the cardiac output and the content of oxygen (co2) in the blood. do2 = co (cardiac output) x co2 (content of oxygen). content of oxygen is calculated by the following formula: co2 = [1.36 x hb x sao2] + .003 x pao2 fig 1: delivery of oxygen v qq cvs hb pao2 mitochondria in a normal individual with hemoglobin of 15gm/dl and 100% saturation with oxygen [sao2 100%], with normal pao2 of 100, the content of oxygen may be calculated as follows: [1.36 x 15 x 100] + .003 x 100 = 20.40 mg/dl + 0.3 mg/dl it is obvious from the above that the major amount of oxygen in blood is carried by hemoglobin (fig. 1) and only a small quantity (0.003 x pao2) is carried dissolved in plasma. it is also clear from the above formula that, in terms of delivery of oxygen to the tissues, sao2 i.e. saturation of hemoglobin with oxygen plays a greater role than pao2. considering the very small amount of oxygen dissolved in plasma (0.003 x pao2), one is inclined to ignore the dissolved oxygen. this is not true as dissolved oxygen can occasionally play a significant role. consider the following example: a child with severe anemia has: hb 3 gm%, fio2 21% (i.e. she is breathing room air), spo2 100 and pao2 100. her content of o2 (co2) is: [1.36 x 3 x 100] + [.003 x 100]= 4.08 mg/dl + 0.3 mg/dl if this child is given increased oxygen (despite having normal spo2), up to fio2 100 then her pao2 becomes 500 (21 x 5 is ≈ 100) hence pao2 will increase 5 times i.e. from 100 to 500) and the formula will now read as: [1.36 x 3 x 100] + [.003 x 500] = 4.08 mg/dl + 1.5 mg/dl there is a 40% net increase in total oxygen carried by blood. this increase in do2 is often sufficient to stabilize the patient, before cross matched blood is available. 2 going back to the equation for do2 [do2 = co (cardiac output) x co2 (content of oxygen), it is important to note that cardiac output occupies a prime place in do2 and is often neglected during oxygen therapy. while a low content of oxygen in blood is often compensated by an increase in the cardiac output (co), if the co is low, content of oxygen cannot increase resulting in significant hypoxia. consider a patient with parenchymal lung disease. some of the deoxygenated blood coursing through non ventilated alveolar tissue will return to the heart in a deoxygenated state resulting in a low mixed venous saturation at the pulmonary artery. an increase in cardiac output in such a case would result in decreased oxygen extraction at the tissue level thereby increasing the mixed venous saturation (the amount of oxygen taken up at the tissue level depends on the cardiac output, low cardiac output results in near complete extraction of oxygen by the tissues (fig 2) from the foregoing it is clear that hypoxia is decreased delivery of o2 to the tissues and can be classified into three types and the treatment accordingly determined (table i). fig 2: showing a diseased side of lung tissue (lower -40% & 65%) and a side where ventilation is carried out normally (upper-100%). on the diseased side the saturation of the mixed venous blood remains unchanged, but with increase in cardiac output (b), increase in the venous saturation (65%) results in a higher average saturation after ventilation (average of 100 & 65) causing a rise in pao2 from 36 to 55 mmhg. (picture from pals provider manual, american heart association). lung 40% lung 65% 100% artery 70% 100% artery 82.5% pulmonary artery blood 40% low co q /q = 50%p s q sat=70%2 pao =362 65% increased co q /q = 50%p s q sat=82.5%2 pao =552 a b cardiac output (ischemic hypoxia) spo2 (hypoxic hypoxia)do2 content of oxygen hb (anemic hypoxia) oxygen therapy – monitoring oxygen therapy once a patient has been put on oxygen, there are several ways by which we can judge the adequacy of oxygen therapy: 1. pulse oximeter 2. a-ao2 gradient 3. pao2/fio2 4. spo2/fio2 pulse oximeter has become an indispensable part of any clinic or hospital. it is very important to understand that the spo2 obtained by the pulse oximeter does not have a linear relationship with the pao2 (see fig 3) the pulse oximeter is in fact now considered the fifth vital sign not only because it is a noninvasive simple estimate of pao2 but because we know that spo2 contributes maximally to content of oxygen (co2). spo2 below 93-94% is considered hypoxemia. this golden figure of 93-94% can be understood if one looks at the 's' slide in figure 2.when the pao2 falls from 100 to 60, there is very little fall in spo2. beyond a pao2 of 60 mmhg, there is a steep fall in spo2, suggesting significant hypoxemia, hence spo2 below 93-94% is considered unsafe. fig 3: relationship between spo2 and pao2 90% 50% 60 100 pao2 (mmhg) o x y g e n s a tu ra ti o n d a b c type of hypoxia treatment priorities primary secondary hypoxemic (↓ spo2) o2 ↑ cardiac output (co), ↑ hb anemic (↓ hb) ↑ hb ↑ pao2, ↑ co ischemic (↓ co) ↑ co ↑ pao2, ↑ hb table i: classification of hypoxia and the treatment priorities 3 pjmsvolume 2 number 2: julydecember 2012 review article there are clinical conditions where spo2 may be normal yet patient may have hypoxia (one of the case scenarios mentioned at the beginning of this article). two common situations where this may occur are: 1. anemia 2. shock these are conditions where even if spo2 is normal, 100% oxygen must be given. as discussed earlier, the dissolved oxygen increases by almost 40% resulting in improved delivery of oxygen to the tissues (do2). remember 0.003 x 500 (fio2 100%) is better than 0.003 x 100 (fio2 21%)! the pulse oximeter has some limitations in its uses (2). the most important is its use in a patient in shock. as the reading is based on pulsatile flow of blood in the extremities, it may be unreliable in shock. in such situations, the probe should be kept over the tongue or ears. another condition where pulse oximeter is unreliable is methhemoglobinemia or carboxyhemoglobinemia. pulse oximetry only reads the percentage of bound hemoglobin. it can be bound to other gasses such as carbon monoxide and still read high even though the patient is hypoxemic. the only noninvasive methodology that allows for the continuous and noninvasive measurement of the dyshemoglobins is a pulseco-oximeter. pulse oximeter has a major limitation in neonates where hyperoxia is as deleterious as hypoxia and pulse oximeter cannot detect hyperoxia. the plateau at the top of the 's' shaped curve means that the pao2 may rise from 100 to 500 but the spo2 will remain 100! pulse oximeter measures only oxygenation, not ventilation. there is a case report of a patient who had a normal spo2 (100%) but had a paco2 650! hence pulse oximeter can never be a substitute for blood gas analysis. a-a o2 gradient: normally the oxygen present in the alveoli (ao2) should be taken up entirely by the blood (ao2) and hence there should be no a-ao2 gradient. but even in normal individuals there exist some alveoli which do not participate in ventilation despite being well perfused (see fig 3) and some alveoli are not perfused despite being filled with o2, resulting in v/q (ventilation/perfusion) mismatch, thereby creating a pao2-pao2 gradient, albeit very small. when this v/q mismatch increases it results in increased pao2-pao2 gradient indicating hypoxemia. pao2= fio2 x 713 – paco2/0.8, and pao2 is calculated from the abg. serial measurement of a-a gradient provides excellent information on oxygenation. for those who cannot face the 'wrath of math', a simpler way to monitor adequacy of oxygen therapy is the pao2: fio2 ratio. normally the ratio is top: ventilated and perfused; middle: nonventilated, perfused; bottom: ventilated, not perfused. a a fig 4: a-ao2 gradient. 100: 0.21 or 500. a value < 300 suggests abnormal gas exchange and < 200 indicates severe hypoxemia. spo2/ fio2 also gives a rough estimate of whether the given oxygen therapy is resulting in adequate tissue oxygenation. a spo2 <94% on simple face mask at 6-10l/mt (roughly fio2 50%) suggests severe hypoxemia. a spo2 of 94% corresponds to pao2 100, and hence the pao2/fio2 ratio would be 100/50, this may suggest the need for ventilator support. oxygen therapy – oxygen delivery devices the choice of the oxygen delivery device depends on the desired fio2 for optimum delivery of oxygen, as well as the age of the child. as is seen in the figure above, the inspired oxygen concentration depends on the type of device and the flow rate. if a child is very irritable and has hypoxemia due to a reversible cause, for e.g. asthma, then oxygen should be given as 'blow by' where the oxygen tube is kept on the chest with the jet directed towards the nose. this will ensure delivery of oxygen at a concentration higher than 21%. nasal cannula should be used in infants at a rate of not more than 2l/mt. flow rates specified with each delivery device must be maintained not only to achieve the desired oxygen delivery but also to prevent carbon dioxide retention especially in the rebreathing devices. self-inflating resuscitating bags should not be used as an oxygen delivery device in spontaneously breathing patients. ideally humidification of oxygen is a must especially when given at > 4l/mt (3). 4 pjmsvolume 2 number 2: julydecember 2012 review article oxygen toxicity: oxygen is so toxic that if it was discovered today, fda will not approve its use! the toxic effects of oxygen are not restricted to neonates. — related to high pao2 – rop — related to high fio2 – 1. bpd 2. absorption atelectasis 3. hypercapnia the toxic effects of oxygen occur through generation of reactive oxygen species such as o , h o , or oh which are 2 2 2 highly reactive and cause oxidative damage to the lipid and proteins on the cell wall. antioxidants like superoxide dismutase, vitamin c, etc are reducing agents, and limit oxidative damage (4). neonates are especially deficient in antioxidants and are more vulnerable to the toxic effects of oxygen. hyperoxia in neonates results in conditions such as retinopathy of prematurity, broncho pulmonary dysplasia, patent ductus arteriosus, necrotising enterocolitis, and periventricular leucomalacia. oxygen and resuscitation: why do we use 100% in resuscitation? this has been a matter of intense debate, and the current consensus, according to the nrp guidelines (2006), is that there is no apparent clinical disadvantage of using room air (21%) for resuscitation of asphyxiated neonates. it has been found that room air resuscitated infants recover more quickly and that neonates resuscitated with 100% o2 had prolonged oxidative stress persisting even after 4 weeks of life (5). key points: · oxygen is a drug that saves lives, and like all drugs its administration deserves careful consideration. • continuous pulse oximeter monitoring is a must to judge the efficiency of oxygen delivery • in extremely agitated patient with reversible cause of hypoxia, e.g. croup, asthma, oxygen is preferably given as 'blow by'. • never use self-inflating bag to provide increased fio2 in spontaneously breathing patients. • if nasal cannula is used, the oxygen flow rate must not be below 2l/mt. • humidification oxygen is must when it is given in a concentration of >4l/mt. • low flow oxygen delivery system versus high flow system is not a question of inferior or superior type of delivery device; it just indicates a variable performance (low flow) as compared to a fixed oxygen concentration delivered (high flow). • oxygen is a part of the fire triangle and hence must be accompanied by ready availability of fire hazard safety. • specified flow rates must be maintained especially in rebreathing systems to decrease co2 retention. • a collapsed reservoir bag in a nonrebreathing system suggests inadequate flow rates. • optimal oxygen for preterm infants is still debated. more studies are needed for a final say. • nrp still recommends resuscitation with 100%. role of 100% o2 during resuscitation should be reassessed. • even a brief period of hyperoxia immediately after birth may have long term consequences. • new strategies to reduce oxidative stress in neonates e.g. antioxidant, may play a big role in making oxygen therapy safer. references: 1. phua j, stewart t, niall f. acute respiratory distress syndrome 40 years later: time to revisit its definition. critical care medicine 2008; 36(10):2912-2921. 2. mardirossian g, schneider r.e. limitations of pulse oximetry. anesth prog 1992; 39(6):194-196. 3. berg md, schexnayder sm, chameides l, terry m, aaron d, robert wh et al. pediatric basic life support: 2010 american h e a r t a s s o c i at i o n g u i d e l i n e s fo r ca rd i o p u l m o n a r y resuscitation and emergency cardiovascular care.pediatrics 2010; 126(5):e1345e1360. 4. deneke sm, fanburg bl. normobaric oxygen toxicity of the lung. n engl j med 1980; 303 (2): 76-86. 5. tin w, dwa milligan, p pennefather, e hey. pulse oximeter, severe retinopathy and outcome in at one year in babies of less than 28 weeks gestation. arch dis child fetal neonatal ed 2001; 84: f106-f110. (no spontaneous breathing) self-inflating or anesthesia bag 10-15 l/mt 95% 100% anesthesia bagflow inflating fio2: 100% non-rebreathing mask + reservoir/ o2 hood 10-15l/mt. fio2: 95% partial rebreathing mask + reservoir 10-12l/mt. fio2: 50-60% simple mask 6-10l/mt. fio2: 40-50% blow by or nasal cannula 5l/m 2-4l/mt fio2: 30% 5 pjmsvolume 2 number 2: julydecember 2012 review article page 6 page 7 page 8 page 9 429 too many requests you have sent too many requests in a given amount of time. case report doi: 10.18231/2348-7682.2017.0029 panacea journal of medical sciences, may-august,2017;7(2): 107-109 107 sinonasal chondromyxoid fibroma: a rare tumour sonali khadakkar1,*, vivek harkare2, nitin deosthale3, priti dhoke4, kanchan dhote5 1,5senior resident, 2professor & hod, 3professor, 4associate professor, dept. of ent, nkp salve institute of medical sciences & research centre, nagpur, maharashtra *corresponding author: email: sonalikhadakkar@yahoo.com abstract chondromyxoid fibroma (cmf) is a relatively rare benign bone neoplasm. cmf of the sinonasal tract is very rare. a 30year-old male presented with nasal obstruction, right nasal mass with headache since two months. a computed tomographyscan showed locally aggressive hypodense, mildly enhancing lesion of size 10.3 cm x 5 cm x 5.1 cm involving right maxillary, ethmoid and frontal sinus with extension into premaxillary area and infratemporal fossa of the same side and into the nasopahrynx. histopathology of biopsy revealed inflammatory polyp. the patient underwent a right medial maxillectomy with ethmoidectomy with excision of whole of the mass by lateral rhinotomy approach. a histological examination showed stellate cells in a chondromyxoid background with mitotic figures. it was provisionally diagnosed as chondroblastic osteosarcoma. immunohistochemistry confirmed the diagnosis of chondromyxoid fibroma. keywords: benign, bone neoplasms, chondromyxoid fibroma, craniofacial. introduction chondromyxoid fibroma is extremely rare tumour. it accounts for less than 1% of all primary bone neoplasms.(1) this distinct tumour is of cartilaginous origin and was first described by jaffe and lichtenstein in 1948.(2) chondromyxoid fibroma is characterised by presence of variable amount of chondroid, fibromatoid and myxoid components. it is most frequently found in young adults of second and third decade of life in long bones of lower extremities and particularly arising from metaphysis.(3) it’s occurrence in craniofacial bones is exceedingly rare. it is a slow growing tumour and develops symptoms over a period of months to years. symptoms depend on the site and size of tumour. it is often mistaken for three other myxoid tumours: chondroma, chondroid chondroma, chondrosarcoma and have greater frequency of occurrence in the craniofacial skeleton.(4-5) here, we report a very rare case of sinonasal chondromyxoid fibroma with a diagnostic dilemma treated by surgical excision. case history a 30-year-old male patient, farmer by occupation visited to ent outpatient department of tertiary health care hospital with a complaint of right sided nasal obstruction with mass protruding from right nasal cavity for 2 months (fig. 1). fig.1: right nasal mass protruding out through vestibule he also noticed ipsilateral swelling over cheek, watering from right eye, headache and anosmia. ent examination revealed brownish crusted mass protruding out of right nostril with flared and tender ipsilateral ala and cellulitis over malar region. there was gross deviation of nasal septum to opposite side. on posterior rhinoscopy, there was a mass occupying whole of the nasopharynx covered with yellow slough. his ophthalmic check-up revealed normal vision and fundus examination in both eyes. histopathology report of biopsy which was done at some other centre was suggestive of inflammatory polyp. a computed tomographic (ct) imaging with iv contrast was done which showed locally aggressive hypodense, mildly enhancing lesion of size 10.3 cm x 5 cm x 5.1 cm involving right maxillary and ethmoid sinuses (fig. 2) and also extending to frontal sinus, premaxillary area and infratemporal fossa of same side and nasopharynx (fig. 3). sonali khadakkar et al. sinonasal chondromyxoid fibroma: a rare tumour panacea journal of medical sciences, may-august,2017;7(2): 107-109 108 fig. 2: ct pns showing hypodense lesion occupying right maxillary and anterior ethmoid sinuses fig. 3: sagittal section of ct pns showing hypodence lesion extending to nasopharymx there was subtle erosion of ipsilateral lamina papyracea. we did repeat biopsy of the mass nasal cavity and histopathology report was consistent with the previous one. histopathology report was not matching the extensive lesion clinically and radiologically with short history. so, we proceeded with caldwel luc’s operation to get deeper biopsy, as the endoscope can’t be negotiated through the huge mass to the nasal cavity. to our surprise, histopathology report was again inflammatory polyp. under general anesthesia, tumour was approached through right lateral rhinotomy approach. right medial maxillectomy with ethomidectomy was done to remove the tumour completely (fig. 4). fig. 4: surgical excision of mass by lateral rhinotomy tumour extending at ipsilateral premaxillary and infratemporal region was also removed. underlying bone was curetted well and surgical site was closed. histopathologically, spindle cells in a chondrmyxoid storma arranged in lobules along with the osteoids with few areas of calcification was seen. the nuclei of spindle cells were showing marked pleomorphism, hyperchromatism and mitosis. the chondrocytes were also showing nuclear pleomorphism. provisional impression of pathologist was chodroblastic tumour, most likely chondroblastic osteosarcoma. to arrive to the final diagnosis, specimen was sent for immunohistochemical analysis. it was positive for vimentin, s-100, smooth muscle actin (sma) and was negative for desmin, cd 31 and cd34.so, we confirmed the diagnosis by immunohistochemistry as benign chondromyxoid mesenchymal tumour with no evidence of unequivocal invasive malignancy. in one year’s followup, patient showed no clinical or radiological evidence of residual or recurrent disease. discussion chondromyxoid fibroma (cmf) is a rare benign tumour that accounts for 1% of all bone tumours.(1) approximately 2/3rd of all cases of cmf occur in the metaphysis of long bones commonly affecting tibia and fibula. craniofacial involvement is extremely rare. mandible and maxilla are more commonly affected in this region. the world health organization defines cmf as “a benign tumour characterized by lobules of spindle-shaped or stellate cells with abundant myxoid or chondroid intercellular material”.(6) this tumour type has been described in neonates and adults, with a peak in second and third decade of life. there is a male predilection; but in cases of cranium and face bones involvement, women prevail (2:1).(7) most common presenting symptoms depend on the site of involvement. sinonasal cmf present with nasal obstruction, clival/ sellar lesions present with headache, sphenoidal/ parasellar lesions present with diplopia. orbital/ zygomatic cmf presents most commonly with exophthalmos and lastly temporal/ occipital cmf is associated with deafness and otalgia during presentation. sonali khadakkar et al. sinonasal chondromyxoid fibroma: a rare tumour panacea journal of medical sciences, may-august,2017;7(2): 107-109 109 there is no established radiological pattern for cmf because of its rarity but they can offer insight into diagnosis before intervention. ct scan shows radiolucent, lobulated, circumscribed lesion with sclerotic rim and cortical expansion or erosion. mri findings are not clearly established because of low occurrence rate. it has low signals on t1 weighted and high signals at t2 weighted images similar to other cartilagenous tumours. cmf is difficult to differentiate histologically as well as clinically. histopathologically, cmf resembles to chondroblastoma and chondrosarcoma.(8-9) misdiagnosis rate reported in literature is 18%.(8) it is very important to distinguish it from chondrosarcoma because management of these two entities differs. cmf is usually well-demarcated nodular lesion with myxoid lobules separated by thin, fibrous septa. importantly, acmf has a pauci-cellular centre rather than the uniform cellular arrangement observed in chondrosarcoma, and mitotic figures are exceptional.(6) in addition, the differential diagnosis includes fibrous dysplasia and chordoma. if the lesion shows significant atypia and mitotic figures diagnosis should be reconsidered. on immunohistochemistry, cmf is most commonly found to be positive for vimentin, smooth muscle actin, desmin and s-100 (variably) and cd34.generally, it is negative for pancytokeratin, carcinoembryonic antigen (cea), and gfap10. sox9 is a transcription factor that was recently described as a master regulator of chondrogenesis. it plays a role in the early phases of chondrocyte differentiation.(11) complete surgical excision is the first line of treatment.(1) because of the functional and cosmetic deformities that result from complete surgical resection a cmf of the craniofacial bones are best managed by curettage. curettage is usually successful but increases the risk of recurrence(1) which is approximately 25%.(12) such recurrence is usually local and malignant transformation is unlikely.(4) role of radiotherapy in the management of cmf is controversial. some authors recommend using radiotherapy for local relapses following surgical excision, particularly at the base of the skull.(13) conclusion a sinonasal cmf is very rare and frequently misdiagnosed. although cmf is a benign bone tumour, it should be differentiated from more aggressive malignant tumour. patients who receive curettage have high recurrence rate. periodic careful surveillance is necessary in such patients. references 1. rahimi a, beabout jw, ivins jc, dahlin dc. chondromyxoid fibroma: a clinicopathologic study of 76 cases. cancer. 1972;30(3):726-36. 2. jaffe hl, lichtenstein l. chondromyxoid fibroma of bone: a distinctive benign tumour likely to be mistaken especially for chondrosarcoma. arch pathol (chic). 1948;45:541-51. 3. wu ct, inwards cy, o’laughlin s, rock mg, beabout j, unni kk. chondromyxoid fibroma of bone: a clinicopathologic review of 278 cases. hum pathol. 1998;29(5):438-46. 4. patinocordoba ji, turner j, mccarthy sw, fagan p. chondromyxoid fibroma of the skull base. otolaryngl head neck surg. 1998;118(3 pt 1):415-8. 5. vishwanathan r, jegathraman ar, ganapathy k, bharati as, govindan r. presellar chondromyxofibroma with ipsilateral total internal carotid artery occlusion. surg neurol. 1987;28(2):141-4. 6. ostrowski ml, spujut hj, bridge ja. chondromyxoid fibroma. in: fletcher cd, unni kk, mertens f, eds. world health organization classification of tumours: pathology and genetics of tumours of soft tissue and bone. lyon: iarc press. 2002; 243. 7. isenberg sf. endoscopic removal of chondromyxoid fibroma of the ethmoid sinus. am j otolaryngol. 1995;16:205-8. 8. carr nj, rosenberg ae, yaremchuk mj. chondromyxoid fibroma of zygoma. j craniofacial surg. 1992;3:217-22. 9. unni k, inward c. 6th ed. philadelphia: lippincott williams and wilkins; 2010. dahlin’s bone tumours; 50-59. 10. morris lgt, rihani j, lebowitz ra, wang by. chondromyxoid fibroma of sphenoid sinus with unusual calcifications: case report with literature review. head neck pathol. 2009;3(2):169-73. 11. veras ef, santamaria ib, luna ma. sinonasal chondromyxoid fibroma. ann diagn pathol. 2009;13:416. 12. nazeer t, ro jy, varma dg, de la hermosa jr, ayala ag. chondromyxoid fibroma of paranasal sinuses: report of two cases presenting with nasal obstruction. skeletal radiol. 1996;25:779-82. 13. mendoza m, gonzález i, aperribay m, hermosa jr, nogués a. congenital chondromyxoid fibroma of the ethmoid: case report. pediatr radiol 1998;28:339-41. original research article doi: 10.18231/2348-7682.2018.0027 panacea journal of medical sciences, september-december, 2018;8(3):116-122 116 normal values of modified functional reach test in indian school going children of age 6 to 12 years abhijeet arun deshmukh1, mrunmayee mukund joshi2,* 1assistant professor, 2internee, dept. of neuro-physiotherapy, vspm’s college of physiotherapy, nagpur, maharashtra, india *corresponding author: email: mrunmayeemjoshi20@gmail.com abstract modified functional reach test is valid and reliable tool to assess sitting balance in children in forward and lateral direction. normative data of modified functional reach test for school going children has not been established yet in central india, as well correlation of anthropometric data with reach distance values not studied, hence this study was undertaken. total 280 children (6 to 12 years), 140 boys and 140 girls, were selected by stratified random sampling method, subdivided into 7 subgroups (10b, 10g in each group) from two schools. height was measured using stature meter, trunk length and leg length were measured using measuring tape, weight was measured using weighing machine, spinal flexibility was tested with the help of sit and reach test, hamstring angle was measured using goniometer by 90-90 test. child reached with dominant shoulder at 90 degree of flexion and abduction in forward and lateral direction respectively while sitting on height adjustable stool with hip and knee at 90 degrees and feet placed neutral on ground. the reach distance was measured using a yard stick mounted on the wall, at the height of child’s shoulder. the mean of three successive trials was calculated. karl pearson correlation moment product was used to determine correlation between age, gender and anthropometric measurements with modified forward and lateral reach. normal values of modified forward and lateral reach were observed as 19.53 to 26.48cm and 17.68 to 22.50cm respectively. height and weight correlated significantly with modified functional reach values. keywords: sitting balance assessment, school children, modified functional reach, modified lateral reach, height, weight. introduction balance is the condition in which all the forces acting on the body are balanced so that the centre of mass (com) is within the limits of stability and the boundaries of base of support (bos).1 the ability to maintain a posture such as balancing in a standing or sitting position, is operationally defined as static balance.1 the ability to maintain postural control during movements, such as reaching for an object or walking across objects, is operationally termed as dynamic balance1. balance emerges from a complex interaction of sensory systems (afferent-visual, cutaneous, proprioceptive), motor systems (effectormuscles, bones, joints), vestibular system and central nervous system (cns).1 these systems work in a coordinated way in order to maintain static postures and during dynamic tasks.1 these systems independently predominate at various rates as age advances. infants and young children (aged 4 months-2 years) are dependent on the visual system to maintain balance. at 3-6 years of age, children begin to use somatosensory information appropriately.1 at the age of 6-8 years, a transition occurs in organisation of postural behaviour by maturation of somatosensory and vestibular system2-4 and beyond this age, the effect of vision becomes less dominant when compared with other systems.5 finally, at 7-10 years of age, children are able to resolve a sensory conflict and appropriately utilize the vestibular system as a reference along with other systems.1 sitting is a milestone achieved by a typically developing child as a part of normal motor development, at the age of 5-8 months and reaching activity is also achieved at the same age which forms the basis for the dynamic balance in sitting position.6 the ability to balance while reaching for a variety of objects both within and beyond arm’s length is important for daily activities.6 in children, sitting balance plays an important role during functional activities such as maintaining or attaining sitting posture, dressing, transferring, bathing, toileting and eating activities and also in activities like playing, hobby, recreation, schooling etc.2,7 in individuals who have neuromuscular dysfunction or have abnormal motor development may show variation in postural adjustments leading to impaired balance.8-12 to assess balance, various age specific scales, tests and measures are available that assess sitting balance individually or as a part of the test such as paediatric clinical test of sensory interaction for balance, seated postural control measure, level of sitting ability scale, paediatric balance scale, bruininks-oseretsky test of motor proficiency, timed get up and go test, sitting assessment for children with neuromotor dysfunction, gross motor function measure, chailey levels of ability, (mfrt), etc.10,13-18 modified functional reach test used for balance evaluation is less time consuming and requires no equipment, easily understood by all age groups and hence is widely used as objective measure to assess dynamic sitting balance.6,10,19 it is defined as the maximal distance one can reach beyond arm length while maintaining a fixed base of support in sitting. modified functional reach test examines movements in two directions, forward and lateral in sitting. it is having high validity and reliability among both adult and paediatric population.10,19,20 the construct validity of mfrt is supported in children typically developing and in children with cerebral palsy.19 the modified functional reach test showed intra class coefficient (icc), intrarater, and inter-rater reliability as 0.84, 0.71, and 0.71 abhijeet arun deshmukh et al. normal values of modified functional reach test in indian school going children…. panacea journal of medical sciences, september-december, 2018;8(3):116-122 117 respectively.19 there are several factors affecting balance like age, height, weight and other anthropometric measurements3,10,21,22 which show vast difference in balance scores among children in developing ages. till date, normal reference values for mfrt are not available for paediatric population between 6-12 years of age in india. hence, the primary purpose of the study was to establish clinical reference values for indian school going children. materials and methods total 280 children were selected of both genders (140 boys and 140girls) by multistage stratified sampling method. a cross sectional study was performed on normal healthy children of age group 6-12 years selected from one urban school and one rural school of nagpur. children were divided into 7 subgroups depending upon age i.e. 6-12 years. the study was carried out over a period of 3 months. children having any neuromuscular or musculoskeletal disorders6, severe known visual defects,6 history of ear infection/pain since last 6 months were excluded from the study. anthropometric measurements of height and weight were done by using stature meter and weighing machine respectively. bmi was calculated and children between the range of 13.37 to 22.15 kg/m2 i.e. (10th and 90th percentile for age 6-12 years.) were included. trunk length and leg length were measured using measuring tape.6,23 universal half goniometer was used to measure hamstring angle24 and sit and reach apparatus was used to assess trunk flexibility.6 children showing no tightness in 90-90 hamstring tightness test were included. a stool with adjustable height was arranged near the wall, where child seated independently with back straight and feet pelvis width apart, touching the floor completely. a yard stick was arranged at the height of the shoulder of the child. forward reach and lateral reach of the children were measured by asking the child to bend with his/her arm flexed at 90 degrees for forward reach and 90 degrees abduction for lateral reach6 (fig. 1-4). three successive measurements were taken in centimetres. mean of the three finding was calculated for each child. no unexpected responses or injuries occurred during testing. fig. 1: starting position for modified forward reach test fig. 2: end position for modified forward reach test fig. 3: starting position for modified lateral reach test fig. 4: end position modified lateral reach test data analysis spss version 20.0 was used for statistical analysis. student’s t-test was used to obtain normal values of modified functional reach test. karl pearson correlation moment product was used to determine correlation between age, gender, height, weight, trunk length, leg length, sit and reach distance and hamstring angle with mfrt and mlrt. statistics were determined at 95% confidence interval. results the mean and standard deviation of anthropometric measurements, sit and reach test distance and 90-90 hamstring tightness angle were explained in table 1. normal values of mfrt and mlrt ranged from19.53 ± abhijeet arun deshmukh et al. normal values of modified functional reach test in indian school going children…. panacea journal of medical sciences, september-december, 2018;8(3):116-122 118 3.57 cm to 26.48 ± 5.27 cm and 17.68 cm ±2.59 cm to 22.50 cm±3.75 cm among both genders between the ages of 6-12 years respectively. (table 2) correlation of mfrt and mlrt with anthropometric measures, trunk flexibility and hamstring angle (table 3, 4): the values of mfrt and mlrt increases with age in both genders and showed a highly significant correlation with height, leg length, trunk length. the mfrt distances showed a significant correlation with weight in both genders whereas, mlrt distances were correlated significantly with weight in girls, but not in boys. the mfrt distances showed a significant correlation with sit and reach test distance (trunk flexibility) in boys but not in girls. the mlrt distances did not show correlation with trunk flexibility in both genders. both distances did not show significant correlation with bmi and hamstring angle in both genders. for children of age 6-12 years mlr mean distance value could be predicted significantly (table 5) (r2=0.48) by mfr mean distance and vice versa in both genders by using following formula: mlr (cm)=7.28+[0.607×mfr(cm)] on evaluation of lateral reach test, it was found that there was no significant difference between right and the left side reach values (graph 1). table 1: mean and standard deviation of demographic data, sit and reach distance, hamstring angle age gender height±sd (cm) weight±sd (kg) bmi± sd(kg/m2) leg length±sd (cm) trunk length± sd (cm) sit and reach distance± sd(cm) hamstring angle± sd(degrees) 6 g 113.35± 3.67 20.25± 3.66 15.70± 2.27 33.90± 1.48 44.65± 1.53 8.50± 3.87 173.50± 10.52 b 114.70± 5.13 18.80± 2.84 14.15± 1.38 34.00± 1.94 43.20± 2.73 8.35± 4.42 172.50± 8.95 7 g 117.60± 4.81 20.85± 3.36 14.80± 1.90 35.55± 2.13 45.60± 2.72 9.15± 3.20 174.75± 9.79 b 122.10± 5.23 22.90± 5.27 15.30± 2.47 37.00± 2.31 47.15± 1.69 7.05± 2.80 160.75± 9.49 8 g 125.85± 4.74 23.10± 2.78 14.45± 1.19 39.55± 2.41 47.80± 2.84 10.30± 1.49 167.25± 6.58 b 126.55± 6.37 23.30± 5.14 14.45± 2.43 38.35± 2.88 46.10± 3.09 10.40± 1.78 169.50± 7.76 9 g 131.55± 6.24 28.55± 5.83 16.40± 2.37 41.65± 2.81 49.15± 3.81 13.50± 3.95 173± 11.16 b 131.05± 4.72 27.50± 7.41 15.85± 3.78 40.65± 2.18 49.75± 3.62 13.30± 4.24 169.75± 13.52 10 g 133.10± 6.46 29.65± 6.23 16.55± 2.54 42.70± 2.69 50.85± 3.31 11.95± 3.83 171.75± 8.47 b 137.75±8.14 30.75± 6.23 16.10± 2.55 42.90± 2.78 50.85± 3.04 10.05± 3.90 169.25± 10.16 11 g 144.70± 9.30 33.80± 8.19 15.95± 2.25 49.80± 5.68 50.10± 6.96 12.55± 4.22 164.75± 11.97 b 141.00±6.03 37.90± 11.48 19.00± 5.70 48.90± 4.29 49.75± 5.86 12.95± 3.45 168.75± 12.76 12 g 150.55± 7.14 40.50± 9.86 17.70± 3.04 47.30± 2.77 58.50± 5.35 9.50± 2.41 166.25± 9.85 b 149.30± 9.29 39.80± 9.23 17.65± 3.10 47.50± 2.96 57.45± 4.44 10.30± 4.65 165.00±9.03 abbreviations: g, girls; b, boys; sd, standard deviation table 2: the normal values of modified forward reach and modified lateral reach (both right and left side) among both genders between the ages of 6 to 12 years. age, y gender mfr(cm) mlr (lt)(cm) mlr(rt)(cm) 6 f 19±4.01 16.80±2.87 17.50±2.98 m 20.05±3.08 18.55±1.98 18.15±2.27 7 f 23.05±3.72 20±3.68 20.10±3.65 m 21.90±5.10 22.45±4.08 23.32±3.19 8 f 23.35±5.37 20.80±6.37 22.25±3.71 m 24.20±3.17 22.75±4.36 22.75±3.87 9 f 22.85±4.18 17.85±3.20 19.10±2.84 m 21.60±3.53 20.35±6.26 19.40±4.16 10 f 24.50±5.30 20.85±3.76 21.45±3.81 abhijeet arun deshmukh et al. normal values of modified functional reach test in indian school going children…. panacea journal of medical sciences, september-december, 2018;8(3):116-122 119 m 22.60±7.91 22.20±3.57 19.95±4.32 11 f 26.80±5.84 21.55±3.84 19.85±3.29 m 26.15±4.76 22.20±3.57 21.80±3.79 12 f 27.45±7.46 22.75±4.01 21.85±4.39 m 24.05±6.71 20.40±4.95 20.85±4.71 abbreviation: f, female; m, male; mfr, modified forward reach; mlr, modified lateral reach table 3: correlation of modified forward reach test with anthropometric measures, sit and reach distance (trunk flexibility), hamstring angle and bilateral lateral reach values age gender height (cm) (r) weight (kg) (r) bmi (kg/m2) (r) leg length (cm) (r) trunk length (cm) (r) trunk flexibility (cm) (r) hamstring angle (degrees (r) modified left lateral reach(cm) (r) modified right lateral reach(cm (r) 6 g 0.04 0.28 0.36 0.08 0.24 0.52 0.492 0.17 -0.17* b 0.03 -0.01* 0.11 -0.12* -0.12* 0.15 0.4 0.09 0.10 7 g 0.38 0.14 -0.30* 0.32 0.002 0.23 0.23 0.20 0.35 b 0.20 0.01 0.08 0.30 0.11 0.18 0.25 0.23 0.36 8 g 0.41 0.28 -0.02* 0.15 0.13 0.07 -0.10* 0.54 0.38 b -0.24 0.05 0.06 0.06 0.33 0.004 0.06 0.45 0.53 9 g 0.13 0.13 0.04 0.17 0.16 0.53 0.12 0.23 0.14 b 0.20 -0.11* 0.18 0.17 0.12 0.21 -0.05* 0.18 0.33 10 g -0.04 0.23 0.37 -0.10* -0.06* 0.39 0.67 0.46 0.68 b -0.37 0.20 0.01 -0.35* -0.02* 0.28 0.7 0.82 0.72 11 g 0.48 0.23 -0.05* 0.21 0.28 0.02 0.04 0.51 0.43 b 0.31 0.30 0.21 -0.39* 0.67 0.28 0.05 0.23 0.57 12 g -0.18 -0.45* -0.58* -0.08* -0.48* -0.19* 0.37 0.49 0.41 b 0.42 -0.009* -0.28* 0.31 0.12 -0.12* 0.009 0.51 0.66 abbreviations: g, girls; b, boys; l, left; r, right,*, negative correlation abbreviations: g, girls; b, boys; l, left; r, right,*, negative correlation values represent karl pearson’s correlation coefficient (r) table 4: correlation of modified lateral reach distances with anthropometric measures, sit and reach distance (trunk flexibility) and hamstring angle age gender height(cm) (r) weight(kg) (r) bmi(kg/m2) (r) leg length(cm) (r) trunk length(cm) (r) trunk flexibility (cm)(r) hamstring angle (degrees) (r) l r l r l r l r l r l r l r 6 g 0.17 -0.17* 0.21 0.14 0.17 0.24 0.20 -0.13* 0.17 -0.23* 0.15 -0.19* 0.53 0.30 b 0.32 0.28 0.49 0.17 0.40 -0.02* 0.46 0.24 0.07 0.32 0.001 0.33 -0.24* -0.12* 7 g -0.02* 0.37 -0.13* 0.280 0.34 0.003 -0.02* 0.24 0.07 0.27 -0.04* 0.35 0.40 -0.05* b 0.19 0.14 0.15 -0.16* 0.10 -0.33* 0.14 0.01 0.19 -0.01* -0.43* -0.13* -0.457* -0.20* 8 g 0.52 0.67 0.47 0.65 0.13 0.33 0.52 0.78 0.06 0.12 -0.30* -0.38* -0.30* -0.40* b 0.18 -0.37* 0.16 0.05 0.09 0.13 0.10 -0.32* 0.19 -0.20* -0.18* 0.41 -0.18* 0.43 9 g -0.19* 0.12 -0.11* -0.15* -0.06* -0.30* 0.01 0.03 0.23 0.28 0.05 0.182 -0.04* 0.007 b -0.45* -0.19* -0.08* -0.28* 0.05 -0.28* -0.21* -0.12* 0.02 -0.05* -0.02* 0.02 0.15 0.14 10 g 0.13 0.05 0.26 0.35 0.28 0.44 0.12 0.009 0.03 0.04 0.50 0.44 0.15 0.37 b -0.20* -0.01* -.002* 0.03 0.15 0.02 -0.20* 0.12 0.04 0.15 0.32 0.40 0.42 0.47 11 g 0.29 0.45 0.19 0.14 0.05 -0.15* -0.27* -0.15* 0.47 0.46 0.48 0.39 -0.14* 0.45 b 0.05 0.25 0.15 0.20 0.18 0.15 0.01 -0.27* 0.22 0.43 -0.27* 0.24 -0.29* -0.07* 12 g -0.25* -0.36* -0.33* -0.26* -0.38* -0.20* -0.12* -0.25* -0.25* -0.33* 0.03 -0.21* 0.59 0.68 b 0.44 0.34 0.08 0.09 -0.16* -0.10* 0.22 0.28 0.40 0.12 0.12 -0.23* -0.22* 0.17 abbreviations: g, girls; b, boys; l, left; r, right, *, negative correlation values represent karl pearson’s correlation coefficient (r) abhijeet arun deshmukh et al. normal values of modified functional reach test in indian school going children…. panacea journal of medical sciences, september-december, 2018;8(3):116-122 120 table 5: regression values and coefficients of mlrt of both sides with mfrt in both genders unstandardized coefficients standardized coefficients t value p value b std. error beta (constant) 7.280 1.594 4.567 0.000 modified left lateral reach(cm) 0.401 0.080 0.322 5.030 0.000 modified right lateral reach(cm) 0.383 0.090 0.272 4.250 0.000 a. dependent variable: modified forward reach(cm) p value < 0.05 considered as statistically significant graph 1: correlation of mlrt on both sides in both genders discussion the anthropometric measurements (height, weight, bmi) (table 1) of the children included in the present study were in agreement with the indian data for the respective age group.17,26,27 the values for modified forward reach and modified lateral reach in age group 6-12 years among both genders have not been established hence this study reported the reference values (table 2). the current study found that the modified functional reach test values were affected by the factors such as height and weight in both genders. this finding is consistent with findings of donahoe and associates (1996)20 where it was stated that as age advances, height and weight increases and also the functional reach. another study by habib and associates (1998) showed that height was the most significant factor for the fr values in pakistani children aged 5-7 years. aa deshmukh and associates 201117 also found that fr values were significantly affected by height in indian girls aged 6-12 years. rosemary and associates (2003)23 found that weight was the only significant factor affecting the fr values in children aged 3-5 years. this finding contradicts the studies by thompson m (2007) and p. singh (2013) where they did not find any significant correlation between anthropometric measures and modified functional reach test values in american and indian adults (20-97 years) respectively. in the present study, modified functional reach test values increases in both genders in parallel with leg length as well as trunk length. this is in accordance with the previous study by p. singh and associates (2013)6 where they found that mfrt and mlrt values were significantly correlated with trunk length in young indian adults (20-39 years). study performed on children by tacar and colleagues(1999)28 found that upper and lower extremity length increases in parallel to height which may explain the results of present study that, as the leg length increases the modified functional reach test values increases well. aa deshmukh and associates (2011)17 also found similar results where high correlations of lengths of upper and lower extremities with frt results were observed only in girls. in present study it is also observed that trunk flexibility had effect on mfrt values in boys. this finding is supported by margaret s et al (2000)29 who found that spinal flexibility is a contributor to functional reach values performed in standing. balance is dependent on tissue flexibility as well as strength and there is a gender difference among children with respect to flexibility and strength. physiologically boys are stronger than girls and at early age both boys and girls are equally flexible as stated in study by stephen haley and associates (1986)30 that anterior spinal flexion measurements for both genders demonstrated no significant trend between ages of 5 and 9years. hence in present study better trunk flexibility and strength among children might have contributed significantly for mfrt values. in this study hamstring length did not contribute to mfrt and mlrt values. this can be explained biomechanically as, in sitting position, two joint hamstring muscle is in a shortened position at knee hence reaching forward may not require complete excursion of hamstring muscles. bmi also did not affect both reach values. the participants were of growing age and as age increased height and weight also showed an increment in their values and hence their ratio i.e. bmi remained constant. moreover, none of the participants in the study were obese so excess adipose tissue did not contribute for limitation of movement.20 for mlrt, height, weight, leg length and trunk length were important factors in girls whereas in boys the distances were not affected by the anthropometric abhijeet arun deshmukh et al. normal values of modified functional reach test in indian school going children…. panacea journal of medical sciences, september-december, 2018;8(3):116-122 121 measurements. this result is in agreement with the study by aa deshmukh and associates (2011)17 where for lateral reach values, height was an important factor among girls. the result of previous study6 stated that trunk length was significantly correlated with lateral reach values in young indian adults (20-39 years). in present study, it was observed that mfrt values are more than mlrt values in both genders. this result is consistent with the study by aa deshmukh (2011)17 where similar results were found for functional reach tests. the reason for this could be explained as in sitting there is a larger bos and shorter lever arm as compared to standing which allows a greater stability. abroader bos while reaching forward as compared to a smaller bos while reaching lateral may be the reason for variation in reach values. while reaching forward the participants could get a visual feedback and hence may have performed better. while reaching laterally as visual feedback had been blocked, the participants depended on somatosensory system and vestibular system which is not fully developed in this age.1 results showed that values of fr were more than mfr whereas lr values were lesser than mlr when compared with the study done by aa deshmukh. (2011).17 during reaching forward in standing, various postural strategies are used such as hip, ankle and trunk, whereas in sitting only trunk strategy is used. in lateral reach, the bos is broader in sitting hence children were able to reach farther as compared to the standing7. it was also found that mfrt and mlrt showed a highly significant correlation with each other i.e. mlrt values can be predicted by mfrt values and vice versa. comparative group statistics of left and right lateral reach do not show any significant difference. hence in the present study, only right side lateral reach distance is considered for statistical analysis. thus from the present study it can be concluded that height and weight are the important factors for mfrt and mlrt values as, parameters like weight, height, leg length, trunk length showed direct correlations with growth. the normal values obtained in this study can be used as baseline data for assessment of balance impairments among children aged 6-12years in india, in conditions like cerebral palsy, down’s syndrome, muscular dystrophies, peripheral neuropathies, spinal structural defects, etc.8-13 in future research, correlation of trunk strength and modified functional reach test can be evaluated. in addition to examining people with sitting balance impairments, further examination of the psychometric properties of the reaching forward and lateral in sitting position, need to be explored in larger sample size. conclusion from the present study it can be concluded that, the range of normal values of mfrt are 19.53 ± 3.57 cm to 26.48 ± 5.27 cm and that of mlrt reach are 17.68 cm ±2.59 cm to 22.50 cm ±3.75 cm respectively in indian school going children of age 6-12 years. among all the anthropometric measures, height and weight contributes significantly to both mfrt and mlrt values. conflict of interest: none. references 1. westcott sl, lowes lp, richardson pk. evaluation of postural stability in children: current theories and assessment tools. phys ther 1997;77:629-645. 2. assaiante c, amblard b. ontogenesis of head stabilization in space during locomotion in children: influence of visual cues. exp brain res 1993;93(3):499-515. 3. riach cl, starkes jl. velocity of centre of pressure excursions as anindicator of postural control systems in children. gait posture 1994;2(3):167-172. 4. hay l, redon c. feed forward versus feedback control in children and adults subjected to a postural disturbance. exp brain res 1999;125(2):153-162. 5. shumway-cook a, woollacott mh. normal postural control. motor control translating research into clinical practice. 2001;158-186. 6. singh p, hujon n. normative data of modified functional reach test in younger and middle-aged north eastern indian population. arch med health sci. 2013;1(2):109-114. 7. o’sullivan sb, schmitz tj. physical rehabilitation. 5th edition. newdelhi, india: jaypee brothers. 373-399. 8. mccaslin dl, gary pj, gruenwald j. the predominant forms of vertigo in children and their associated findings on balance function testing. otolaryngol clin north am 2011;44(22):291307. 9. smith rm, emans jb. sitting balance in spinal deformity. spine.1992; 17(9):1103-1109. 10. lynch sm, leahy p, barker sp. reliability of measurements obtained with modified functional reach test in subjects with spinal cord injury. phys ther 1998;78:128-133. 11. wright mj, galea v, barr rd. proficiency of balance in children and youth who have had acute lymphoblastic leukaemia. phys ther 2005;85(8):782-790. 12. patricia d ed. cash’s textbook of neurology for physiotherapists. 4thedition. new delhi, india. 435-457,517524,552-589. 13. list of assessment tools used in paediatric physical therapy.section on paediatrics. american physical therapy association. 14. available:https://google.co.in/url?q=https://med.unc.edu/ahs/p hysical/files/school-basedptdocs/ped%20assessment%20tools.pdf&sa=u&ei=pwkvz crll3guatgsol4aw&ved=0ca8qfjaa&usg=afqjcngz7q qqtyvamhhhg0w_jfspuzqx5a. 15. harris sr, gregson jl, field d, fife se, roxborough la, armstrong rw. development of a clinical measure of postural control for assessment of adaptive seating in children with neuromotor disabilities. phys ther 1991;71:981-993. 16. knox v. evaluation of the sitting assessment for children with neuromotor dysfunction (sacnd) as a measurement tool in cerebralpalsy: a case study. physiother 2002;88(9):534-541. 17. pountney te, cheek l, green e, mulcahy c, nelham r. content andcriterion validation of the chailey levels of ability. physiother 1999;85(8):410-416. 18. deshmukh aa, ganesan s, tedla jl. normal values of functional reach and lateral reach tests in indian school children. pediatr phys ther 2011;23:23-30. 19. plisky pj, gorman pp, elkins b. the reliability of an instrumented device for measuring components of the star excursion balance test. n am j sports phys ther 2009;4(2):92. abhijeet arun deshmukh et al. normal values of modified functional reach test in indian school going children…. panacea journal of medical sciences, september-december, 2018;8(3):116-122 122 20. thompson m, medley a. forward and lateral sitting functional reach in younger, middle-aged, and older adults. j geriatr phys ther 2007;30(2):43-47. 21. donahoe b, turner d, worrell t. the use of functional reach as a measurement of balance in boys and girls without disabilities 5 to 15years. pediatr phys ther 1994;6:189-193. 22. bartlett d, birmingham t. validity and reliability of a pediatric reach test. pediatr phys ther 2003;15:8492.doi:10.1097/01.pep.0000067885.63909.5c 23. habib z, westcott s. assessment of anthropometric factors on balance tests in children. pediatr phys ther 1998;10:101-109. 24. norris ra, wilder e, norton j. functional reach test in 3to 5 year old children without disabilities. pediatr phys ther 2008;20:47-52.doi:10.1097/pep.0b013e31815ce63f. 25. marwah rk, tandon n, ganie ma, kanwar r, shivprasad c, sabharwal a, et al. nationwide reference data for height, weight and body mass index of indian schoolchildren. ntl med j india 2011;24(5):269-277. 26. chakravarti d. indian anthropometric dimensions for ergonomic design practice. nid 1997. 27. katz k, rosenthal a, yosipovitch z. normal ranges of popliteal angle in children. j pediatr orthop 1992;12(2):229231. 28. ghai op ed., gupta p ed., paul vk. essential pediatrics. 6th edition. delhi: cbs publisher and distributor: 2005. 29. tacar o, dogruyol s, hatipoglu es. lower and upper limb length of urban and rural 7-11 years old turkish school children. anthropol anz 1999;57:269-276. 30. schenkman m, morey m, kuchibhatla m. spinal flexibility and balance control among community-dwelling adults with and without parkinson’s disease. j gerontol a bio sci med sci 2000; 55(8):m441-m445. doi:10.1093/gerona/55.8.m441. 31. haley sm, tada wl, carmichael em. spinal mobility in young children a normative study. phys ther 1986;66:16971703. https://www.ncbi.nlm.nih.gov/pubmed/?term=katz%20k%5bauthor%5d&cauthor=true&cauthor_uid=1552027 https://www.ncbi.nlm.nih.gov/pubmed/?term=rosenthal%20a%5bauthor%5d&cauthor=true&cauthor_uid=1552027 https://www.ncbi.nlm.nih.gov/pubmed/?term=yosipovitch%20z%5bauthor%5d&cauthor=true&cauthor_uid=1552027 https://www.ncbi.nlm.nih.gov/pubmed/1552027 original research article panacea journal of medical sciences, january-april,2016;6(1): 31-33 31 menstrual hygiene: knowledge and practice among adolescent school girls channawar kanchan1,*, prasad vsv2 1consultant paediatrician, 2chief pediatric intensivist and neonatologist, dept. of paediatrics, lotus hospital for women and children, lakadikapul, hyderabad, telangana 500035 *corresponding author e-mail: drkanchanc@yahoo.co.in abstract menstruation is generally considered as unclean in the indian society. isolation of the menstruating girls and restrictions being imposed on them in the family, have reinforced a negative attitude towards this phenomenon. there is a substantial lacuna in the knowledge about menstruation among adolescent girls. good hygienic practices such as the use of sanitary pads and adequate washing of the genital area are essential during menstruation. this cross-sectional, questionnaire-based study was carried out to assess the knowledge and the practices of menstrual hygiene among rural and urban school going adolescent girls in sharda vidyalaya, hyderabad. two hundred and sixty three adolescent girls of age 13-16 years were involved in this study. a pre-designed pre-tested semi-structured questionnaire was prepared for collection of data. only 154 (58.5%) of the participants were aware about menstruation before menarche and the most important sources of the information were grandmothers, and friend, while sisters, mother and teachers were the other sources. majority 226 (85.9%) of the girls were not aware of the cause of the bleeding. there are different types of restrictions which were practiced during menstruation. we concluded that the proper menstrual hygiene and correct perception can protect the women from suffering. the girls should be educated about the facts o f menstruation, physiological implication, about the significance of menstruation and development of secondary sexual characters, and above all about proper hygienic practices and selection of disposable sanitary menstrual absorbent. keywords: adolescent girls, menstruation, menstrual hygiene and practice. introduction adolescents are a major and most developing building block of the world’s population. a culture of silence surrounds the topic of menstruation and related issues; as a result many young girls lack appropriate and sufficient information regarding menstrual hygiene. these social taboos and cultural barriers create various problems for these growing girls. menstruation is still regarded as something unhygienic or dirty in our indian society. the reaction to menstruation depends on awareness and knowledge about the problem. the manner in which a girl learns about menstruation and its associated changes may have an impact on her response to the event of menarche(1). in many parts of the developing countries, menstruation and related issues are supposed to be invisible and silent. this leads to lack of appropriate information regarding menstrual hygiene. this may result in inaccurate and unhealthy behavior during their menstrual period. menstrual hygiene deals with the health issues and requirements of young girls during menstruation or menstrual cycle. attitude of parents and society in discussing the related issues are obstacle to the right kind of information, especially in the rural areas. menstruation is thus considered to be a matter of awkwardness in most cultures. menstrual hygiene is an issue that is inadequately acknowledged and has not received enough attention in the reproductive health and water, sanitation and hygiene (wash) sectors in developing countries including india and its relationship with and impact on achieving many millennium development goals (mdgs) is rarely acknowledged. studies that make this problem visible to the concerned policymakers and inform practical actions are very much warranted. the interplay of socio-economic status, menstrual hygiene practices and rti are noticeable. women having better knowledge regarding menstrual hygiene and safe practices are less vulnerable to rti and its consequences(2). therefore, increased knowledge about menstruation right from early days may escalate safe practices and may help in mitigating the suffering of millions of women. with this background our study was conducted to evaluate the knowledge, beliefs, and source of information regarding menstruation among the adolescent girls of the secondary school and also to identify the status of menstrual hygiene among them. material and methods a cross-sectional, questionnaire-based study among adolescent school students was conducted in sharda vidyalaya in hyderabad in august 2015. two hundred and sixty three adolescent girls of age 13-16 years were involved in this study. a pre-designed pretested semi-structured questionnaire was prepared for data collection. the school authority was contacted and the purpose of the study was explained. after taking consent from the school the study was started. the girls were explained about the rationale of the study and were assured of privacy. consent was obtained verbally from the girls before administering the questionnaire which included questions regarding the knowledge and awareness regarding menstruation, the source of information and practices followed to maintain channawar kanchan et al. menstrual hygiene: knowledge and practice among adolescent school girls panacea journal of medical sciences, january-april,2016;6(1): 31-33 32 menstrual hygiene. the demographic data including family details, parent’s education, occupation, housing conditions, house type, toilet facility, and water supply in the toilet were enquired and documented. the menstrual hygiene questionnaire included questions about the type of absorbent used, its storage place, the use of clean or unclean napkins and the frequencies of changing and cleaning them. the data about personal hygiene included washing and bathing during menstruation, the practice of wearing washed clothes. before filling the questionnaire, they were instructed on how to fill. adequate time was given to read and fill up the questionnaire. the students were asked to drop their sheets in a drop box provided after completion. this was followed by a talk on the normal physiology of menstruation, the importance of maintaining hygiene and safe hygienic practices during menstruation. queries and concerns of the participants were also addressed. data were then compiled in an excel sheet and were analyzed by using epi info™ version 3.5.1 (release date: august 18, 2008). appropriate statistical tests were applied to study the test of significance. results in the present study, 263 adolescent girls of age group 13-18 years of class 810 were included. the study population were mainly hindu (71%), and nuclear family, number of family member being between 5-10, the education of their mothers are mostly secondary. it was evident that only 154 (58.5%) of the participants were aware about menstruation before menarche and the most important sources of the information were grand mothers, and friend, while sisters, mother and teachers were the other sources. majority 226 (85.9%) of the girls were not aware of the cause of the bleeding, only 22 (8.3%) knew about the source of menstrual blood is uterus and 178 (67.6%) knew that it’s a natural phenomenon. the study on the practices during menstruation showed that 240(91.2%) girls used sanitary pads during menstruation, 18 (6.8%) girls used cloth pieces and 5(1.9%) used tampons. out of 263 girls who used sanitary napkins or cloths, 5.3% girls changed it once a day, 17.1% twice a day, 49.1% girls thrice a day, 28.5% girls changed it 4 times a day. 74.1% girls threw the pads in house dustbin and 25.8% girls flushed in toilet. 92% girls thought menstruation to be dirty, 87.8% girls bathed daily during menses. 33.4% girls washed the genitals with only water and 66.5% girls with soap and water. 246 (93.5%) girls washed hands regularly after using washroom. there are different types of restrictions which were practiced during menstruation. among them, 217 (82.5%) girls did not attend any religious activity or visit temples, 46 (17.4%) girls were not allowed to do the household work, 46 (17.4%) girls were not allowed to sleep on the routine bed, 4 (1.5%) girls were not allowed to play outside, and 5 (1.9%) girls were not allowed to attend marriages during menstruation while 14 (5.3%) had food restriction during menstruation. discussion the present study was conducted in 263 adolescent girls of which majority girls (78.7%) were of age group 13-15 years. drakshayani dk et al(3) reported the age of menstruating girls as 14-17 years with maximum (76.3%) number of girls between 14-15 years of age which is in accordance with our findings. though it is desirable to have school teacher or health worker to be the first source of information ensuring that right knowledge has been imparted, it was seen that major source of information in the study was grandmother (41.1%) followed by friends (40.3%) which is also similar to other studies(4-8). it was observed that the most common source of information were mothers which retells the fact that mothers of adolescent girls should be essential part of all programs on adolescent health and especially menstrual hygiene. it was seen that though almost all girls had heard about menstruation, the level of knowledge was poor which is similar to study by shanbhag d et al(9). it was observed in this study that 67.6 % girls’ believed it to be a physiological process, whereas in a similar study, 86.2% believed it to be a physiological process(7). it was very sad to observe in the study, that most of the girls (85.9%) did not know the cause of the menstrual bleeding. only 8.3% of the study girls were aware that menstrual bleeding came from the uterus which is accordance with the similar study(10). the hygiene related practices of women during menstruation are of considerable importance, as they affect their health by increasing their vulnerability to infections, especially infections of the urinary tract and the perineum. studies which were reported from india and other developing countries have highlighted the common practices which have prevailed among the adolescent females(7,11). it was seen in present study that 91.2% used pads and 6.8% used clothes whereas in similar study conducted it was found that 62% girls used clothes while 38% used sanitary pads. the use of pads was higher which was probably due to the fact that availability was high in these areas and also due to influence of television which has increased awareness regarding availability and use of sanitary napkins. other researchers, in their studies, also reported that more than three fourth of the girls used cotton clothes and reused them after washing(12-14). privacy for washing, changing or cleaning purpose is something very important for proper menstrual hygiene. in the study, it was found that 66.5% girls washed the genitals with soap and water, 33.4% with only water. a study which was conducted by another author revealed that only 34.3% of the girls satisfactory cleaned their genitalia (13, 15). soap and water were the commonest materials which were used by 223 girls (57.2%) for cleaning the channawar kanchan et al. menstrual hygiene: knowledge and practice among adolescent school girls panacea journal of medical sciences, january-april,2016;6(1): 31-33 33 external genitalia. in the present study, the commonly practiced methods of disposal of the used absorbent were, house dustbin 74.1%. different restrictions like 217 (82.5%) girls did not attend any religious activity or visit temples, 46 (17.4%) girls were not allowed to do the household work, 46 (17.4%) girls were not allowed to sleep on the routine bed, 4 (1.5%) girls were not allowed to play outside, and 5 (1.9%) girls were not allowed to attend marriages during menstruation while 14 (5.3%) had food restriction during menstruation, possibly due to the different rituals in their communities; the same were practiced by their mothers or other elderly females in the family, due to their ignorance and false perceptions about menstruation. it emphasizes upon developing healthy attitude towards human reproduction and family life among older school students. health professionals should organize educative sessions for parents so that they can be trained to give adequate knowledge on reproductive health problems to their children. conclusion this study was conducted to ascertain knowledge of menstrual hygiene among the adolescent girls. the study revealed that the knowledge on menstruation is poor and the hygiene practiced is often not optimal. we concluded that the proper menstrual hygiene and correct perception can protect the women from suffering. the girls should be educated about the facts of menstruation, physiological implication, about the significance of menstruation and development of secondary sexual characters, and above all about proper hygienic practices and selection of disposable sanitary menstrual absorbent. this can be achieved through educational television programs, compulsory sex education in school curriculum and through school/nurses health personnel. thus the above findings support the need to encourage safe and hygienic practices among adolescent girls and bring them out of traditional beliefs, misconceptions and restriction regarding menstruation. menstrual health is an important part of life cycle approach to women’s health, so it is important for all adolescent girls that they should get a loud and clear messages and services on this issue. conflict of interest: none source of support: nil references 1. rao s, joshi s, kanade a. height velocity, body fat and menarcheal age of indian girls. indian pediatr 1998;35:619-28. 2. wasserheit jn. the significance and scope of reproductive tract infections among third world women. suppl int j gynecol obstet 1989;3:145-68. 3. drakshayani dk, venkata rp. a study on menstrual hygiene among rural adolescent girls. indian j of med sci 1994;48(6):139-43. 4. singh mm, devi r, gupta ss. awareness and health seeking behavior of rural adolescent school girls on menstrual and reproductive health problems. indian j of med sci 1999;53:439-43. 5. nayar p, grover vl, kannan at. awareness and practices of menstruation and pubertal changes amongst unmarried female adolescents in a rural area of east delhi department of community medicine, university college of medical sciences & gtb hospital, dilshad graden, delhi 110095, india, 2007;32(2):156-7. 6. nagar s, aimol kr. knowledge of adolescent girls regarding menstruation in tribal areas of meghalya. stud tribes tribals 2010;8(1):27-30. 7. dasgupta a, sarkar m. menstrual hygiene: how hygienic is the adolescent girl? indian j community med april 2008;33(2):77–80. 8. dube s, sharma k. knowledge, attitude and practices regarding reproductive health among urban and rural girls: a comparative study. ethno med 2012;6(2):85-94. 9. shanbhag d, shilpa r, d’souza n, josephine p, singh j, goud br. perceptions regarding menstruation and practices during menstrual cycles among high school going adolescent girls in resource limited settings around bangalore city, karnataka, india. international j of collaborative research on internal medicine and public health 2012;4(7):1353-62. 10. water aid: is menstrual hygiene and management an issue for adolescent girls? water aid in south asia publication; 2009. 11. el gilany a, badwi k, el. fedawy s. menstrual hygiene among adolescent school girls in mansoura, egypt. reproductive health matters 2005;13(26):147-52. 12. khanna a, goyal rs, bhawsar r. menstrual practices and reproductive problems: a study of adolescent girls in rajasthan. journal of health management 2005;7(1):9197. 13. mudey ab, keshwani n, mudey ga, goyal rc. a cross-sectional study on the awareness regarding safe and hygienic practices amongst school going adolescent girls in the rural areas of wardha district. global journal of health science 2010;2(2):225-31. 14. quazi sz., gaidhane a., singh d. beliefs s and practices regarding menstruation among the adolescent girls of high schools and junior colleges of the rural areas of thane district. journal of dmimsu 2006;2:76. 15. omidwar s, begum k. factors which influence the hygienic practices during menses among girls from south india: a cross sectional study. international journal of collaborative research on internal medicine and public health 2010;2:411-23. editorial doi: 10.18231/2348-7682.2017.0001 panacea journal of medical sciences, january-april,2017;7(1): 1 1 cell free fetal dna (cffdna): an excellent method for early non-invasive prenatal diagnosis sulabha joshi professor & hod, dept. of obstetrics & gynecology, nkp salve institute of medical sciences & research centre, nagpur, maharashtra email: sulabhaajoshi@gmail.com objective of antenatal care is to ensure a normal pregnancy culminating in delivery of healthy baby and healthy mother. a quality antenatal care aims at identification and screening of high risk cases and prevention, early detection and timely management of complications. prenatal screening and diagnosis is routinely offered in antenatal care and is considered to be important in antenatal counseling about the continuation of pregnancies affected by chromosomal or genetic disorders. prenatal testing is now part of established obstetric practice in countries where facilities are available. it has two categories, prenatal screening which is done in all antenatal women to determine risk of having down syndrome and prenatal diagnosis which is done in high risk cases to provide a definitive diagnosis of a particular disorder. diagnostic testing is done by chorionic villus sampling between 11 to 14 weeks gestation or amniocentesis after 15 weeks. this approach to obtaining fetal dna currently provides the gold standard test for prenatal diagnosis. however, these invasive procedures carry a risk of miscarriage of around 1%.(1) to reduce this risk of miscarriage and allow earlier testing search for a reliable and convenient method for non-invasive prenatal diagnosis has long been going on. some researchers have investigated using fetal cells obtained from the cervical mucus(2) but most research has focused on detection of genetic material from the fetus present in the maternal circulation. cell-free fetal dna in maternal blood represents extracellular dna, originating from trophoblastic cells. it is probably a product of apoptosis (programmed cell death), resulting in fragmentation and ejection of chromosomal dna from the cell.(3) however, majority of cell-free dna in maternal blood is of maternal origin with cell-free fetal dna representing only 3% to 6% of the total cell-free circulating dna. cell free fetal dna consists predominantly of short dna fragments rather than whole chromosomes. in the maternal blood fetal dna can be detected from the 4th week of gestation and the concentration increases with gestational age.(4-5) as against fetal cells, cffdna is rapidly cleared from the maternal circulation with a half life of 16 min and is undetectable 2 hour after delivery.(6) although the majority of work to date has focused on cffdna, both types of cffna, i.e. dna and rna, could potentially be used for the nipd of specific genetic characteristics of the fetus. clinical applications of cffdna analysis in prenatal screening include aneuploidy, rh d status, fetal sex determination, single gene disorder, and diseases associated with abnormal placentation. ethical issues as the test is simple and can be used very early without any risk to the mother, cffdna can be used for fetal sex determination and can be misused in a country like india (because of the wide preference of a male child). in near future, this technology may be applied to detect other genetic traits also present in the mother, for e.g. brca1/2 mutations in breast cancer, which may be possibly diagnosed prenatally using cffdna. the addition of tests for increased possibility of developing adult-onset diseases is ethically more risky than testing for inherited or congenital disorders, because there is a possibility that the disorder may never develop. in conclusion, we can say that early nipd of the genetic status of a fetus can be detected from 4 weeks gestation by analysis of cffdna in maternal circulation which is highly specific and sensitive in detection of aneuploidy, rh status, single gene disorder, and sex linked diseases. high levels of cffdna can predict disorders like preeclampsia and measures to prevent complications can be initiated early. further research in analysis of cffdna will be useful in many diagnostic areas. references 1. mujezinovic f, alfirevic z. procedure-related complications of amniocentesis and chorionic villous sampling: a systematic review. obstet gynecol 2007;110(3):687–694. 2. fejgin md, diukman r, cotton y, weinstein g, amiel a. fetal cells in the uterine cervix: a source for early non-invasive prenatal diagnosis. prenat diagn 2001;21:619–621. 3. jahr s, hentze h, englisch s, hardt d, fackelmayer fo, hesch rd, et al. dna fragments in the blood plasma of cancer patients: quantitations and evidence for their origin from apoptotic and necrotic cells. cancer res 2001;61:1659–1665. 4. illanes s, denbow m, kailasam c, finning k, soothill pw. early detection of cell-free fetal dna in maternal plasma. early hum dev 2007;83:563–566. 5. lo ymd, tein msc, lau tk, haines cj, leung tn, poon pmk, et al. quantitative analysis of fetal dna in maternal plasma and serum: implications for noninvasive prenatal diagnosis. am j hum genet 1998b;62:768–775. 6. lo ymd, zhang j, leung tn, lau tk, chang amz, hjelm nm. rapid clearance of fetal dna from maternal plasma. am j hum genet 1999c;64:218–224. original research article doi: 10.18231/2348-7682.2017.0006 panacea journal of medical sciences, january-april,2017;7(1): 19-21 19 a comparative study of sensitivity of sputum microscopy by direct method versus sodium hypochlorite concentration method at rntcp centre kalpana date1,*, neena nagdeo2, meenal kulkarni3 1,2,associate professor, dept of microbiology, 3associate professor, dept of community medicine, nkp salve institute of medical sciences & research institute & lata mangeshkar hospital, nagpur, maharashtra *corresponding author: email: datekalpana@gmail.com abstract in revised national tuberculosis control program (rntcp), microscopic examination of sputum for afb plays an important role in the initial diagnosis of tuberculosis. decontamination and liquefaction with by 5% sodium hypochlorite increases sensitivity and safety for handling specimen. in this prospective hospital based cross sectional analytical study, patients of all ages and either sex coming to rntcp centre were included according to rntcp criteria. from each patient, two samples of sputum were collected one spot and one morning. one set of smears was prepared by rntcp guidelines and remaining samples were concentrated by using 5% naocl, followed by centrifugation and staining with zn stain. both set of smears were observed by two observers to remove observer’s bias. a total of 882 patients were included in the study with 577 (65%) males and 305 (35%) females. a total of 172(19.5%) patients were positive by rntcp method whereas 201(22.79%) patients were positive by concentration method diagnosing 29 additional patients. this constitutes a rise of 3.29%. this constitute 16.86% rise in case detection over rntcp method. there is a rise in smear positive cases after concentration with 5% sodium hypochlorite solution. the bleach method has advantage over routine rntcp method as it is simple, does not require any additional expertise, is safe, reagents are also affordable and easily available and could diagnose additional cases. keywords: tuberculosis, sodium hypochlorite, sputum microscopy. introduction tuberculosis (tb) remains a worldwide public health problem despite the fact that the causative organism was discovered more than 100 years ago.(1) the major objective of the tb control programs is to identify and treat the patients with infectious pulmonary tuberculosis, the diagnosis of which relies on a bacteriological examination of the sputum. direct microscopy with ziehl neelsen staining is still most widely used and it is specific, fast and cheap method. the program has approved led microscopes but these are not provided at every centre. the culture of mycobacterium is the reference method for the detection of the tubercle bacilli, but it is prohibitively slow and it requires special safety procedures in laboratories.(2) many automated culture systems and molecular techniques have been developed which require less turnaround time but are costly. in revised national tuberculosis control program (rntcp), microscopic examination of sputum for afb plays an important role in the initial diagnosis of tuberculosis. the microscopic examination requires 10(4) bacilli per milliliter of sputum in order to be detected on smear. considering the amount of sputum material that is examined in oil immersion field, chances of missing the organism are high thus reducing the sensitivity. much of the transmission of tb can occur even before the concentration in sputum reaches a critical level when it is diagnosed. a negative smear does not exclude the diagnosis of tuberculosis, as about 55% of pulmonary tuberculosis cases worldwide harbors low bacillary load. it has also been established that sputum smear microscopy is less sensitive in hiv – tb co infection where sputum smear tends to be negative.(3,4,5) the concentrations of 2-5% of sodium hypochlorite (naocl) digest the sputum products and they inactivate the mycobacteria without altering their structures, so that even when they are killed, they can still be stained and observed. this provides a greater security for laboratory use. further centrifugation or sedimentation concentrates the acid fast bacilli (afb) in the mixture and it increases the rate of the positivity.(6) with this background an operational research was planned to look for increase in sensitivity of sputum smear microscopy by concentration after pre-treatment with sodium hypochlorite over routine rntcp method. materials and methods this prospective hospital based cross sectional analytical study was carried out as an operational research in the department of microbiology, nkpsims & rc, nagpur after obtaining permission from institutional ethics committee. patients of all ages and either sex coming to rntcp centre were included according to rntcp criteria, having:  cough for two weeks or more duration  known contacts of sputum smear positives irrespective of duration of cough  extra pulmonary tb irrespective of duration of cough. after obtaining informed consent, two sputum samples (1spot and 1 morning sample) from each kalpana date et al. a comparative study of sensitivity of sputum microscopy by direct method…. panacea journal of medical sciences, january-april,2017;7(1): 19-21 20 patient were collected in a clean, wide mouth labeled container. two sets of sputum smears were prepared from each sample. for the first set the mucopurulent portion of the sputum was taken on a new, clean and grease free glass slide and the smears were heat fixed and stained by modified zn staining using 25% h2so4 as a decolourizer. equal volume of 5% sodium hypochlorite was added to the test tube and kept at room temperature for half an hour. the test tube was shaken intermittently after which approximately 8 ml of distilled water was added to the test tube and it was centrifuged at 3000 g for 15 min. the supernatant was carefully discarded and smears prepared from the sediments.(7) the smears were heat fixed and stained similarly. to remove observer’s bias slides prepared by both the methods were observed by two experienced microbiologist separately by bright field microscopy and graded according to the rntcp guidelines. in view of potential aerosol formation during manipulation of sputum samples for second set of smears, bio-safety cabinet was used. all the data was managed in microsoft excel and statistical analysis was done using epi-info. pearson’s chi-square test was used for comparative evaluation between two groups. results a total of 882 patients were included in the study with 577 males (65.42%) and 305 females (34.58%), a ratio of 1.89. total samples collected and processed from 882 patients were 1764. from each patient two samples were collected one spot and one morning sample. of the 882 patients, 172 (19.5%) were positive by routine method employed by rntcp and 201(22.79%) were found positive by sodium hypochlorite concentration method. this constitutes an increase of 3.29% over routine method (p= 0.0908) (table 1 and fig. 1). these additional 29 cases diagnosed by hypochlorite concentration method constituted 16.86% rises in case detection when compared to rntcp method. thus concentration method is found to be more sensitive. another advantage reported by both the observers was clear fields with less debris in smears processed by sodium hypochlorite concentration method thus making it less strenuous for the observers. table 1: comparative evaluation of sodium hypochlorite concentration method over routine rntcp method positive cases negative cases total sodium hypochlorite concentration method 201 681 882 chi square value=2.859 rntcp method 172 710 882 p=0.0908 total 373 1391 1764 fig. 1: increase in number of cases detected by conc. method discussion sputum smear microscopy is still the backbone for diagnosis of pulmonary tuberculosis. it is rapid, inexpensive and highly specific method for detection of afb in sputum specimen. however the disadvantage is its low sensitivity. there are several methods that can be used to improve sensitivity, but their applicability in a national program and in resource limited settings are limited. bleach processing of sputum smears prior to microscopy may be a cheap and effective way to improve on the sensitivity of the direct smear.(8) pretreatment with sodium hypochlorite is not labour intensive and can be easily carried out by the existing technical team with only centrifuge machine as additional requirement. sodium hypochlorite increases sensitivity of test and makes sample safer for handling. bleach itself is inexpensive and readily available almost everywhere. the half-life of naocl is about 12 months; it is likely to be reduced by 1 month if the bottle is opened and by about 3 months if the ambient temperature is high (around 300c).(9) this has to be kept in mind. in this study additional 29 patients were diagnosed using concentration method which otherwise would not have been diagnosed by rntcp method and would have gone undetected as open cases. this constitute 16.86% rise in case detection over rntcp method. further 25 out of 29 (86.20%) of these cases were diagnosed after concentration from a spot sample. only 4 cases needed the morning sample. at least the samples which are negative by routine rntcp method can be retested by sodium hypochlorite concentration technique. if centrifuge is available results can be given on the same day as the procedure is not lengthy. conclusion there is significant rise in smear positive cases after concentration with 5% sodium hypochlorite solution. considering its low cost, decontaminating and liquefaction properties with better sensitivity, this kalpana date et al. a comparative study of sensitivity of sputum microscopy by direct method…. panacea journal of medical sciences, january-april,2017;7(1): 19-21 21 method is safe and can be of vital importance; at least for smear negative cases.can the sample size be reduced to one with this concentration method which is also safe for laboratory workers? we need large scale metacentric studies. references 1. park k. epidemiology of communicable disease; park’s textbook of preventive and social medicine. 21st ed. jabalpur, india: m/s banarasidas bhanot publishers; 2011;164-65. 2. gebre n, karlsson u, jönsson g, macaden r, wolde a, assefa a, et al. improved microscopical diagnosis of pulmonary tuberculosis in developing countries. trans r soc trop med hyg. 1995 mar-apr;89(2):191-93. 3. verma sk, mahajan v. hiv-tuberculosis co-infection. int j pulmonary med2008;10:1. 4. rntcpan overview. a manual for sensitization of medical college faculty.1st ed. mumbai: maharashtra state tb control society; 2004. jul. 5. saxena s, mathur m, talwar v. detection of tubercle bacilli in sputum: application of sodium hypochlorite concentration method. j comm dis2001;33:241–4. 6. ongkhammy s, amstutz v, barennes h, buisson y. the bleach method improves the detection of pulmonary tuberculosis in laos. int j tuberc lung dis. 2009 sep;13(9):1124-9. 7. cheesbrough, m. (1985) medical laboratory manual for tropical countries. vol 11, microbiology 105, 294-297. uni press, cambridge. 8. srikanth p, kamesh s, daley p. bleach optimization of sputum smear microscopy for pulmonary tuberculosis. indian journal of tuberculosis 2009 oct;56(4):174-84. 9. ängeby k. a. k., hoffner s. e, diwan v. k. should the ‘bleach microscopy method’ be recommended for improved case detection of tuberculosis? literature review and key person analysis int j tuberc lung dis 2004;8(7):806–815. 429 too many requests you have sent too many requests in a given amount of time. original research article panacea journal of medical sciences, january-april,2016;6(1): 26-30 26 labour admission test (lat) as a predictor of intrapartum fetal distress vijay nikita1,*, kumare bhavna2 1,2lecturer, department of obstetrics & gynaecology, nkpsims & rc, digdoh hills, hingna road, nagpur440019. *corresponding author e-mail: nikitarvijay@gmail.com abstract labour is the most crucial period for the foetus to see whether it can sustain hypoxia due to stress of uterine contraction. fetal surveillance during labour is a demanding and arduous task. however, the wellbeing of the foetus in labour is one of the cardinal concerns in obstetric care. the present study was carried out to determine the effectiveness of labour admission test in case of detecting fetal hypoxia in labour and to correlate the findings of the test with perinatal outcome irrespective of their antenatal risk status. a prospective observational study was undertaken in 100 pregnant women with 37 completed weeks of pregnancy in early stage of labour with cephalic presentation. data generated was analysed statistically by nonparametric chisquare test with spss package version10. statistical significance was calculated between reactive and nonreactive group with pvalue of < 0.05. the results of labour admission test were reactive in 77%, equivocal in 20% and ominous in 3%. women with reactive lat were observed low risk of developing intrapartum fetal distress (5.2%) as compared to 40% of equivocal and 66.7% of ominous group. the incidence of moderate to thick meconium stained liquor was significantly high in ominous (33.3%) and equivocal group (25%) as compared to reactive group (3.9%). the admission in neonatal intensive care unit (nicu) was significantly high in ominous test group (66.7%) as compared to those with equivocal (15%) and reactive (1.3%) test groups. neonatal mortality was also observed in one (33.3%) baby from ominous test group. operative delivery for fetal distress was observed in 3.9% of reactive group, in 40% of equivocal group and in 66.7% of ominous group. the labour admission test is a simple, suitable and economical viable test for the detection of intrapartum fetal distress in case of next few hours of labour in low resource countries where pregnant women presents first time labour or where the facilities of scalp ph is not available or the procedure is not done in labour wards. keywords: cardiograph, fetal distress, foetal hypoxia, labour admission test, perinatal outcome. introduction labour is the most crucial period for the foetus to see whether it can sustain hypoxia due to stress of uterine contractions. fetal surveillance during labour is a demanding and arduous task. however, the wellbeing of the foetus in labour is one of the cardinal concerns in obstetric care. additionally, there are no reliable auscultatory indicators for fetal distress except for extreme changes in heart rate of fetus; the concept of intra-partum surveillance with electronic fetal heart monitor came into picture to detect fetal hypoxia at the earliest before permanent neurological damage occurs. the objective of this is to reduce perinatal mortality and morbidity(1). the labour admission test (lat), first described by ingemarsson is a short strip (20 minutes) of cardiotocography (ctg) carried out when a woman is admitted in labour with a low risk pregnancy(1-2). the aim of the study is to assess fetal wellbeing in early labour and identify those foetuses that may be already hypoxic or may not withstand the stress of uterine contraction(1). such foetuses may require immediate delivery or continuous foetus heart rate monitoring using ctg throughout labour in order to prevent adverse perinatal outcome(1). electronic monitoring of fhr in labour is a routine practice in developed countries but economic constraints; inadequate antenatal care in developing countries limits its routine use. hence, selection of foetuses that would require continuous monitoring becomes necessary in such settings(3). the purpose of the study is to assess the predictive value of lat in detecting fetal hypoxia at the time of labour admission and correlates its result with perinatal outcome in obstetric population irrespective of their antenatal risk status. material and methods the study was approved by the institutional ethics committee. this study was conducted at labour room complex, department of obstetrics and gynaecology at nkpsims & lmh, nagpur during november 2013 to april 2014. we included the 100 cases randomly both high and low risk who had completed gestational age 37 weeks with cephalic presentation in early stage of labour. pregnant women with congenital malformed baby, multiple foetus, abnormal lie and presentation, previous scar, cord prolapse and abruption placentae were excluded from the study. a written informed consent from the patient was taken who included in the present study. all women were subjected to an admission ctg, which included a 20 minute recording of fhr and uterine contractions. on admission, the details of women's and their history were documented including age, parity antenatal care, menstrual, obstetric, and medical history. before subjecting the patient for lat, general physical, per abdominal and vaginal examination were performed to determine the vijay nikita et al. labour admission test (lat) as a predictor of intrapartum fetal distress panacea journal of medical sciences, january-april,2016;6(1): 26-30 27 stage of labour. fhr tracing were categorized according to nice clinical guidelines 2007 as reactive, equivocal or ominous(4). after the admission test, monitoring of patients during labour was done intermittently by auscultation for one minute, every 30 minute in first stage of labour and every 5 minutes in second stage of labour post contraction in reactive group. cases with equivocal group were put on continuous ctg monitoring. delivery was hastened by operative or instrumental intervention depending of stage of labour in ominous group. the liquor colour and apgar score of each neonate was determined after delivery. outcome measure: foetus/neonate that showed one of the following was considered as to be distressed: 1. ominous fhr leading to c-section / operative delivery. 2. presence of moderate –thick meconium stained liquor (msl). 3. apgar score at 5min<7. 4. admission into neonatal intensive care unit (nicu). 5. incidence of intrapartum/ neonatal mortality. statistical analysis: data obtained from the study groups were analyzed and statistically verified by nonparametric chi-square test with the use of computer software spss version10. statistical significance was calculated between reactive and nonreactive group where ever possible. a p-value of < 0.05 was considered as the definition of statistical significance. results majority of the pregnant women were between the age group of 21-30 years (75%) and primigravida (62%). of the total cases, 38 were high risk and 62 were low risk pregnancies. only 5.2% of women with reactive admission test (77%) showed evidence of fetal distress. of the 20 women who had equivocal trace, 8(40%) babies had fetal distress, whereas 66.7% babies with ominous admission had fetal distress (table 1). table 1: results of admission test and incidence of fetal distress results at result foetal distress n % n % reactive 77 77 4 5.2 equivocal 20 20 8 40 ominous 3 3 2 66.7 (data are expressed in number (n) and percentage (%), p value <0.001) these results are comparable to various other studies (table 2). it is can be observed from table 1 and table 2 that numbers of fetal distress significantly increase with worsening of admission test (p <0.001). table 2: comparison of various studies for incidence of foetal distres study no incidence of fetal distress (%) reactive equivocal ominous rahman et al. (7) 176 7 39 85 nagure et al. (8) 160 11.3 39.1 85.7 kansal et al. (9) 500 16 62.9 97.3 hegde at al.(10) 200 3.6 15 75 present study 100 5.2 40 66.7 33.3% patients with ominous test had moderate to thick meconium, compared to 25% and 3.9% in equivocal and reactive groups (p< 0.001). 66.67% of babies born to patients with ominous lat had nicu admission compared to 15% and 1.3% of those babies born to patients with equivocal and reactive at respectively( p<0.001). there was no intrapartum death in babies born to mothers in reactive and equivocal groups, where as one baby (33.3%) died in ominous group due to birth asphyxia (table 3). table 3: relationship between fetal/neonatal outcomes and admission test parameters reactive (n = 77) equivocal ( n = 20) ominous (n = 3) mod-thick msl n 3 3.9% n 5 25% n 1 33.33% apgar score at min<7 1 1.3% 3 15% 2 66.67% nicu admission 1 1.3% 3 15% 2 66.67% neonatal death 0 0 1 33.33% vijay nikita et al. labour admission test (lat) as a predictor of intrapartum fetal distress panacea journal of medical sciences, january-april,2016;6(1): 26-30 28 spontaneous vaginal delivery was high 89.6% in reactive group women. 11 women in equivocal and 3 women in ominous group had instrumental/operative delivery and in majority of these patients indication was fetal distress. incidence of operative delivery significantly increases as the admission test result worsens (table 4). table 4: type of delivery with the results of lat and incidence of fetal distress type of delivery reactive (n=77) equivocal (n=20) ominous (n=3) spontaneous vaginal delivery with fetal distress without fetal distress 69 (89.6%) 1 (1.4%) 68 (98.6%) 9 (45%) 1(11.1%) 8 (88.9%) forceps/ventous with fetal distress without fetal distress 2 (2.6%) 1 (50%) 1 (50%) 3 (15%) 2 (66.7%) 1(33.3%) 1 (33.3%) 1 (100%) lscs with fetal distress without fetal distress 6 (7.8%) 2 (33.3%) 4 (66.7%) 8 (40%) 5 (62.5%) 3 (37.5%) 2 (66.7%) 2 (100%) (data are expressed in number (n) and percentage (%) interval between at and detection of fetal distress was 6-9 hrs in reactive and equivocal groups and 3 hrs in ominous group (table 5). table 5: interval between at and detection of foetal distress time (hours) test 3 6 9 total reactive (n= 77) 1 3 4 equivocal (n= 20) 2 6 8 ominous (n= 3) 2 2 at has high specificity and low false positivity and comparable to other studies (table 6). table 6: sensitivity and specificity of at parameters present study rahman et al. (2007-09) ingemarsson et al. (1984-85) sensitivity 73.6% 63% 23.5% specificity 94% 91% 99.4% ppv 60.8% 55% 40.0% npv 97% 93% 98.7% discussion even though labour and delivery is regarded as a normal physiological process, the intrapartum complications can arise very quickly and unexpectedly in both high and low risk pregnancy. intermittent auscultation and continuous electronic monitoring are considered acceptable methods of intrapartum surveillance in both low and high risk pregnancies. it is also recommended that a 1 to 1 nurse-patient ratio be used if auscultation is employed. economic constraints, busy labour rooms with lesser staff and few monitors in developing countries limits routine and continuous electronic monitoring of fetal heart in labour(5). the baseline fetal heart rate (fhr) can be measured with intermittent auscultation while other features like baseline variability, acceleration and deceleration(5-6) are difficult to measure leading to late diagnosis of fetal distress and acidosis. lat helps to identify those foetuses that may be already be hypoxic or may not withstand the stress of uterine contractions which can expose them to hypoxia in labour(1). so, lat can be used as a screening tool in early labour to identify unsuspected cases of fetal jeopardy that may benefit with continuous electronic fetal heart monitoring during labour(1). the present study showed evidence of fetal distress in 5.2% babies from reactive group, 40% from equivocal group and 66.7% from ominous group (table 1). similar observations were demonstrated by rahman et al(7), nagure et al(8), kansal et al(9) and hegde et al(10) studies as shown in table 2. our present study and most of the studies(7-10) confirms that labour admission test with ominous, followed by equivocal result has higher risk of intrapartum fetal distress as compared to reactive result and these particular group of women requires continuous electronic fetal heart monitoring. as per criticism of various authors, the policy of efm states that it lead to increase in intervention rates with no evidence of fetal benefits(11). antepartum risk factors are not accurate as predictors of fetal outcome vijay nikita et al. labour admission test (lat) as a predictor of intrapartum fetal distress panacea journal of medical sciences, january-april,2016;6(1): 26-30 29 as fetal heart rate changes and fetal acidosis might occur with some frequency in high and low risk groups(11). in the present study, 100 pregnant women were admitted in labour with 38% of the cases in high risk group and 62% in low risk group. the high risk factors were pregnancy induced hypertension (pih), premature rupture of membrane (prom), eclampsia, severe anaemia, intrauterine growth restriction (iugr), and bad obstetrics history (boh). the results can be compared with the findings of kamal buckshee et al study(12), (32% in high risk and 68% in low risk) and dwarakanath et al study(11) (40.5% in high risk and 59.5% in low risk group). it has been recognized that meconium passage is a manifestation of normally maturing gastrointestinal tract or is the result of vagal stimulation from umbilical cord compression. but in global sense, meconium passage is still considered as a sign of fetal distress occurring due to fetal hypoxia and is considered a marker of adverse perinatal outcome. however, neonatal morbidity and mortality is primarily the result of thick tenacious meconium rather than thin meconium. in present study, the incidence of moderate to thick meconium stained liquor was significantly high in ominous group (33.3%) as compared to equivocal (25%) and reactive group (3.9%). we found that the incidence of admission of newborn in intensive care unit was highest in ominous at group (66.6%) compared to equivocal (15%) and reactive group (1.3%). this finding is in agreement with studies conducted by rahman et al(7), nagure et al(8). operative delivery for fetal distress was required only in 3.9% patients in reactive group, 40% in the equivocal group and 66.7% in the ominous group. in ominous group lscs for fetal distress done in ingemarsson study(2) 20% cases were taken, in dwarakanath et al(11) lscs for fetal distress done in 35%, 50% in buckshee et al study(12), and in rose jophy et al study(13) lscs done in 33.33% for lscs for fetal distress. the interval between lat and development of fetal distress in the present study was 6-9 hours in reactive and equivocal group and 3 hours in ominous group. shakira et al(14) have shown this interval to be 6 hours in reactive group, while ingemarsson et al(2) and kulkarni et al(15) showed this interval to be 6 hours and 5 hours respectively. kushtagi et al(16) have shown this interval to be 6 hours after reactive lat in low risk and 3 hours in high risk mothers. most of the foetuses developed fetal distress within 6 hours in the study by gurang et al(17). so it can be speculated that lat has some prognostic value for the first few hours if admission to detect fetal hypoxia. lat cannot be expected to predict fetal distress after several hours of labour with other influential factors like prolonged labour, cord problems which may become functional as the labour progresses. so in cases where admission to delivery interval is more than 6-8 hours, intrapartum ctg should be repeated to detect fetal distress. table 6 shows that at has high 94% specificity and low false positivity. rahman et al(5) reported 95% specificity and ingemarsson et al(2) also reported a very high specificity of test (99%). the high specificity of the admission test means that a normal test accurately excludes adverse fetal status at the time of testing. conclusion the labour admission test is a simple, convenient, non-invasive and economical screening test in high as well as low risk pregnancies. it can be used for the detection of intrapartum fetal distress during early hours of labour in low resource countries. where pregnant women present in labour for the first time or where the facilities of scalp ph is not available in labour wards. the labour admission test cannot predict the development of any acute asphyxia insult during the labour. the high specificity of the test helps to screen hypoxic foetuses in a busy labour ward and thus decreases morbidity and mortality. conflict of interest: none source of support: nil references 1. talaulikar vs, arulkumaran s. labour admission test. intl j infer fetal med 2011;2(3):89-95. 2. ingemarsson i, arulkumaran s, ingemarsson e, tambyraja rl, ratnam ss. admission test: a screening test for fetal distress in labour. obstet gynecol 1986;68(6):800-806. 3. rahman h, renjhen p, dutta s, kar s. admission cardiotocography; its role in predicting fetal outcome in high risk obstetric patients. australas med j 2012;5(10);522-7. 4. national institute for health and clinical excellence, nice clinical guideline 55-intrapartum care, september 2007:44-5. 5. rahman h, renjhen p, dutta s. reliability of admission cardiography in predicting adverse perinatal outcome in low risk obstetric population. indian obstetrics & gynaecology journal for basic & clin research 2012;2(4):6-10. 6. gibb d, arulkumaran s. the admission test: clinical scenarios fetal monitoring in practice, oxford; boston: butterworth-heinemann; 1997;67-72. 7. rahman h, renjhen p, dutta s. reliability of admission cardiotocography for intrapartum monitoring in low resource setting. niger med j 2012;53(3):145-9. 8. nagure a, umashankar m, dharmavijay n, mahedarakshan s. admission cardiotocography: its role in predicting foetal outcome in high–risk obstetric patient. indian journal of basic and medical research 2013;3(1):156-164. 9. kansal r, panjeta p, mahendra r, bansal i, goel g, agrawal n. to study the association between labour admission test and mode of delivery. int j pharm med res 2014;2(4):109-112. 10. hegde a, kore s, srikrishna s, ambiye vr, vaidya pr. admission test: screening for prediction of fetal outcome in labour. j obstet gynecol india 2001;51(2):35-8. vijay nikita et al. labour admission test (lat) as a predictor of intrapartum fetal distress panacea journal of medical sciences, january-april,2016;6(1): 26-30 30 11. dwarakanath l, laxmikantha g, chaitra sk. efficacy of admission cardiography (admission test) to predict obstetric outcome. journal of evolution of medical and dental sciences 2013;2(5):418-23. 12. buckshee k, deka d, padmaja v. admission test as predictor of fetal outcome. j obstet gynecol india 1999;49(2);36-7. 13. jophy r, thomas a, jairaj p. admission test as a screening procedure for perinatal outcome. j obstet gynecol india 2002;52(5);26-9. 14. shakira p, haleema h. effectiveness of admission test. j dow univ health sci 2007;1(1):20-25. 15. kulkarni aa, shroti an. admission test a predictive test for fetal distress in high risk labor. j obstet gyneacol res 1998;24:255-9. 16. kushtagi p, naragonis s. labour admission test: an effective risk screening tool. j indian med assoc 2002;100:234-6. 17. gurung g, rana a, giri k. detection of intrapartum fetal hypoxia using admission test. n j obstet gynaecol 2006;1(2):10-13. original research article doi: 10.18231/2348-7682.2016.0006 panacea journal of medical sciences, september-december,2016;6(3): 138-141 138 metabolic syndrome and its correlates in type 2 diabetes mellitus shilpa aniruddha deoke1,*, raveendra madhav kshirsagar2 1associate professor, 2lecturer, dept. of medicine, nkp salve institute of medical sciences, nagpur *corresponding author: email: dr.shilpa_deoke@rediffmail.com abstract insulin resistance and/or diabetes are an integral component of metabolic syndrome. diabetes with metabolic syndrome is associated with an increased risk for cardiovascular morbidity and mortality. concurrence of the two poses an increased risk of diabetic microvascular complications; though few studies have not shown a positive correlation. hence the study was carried out to investigate the association between the two entities. this hospital based cross-sectional study was carried out at a tertiary care centre. consecutive type 2diabetics meeting the inclusion criteria were included in the study. detail history, clinical examination (anthropometry, screening for diabetic complications) and laboratorial investigations were done in all study subjects. data was analyzed using chi square and student’s ‘t’ test. total 59 type 2 diabetic subjects were included in the study. 86.44% patients had metabolic syndrome. significantly more patients with ms had coronary heart disease (p=0.0011), whereas the microvascular complications were not significantly different in the two groups (p>0.05). 86.44% diabetic subjects amongst the study group had ms. presence of ms in type 2diabetes is a risk indicator of coronary heart disease. chronic microvascular complications occur in diabetics irrespective of the presence of ms. keywords: type 2 diabetes, metabolic syndrome, complications. introduction the metabolic syndrome (ms) is a distinct pathobiological entity characterized by insulin resistance, hypertension, atherogenic dyslipidemia (high triglycerides and/or low hdl cholesterol) and central obesity. since the time it was first described, various definitions have been proposed and revised from time to time.(1-3) insulin resistance/hyperinsulinemia remains the core biologic entity in all the definitions.(4) mswith or without diabetes is a predictor of coronary heart disease (chd); the simultaneous presence of both the entities predisposes the individual for increased chd riskand premature mortality.(5-7) furthermore, presence of ms in diabetic patients is a risk indicator of chronic microvascular complications.(5-6,8-10) there are, however few studies which have shown a negative association between presence of ms and microvascular complications in diabetics.(11-12) thus detection of ms in type 2 diabetes can be used as a simple, safe and non-invasive tool to predict chd and/or microvascular complications. hence the present study was undertaken to determine the rate of occurrence of ms in type 2 diabetes and to investigate the association of ms with the various complications in diabetes. material and methods the present study was a hospital based crosssectional study carried out at a tertiary care centre, initiated after approval by the institutional ethics committee. consecutive type 2 diabetic subjects willing to participate in the study were included in the study after informed consent. detailed history and clinical examination was done in all the study subjects. patients already receiving lipid lowering drugs and unwilling to participate were excluded. patients with clinical suspicion of hypothyroidism were also excluded. the various parameters studied were duration of diabetes, weight, height, bmi, waist circumference, waist: hip ratio, blood pressure, hba1c, fasting lipid profile, fundus examination and urine for proteinuria. weight (in kg) was recorded in light clothes without shoes, waist circumference was measured mid-way between the lower costal margin and, hip circumference was measured as the greatest distance at the hip. hypertension was defined as blood pressure more than 130/85 mm hg or already on treatment of hypertension. waist circumference ≥90 cm in males and ≥ 80 cm in females; whr ≥0.90 in males and≥0.85 in females was considered abnormal. fasting and post meal:-done by god/pod method (with the kit manufactured by bio in-vitro diagnostic pvt. ltd. fasting lipid profile was done in all subjects after an overnight fast of 8-10 hours. hdl cholesterol and hdl-cholesterol sub fractions were measured by serial precipitation method of (nilson and ekiman, 1977) using dextran sulphate and magnesium chloride. triglyceride levels were measured by gpo-pop method. all subjects were screened for chd, diabetic retinopathy, diabetic nephropathy and diabetic neuropathy. chd was diagnosed based on history of chest pain and/or ecg changes suggestive of ischemia/ infarction. fundus examination was done in all patients by a trained ophthalmologist to detect proliferative and /or non-proliferative diabetic retinopathy. neuropathy was defined as presence of clinical symptoms and signs of neuropathy (hyposthesia/anesthesia/absent ankle shilpa aniruddha deoke et al. metabolic syndrome and its correlates in type 2 diabetes mellitus panacea journal of medical sciences, september-december,2016;6(3): 138-141 139 jerks). nephropathy was diagnosed by doing urine analysis by dipsticks. ms was diagnosed according to idf criteria.(3)since all the patients were diabetics, ms was diagnosed if they had any two of the following – increased waist circumference (> 90 cm in males, >80 cm in females), hypertension (>130/85 mm of hg), increased triglycerides (>150 mg)and reduced hdl cholesterol (< 40 in males, <50 in females). data was analyzed using chi square and student’s ‘t’ test. results total 59 diabetic subjects meeting the inclusion criteria were included in the study. there were 33 males and 26females; the male: female ratio was 1.27:1. maximum (69.49%) subjects were in the age group 5069 years, irrespective of the gender (table 1). table 1: age and gender distribution of study subjects age(years) gender (n=59) total (n/%) female male <40 0 1 1(1.69) 40-49 5 6 11(18.64) 50-59 12 10 22(37.29) 60-69 7 12 19(32.20) ≥70 2 4 6 (10.17) total 26 33 59(100) 51 (86.44%) of the 59 subjects had ms. the proportion of subjects with ms increased upto 60 years after which a decline in the number was seen (table 2). the duration of diabetes in the study group ranged from newly detected diabetics upto 15 years. none of the subjects had duration more than 15 years. an attempt was made to compare the presence of ms with the duration of diabetes and it was found that the proportion increased with an increase in the duration of diabetes (76.67%, 90.91% and 100% patients with duration less than 5, 5-10 and more than 10 years respectively) (table 3). table 2: distribution of study subjects according to presence of ms age (years) ms (n=59) absent (n/%) present (n/%) <40 (n=1) 1(1.69) 0(0) 40-49 (n=11) 2(3.39) 9(15.25) 50-59 (n=22) 3(5.08) 19(32.20) 60-69 (n=19) 1(1.69) 18(30.51) ≥70 (n=6) 1(1.69) 5(8.47) total () 8(13.56) 51(86.44) table 3: distribution of diabetic subjects with ms according to duration of diabetes dm duration (years) ms absent (n/%) present (n/%) 0-5 (n=30) 7(23.3) 23(76.67) 5.1-1 (n=11) 1(9.09) 10(90.91) 10.1-15 (n=4) 0(0) 4(100) total (n=59) 8(100) 51(100) on studying the various characteristics of subjects with and without ms, significant differences were found only for systolic blood pressure (p=0.009), and triglycerides (p=0.017). glycated hemoglobin (p=0.062)and systolic blood pressure (p=0.073) also showed significant difference though it failed to reach statistically significant proportions (table 4). table 4: mean values of various characteristics in study subjects with and without ms parameter ms mean value standard deviation (±) standard error mean t value p value age (years) present 57.69 8.901 1.246 1.494 0.141 absent 52.38 12.094 4.276 duration of dm (years) present 4.22 3.443 0.482 1.469 0.147 absent 2.38 1.923 0.680 bmi (kg/m2) present 23.74 2.7603 0.3865 1.826 0.073 absent 21.81 2.928 1.0352 whr present 0.956 0.0827 0.01158 1.322 0.191 absent 0.914 0.0835 0.0295 sbp(mm of hg) present 137.18 13.654 1.912 2.686 0.009 absent 123.25 13.477 4.765 dbp(mm of hg) present 84.35 8.330 1.166 84.35 8.330 absent 76.75 7.851 2.776 fbs (mg/dl) present 192.51 151.004 21.145 0.454 0.652 absent 167.88 55.355 19.571 pmbs(mg/dl) present 257.49 75.947 10.635 1.272 0.208 absent 296.75 111.378 39.378 shilpa aniruddha deoke et al. metabolic syndrome and its correlates in type 2 diabetes mellitus panacea journal of medical sciences, september-december,2016;6(3): 138-141 140 hba1c present 8.51 1.286 0.180 1.903 0.062 absent 9.50 1.852 0.655 total cholesterol (mg) present 178.73 37.397 5.237 0.501 0.618 absent 185.88 38.294 13.539 hdl cholesterol (mg) present 42.41 7.108 0.995 1.517 0.135 absent 47.13 13.506 4.775 tg (mg) present 164.10 49.357 6.911 2.454 0.017 absent 120.38 21.948 7.760 ldl cholesterol (mg) present 87.59 37.721 5.282 0.767 0.446 absent 98.50 35.096 12.408 bmi – body mass index, whr – waist: hip ratio, sbp – systolic blood pressure, dbp – diastolic blood pressure, fbs – fasting blood sugar, pmbs – post meal blood sugar the association between the presence of diabetic complications and ms was studied and it was found that the presence of ms was a significant indicator of only chd (p value = 0.0011) whereas ms was not significantly associated with other diabetic complications like diabetic nephropathy, neuropathy and retinopathy (p value 0.99, 0.478 and 0.99 respectively)(table 5). table 5: table showing association of ms with diabetic complications complications ms ‘p’ value absent (n=8) present (n=51) nephropathy absent (n=41) 6 35 0.99 present (n=18) 2 16 retinopathy absent (n=48) 7 41 0.99 present (n=11) 1 10 neuropathy absent (n=46) 5 41 0.478 present (n=13) 3 10 chd absent (n=57) 57 0 0.0011 present (n= 2) 0 2 discussion the present study reveals a very high rate (86.44%) of occurrence of ms. though the reported prevalence of ms in general population is 19.5%,(13) its prevalence in type 2 diabetes is much higher. similar high prevalence rates have been described by previous studies. song et al found a prevalence rate of 93.1% by idf criteria and 90.1% by ncep atp iii criteria.(14)other studies have observed a varying rate from 66.2% to 73.3%.(5,9,15) varying definitions of ms and different ethnicities are the probable causes of this wide variation in the prevalence rates. in the present study, the proportion of diabetic subjects with ms decreased with increasing duration. raman r et al observed a similar trend but observed a gender difference (only males were noted to have this trend).(9) shimajiri et al(8) and ghani et al(16) also noticed a decreased prevalence of ms with increased duration of diabetes. the possible reason for this trend was suggested to be decreased bmi as a result of successful interventions for lifestyle modification. however song et al(5) and bonadonna et al(14) in their study found positive relation between duration of disease and prevalence of ms. amongst the various complications of diabetes, ms was found to be significantly associated with only chd (p=0.0011) whereas its presence was not found to be significantly associated with microvascular complications (p>0.05). significant positive correlation of ms with chd has been shown in previous hospital as well as population based studies.(5,7,17-18) ms being a congregation of various cardiometabolic risk factors confers an increased risk for chd. as for the microvascular complications, no significant association between ms and the complications was observed in the present study. this observation is similar to that observed by earlier studies.(11-12) however many other studies have shown a positive correlation between the two.(5,7-10,18) conclusion in the present hospital based study, 86.44%diabetic subjects had ms. ms did not show significant correlation with duration of diabetes. whereas ms in type 2 diabetes does not predict microvascular complications, it is a risk indicator of chd. since chd is a major cause of morbidity and mortality in type 2 diabetes, early suspicion and intervention in the form of modification of the various risk factors responsible for chd would be beneficial to the patients. diabetics with ms should be screened for the presence of ms and focused and robust counseling for lifestyle modification in this subset of population is needed. limitations the present study is a hospital based study. however, its small sample size is undoubtedly its major limitation. further, the definitions of various diabetic shilpa aniruddha deoke et al. metabolic syndrome and its correlates in type 2 diabetes mellitus panacea journal of medical sciences, september-december,2016;6(3): 138-141 141 complications probably underestimate the prevalence of these complications. references 1. reaven gm. banting lecture 1988. role of insulin resistance in human disease. diabetes 1988;37:1595– 1607. 2. expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. executive summary of the third report of the national cholesterol education program (ncep) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel iii). jama 2001;285:2486– 2497. 3. alberti kg, eckel rh, grundy sm. harmonizing the ms: a joint interim statement of the international diabetes federation task force on epidemiology and prevention; national heart, lung, and blood institute; american heart association; world heart federation; international atherosclerosis society; and international association for the study of obesity. circulation 2009;120:1640-1645. 4. paresh d, ahmad a, ajay c, priya m, rajesh g. ms :a comprehensive perspective based on interactions between obesity, diabetes, and inflammation. circulation 2005,111:1448–1454. 5. metascreen writing committee, bonadonna rc, cucinotta d, fedele d, riccardi g, tiengo a: the ms is a risk indicator of microvascular and macrovascular complications in diabetes: results from metascreen, a multicenter diabetes clinic-based survey. diabetes care 2006,29:2701-07. 6. cheng y, zhang h, chen r, yang f, li w. cardiometabolic risk profiles associated with chronic complications in overweight and obesetype 2 diabetes patients in south china. plos one 9(7): e101289. 7. isomaaa b, henricsson m, almgren p, tuomi t, taskinen mr, groop l. the ms influences the risk of chronic complications in patients with type ii diabetes. diabetologica 2001,44:1148-54. 8. abdul-ghani m, nawaf g, nawaf f, itzhak b, minuchin o, vardi p. increased prevalence of microvascular complications in type 2 diabetes patients with the ms. isr med assoc j 2006,8:378-82. 9. raman r, gupta a, pal ss. prevalence of ms and its influence on microvascular complications in the indian population with type 2 diabetes mellitus. sankara nethralaya diabetic retinopathy epidemiology and molecular genetic study (sn-dreams, report 14). diabetology and ms 2010 2:67. doi:10.1186/1758-59962-67. 10. pang c, jia l, hou x, gao x, liu w, bao y, et al. the significance of screening for microvascular diseases in chinese community-based subjects with various metabolic abnormalities. plos one 2014;9(5):e97928. doi:10.1371/journal.pone.0097928. 11. iwasaki t, togashi y, ohshige k. neither the presence of ms as defined by the idf guideline nor an increased waist circumference increased the risk of microvascular nor macrovascular complications in japanese patients with type 2 diabetes. diabetes res clin pract 2008;79(3):427-32. doi: 10.1016/j.diabres.2007.10.035. 12. carole ac, christine cj, retnakaran r. impact of the ms on macrovascular and microvascular outcomes in type 2 diabetes mellitus united kingdom prospective diabetes study 78.circulation 2007;116:2119-2126. 13. sawant a, mankeshwar r, shah s, raghavan r, dhongde g, raje h, et al. prevalence of metabolic syndrome in urban india. cholesterol 2011;2011:920983. 14. song sh and hardisty ca. diagnosing metabolic syndrome in type 2 diabetes: does it matter? q j med 2008; 101:487–491. doi:10.1093/qjmed/hcn034. 15. jacob b, george at, antony tp, jose r, sebastian sr. prevalence of metabolic syndrome in newly detected type 2 diabetes mellitus. academic medical journal of india 2015 mar 29;3(1):8-12. 16. shimajiri y, tsunoda k, furuta m, kadoya y, yamada s, nanjo k, et al. prevalence of metabolic syndrome in japanese type 2 diabetic patients and its significance for chronic vascular complications. diabetes res clinpract 2008,79:310-7. 17. cheng y, zhang h, chen r, yang f, li w. cardiometabolic risk profiles associated with chronic complications in overweight and obese type 2 diabetes patients in south china. plos one 2014; 9(7): e101289. doi:10.1371/journal.pone.0101289. 18. bonora e, targher g, formentini g, calcaterra f, lombardi s. the metabolic syndrome is an independent predictor of cardiovascular disease in type 2 diabetic subjects. prospective data from the verona diabetes complications study. diabet med 2004;21:52–58. original research article http://doi.org/10.18231/j.pjms.2019.002 panacea journal of medical sciences, january-april, 2019;9(1):3-6 3 assessment of histopathological effect of factory effluents on the liver and kidney tissues of chickens (gallus gallus domestica) reared around factory sites in nnewi metropolis, anambra state, nigeria a.n. okpogba1, e.c. ogbodo2*, m.n. izuogu3, a. k. amah4, d.c. ejiofor5, i. wopara6, f.n. ujowundu7, c. nwanegwo8, e.u. modo9, c.n. chinaka10 1dept. of human biochemistry, faculty of basic medical sciences, 2dept. of medical laboratory science, faculty of health sciences and technology, 3dept. of human anatomy, faculty of basic medical sciences, 4,5,8dept. of human physiology, 6,7,9,10dept. of biochemistry, 1,2,3nnamdi azikiwe university, nnewi campus, anambra state, nigeria, 4,5,8college of medicine, imo state university, owerri, nigeria, 6,7,9,10madonna university, elele campus, rivers state, nigeria *corresponding author: e. c. ogbodo email: augustinee442@gmail.com abstract exposure to factory effluents comes with deleterious consequences. the purpose of this study was to assess the histopathological effect of factory effluents on the liver and kidney tissues of chickens (gallus gallus domestica) reared around factory sites in nnewi metropolis, anambra state, nigeria. a total of twenty-nine chicks comprising of sixteen chicks exposed to factory sites and thirteen non-exposed chicks were grown to adult birds (chickens) for the study and were allowed to feed from the surrounding homeland of the factories including lead acid battery manufacturing factory (a), metal fabricating factory (b) and metal forging factory (c) respectively until they were aged between four and five months as adult birds (chickens) for the study. the chickens were sacrificed to obtain the liver and kidney tissues for histological analyses. the histopathological evaluation of the effect of the factory effluents on the liver and kidney tissues of birds reared around the four factories (a-d) and control were done by microscopic examination of haematoxylin and eosin (h&e) stained sections. the results obtained in factory a, b and c showed widening of the liver central vein and thickening of the vessels with invasion of the surrounding areas by chronic inflammatory cells as against the controls which showed fairly normal liver tissues with normal liver parenchyma cells with a central vein containing blood cells. also, the photomicrographs of the kidney tissues of birds reared around factory a, b and c showed evidence of marked glomerulo-nephritis and hypercellularity with evidence of glomerulosclerosis and hyalinization of the glomeruli as against the normal glomeruli and tubules found in the control birds. these results indicate that the environment where these birds are reared is a potential threat to the lives of the birds reared around these factories. keywords: factory site, factory effluents, liver, kidney, chicken (gallus gallus domestica), nnewi metropolis. introduction metabolic activity has been shown to be an important factor that enhances the success of adaptation of vertebrates to their environment.1 the vertebrate liver is involved in absorption of nutrients from the digestive tract which are subsequently processed and stored. the metabolic functions of the liver include protein synthesis, storage, bile secretion, detoxification and inactivation of harmful substances.2 the basic structural and functional unit of the liver is the acinus, which consist of hepatic lobule and portal triad (also called glisson's sheath).3 the hepatic lobules are the functional units of the liver. the sinusoids are capillary networks which are localized in the spaces between hepatic plates. the liver synthesizes bile which eventually empty into the gall bladder.4 the sections of a normal gallus gallus domesticus liver showed hepatocytes disposed in cords and clusters. the hepatocytes possessed centrally placed nuclei. the intervening fibro-vascular connective tissue displayed nucleated red cells with congested hepatic veins and portal triad similar to those of mammals.5 the kidneys are a pair of bean-shaped organs present in all vertebrates. they remove waste products from the body, maintain balanced electrolyte levels, and regulate blood pressure.6 the kidneys of gallus gallus domesticus are flattened organs embedded in ventral surface of synsacrum bone and each incompletely divided into three lobes; cranial, middle and wider-largest caudal lobes.7 kidney lobes of gallus gallus domesticus show a subdivion into units called lobules. each lobule has a cortex and medulla.8 the nephron is the functional unit of kidney and greatly varies in its structure amongst different vertebrates; also the structure of nephrons shows variable degree of differences among species. in birds, kidneys have two kinds of nephrons; a reptilian type --small sized, with no loops of henle, and a mammalian type large size with long or intermediate loop length.9 environmental pollution is a major global problem posing serious risk to man and animals. the development of modern technology and the rapid industrialization are among the foremost factors for environmental pollution. the environmental pollutants are spread through different channels, many of which finally enter into food chain of livestock and man.10 there is increasing concern about environmental pollutants emanating into the livestock production systems.11 pollution of the environment has significant impact on living organisms. reports from developed countries have documented adverse impact of pollution on domestic and wild animals in the form of specific chemical toxicities, behavioural changes and population decline. heavy metals are one of such chemical effluents released by industries. heavy metals from industrial waste contaminate drinking water, soil, air, fodder and food. a. n. okpogba et al. assessment of histopathological effect of factory effluents on the liver and kidney…. panacea journal of medical sciences, january-april, 2019;9(1):3-6 4 the toxic heavy metals like cadmium, lead and mercury affect biological functions, affecting hormone system and growth.12 many heavy metals accumulate in one or more of the body organs in food animals and are transmitted through food causing serious public health hazard. these toxicants are accumulated in the vital organs including liver and kidney and exert adverse effects on domestic animals. many surveys involving human population in industrial, mining and urban areas have indicated toxicities due to effluents. pesticides, heavy metals and other agro-chemicals are some of the major causes of environmental toxicity in farm animals.12 liver is the major target organ for xenobiotics and thus, is frequently cited as the site of parenchymal damage following exposure to various chemical agents.13-14 kidney is severely affected by different toxic chemical which is evident in form of pathological changes such as necrosis of hematopoietic tissue, vacuolation of tubular cells, dilation of glomerular capillaries and degeneration of epithelial cell linings.15 in kidney, histopathological changes were seen in glomeruli, tubuli and interstitial tissue. there was thickening of the glomerulary basement membranes and hypercellularity. epithelial degeneration of the tubules and intracytoplasmic hyaline droplets were detected in many tubules.16 basement thickening was also seen in tubulary basement membranes. in addition, hyaline casts were detected within the some tubules. some degenerative and necrotic changes, especially, pyknosis, were observed. hepatocytic degeneration is a common histopathological finding following toxicity of heavy metals.16 therefore, the purpose of this study was to assess the histopathological effect of factory effluents on the liver and kidney tissues of chickens (gallus gallus domestica) reared around factory sites in nnewi metropolis, anambra state, nigeria. materials and methods experimental site this study was carried out around three factories including lead acid battery manufacturing factory (a), metal fabricating factory (b) and metal forging factory (c), all located within nnewi metropolis, anambra state, nigeria. experimental design this is a cross sectional study designed to assess the histopathological effect of factory effluents exposure on the liver and kidney tissues of chickens (gallus gallus domestica) reared around factory sites in nnewi metropolis, anambra state, nigeria. a total of twenty-nine (29) chicks comprising of sixteen (16) chicks exposed to factory sites and thirteen (13) non-exposed chicks were grown to adult birds (chickens) for the study. the chicks in the exposed group were obtained from the surrounding households, about 250m, to these factories under study (lead acid battery manufacturing factory, metal fabricating factory and metal forging factory) while the chicks to serve as control were obtained in elele. they were aged between four (4) and five (5) months. they were allowed to feed from the surrounding homeland until they were due for the experiment. control chickens of the same age group were obtained from environments outside nnewi. the chickens were sacrificed to obtain the kidney and liver tissues for analyses. histopathological examination the liver and kidney tissues from each group of rats were collected in 10% formalin for 15 days. thereafter, the well fixed tissues were processed, sectioned and stained following standard procedure.17 the histopathological evaluation of the effect of the factory effluents on the liver and kidney tissues of birds reared around the three factories and control were done by microscopic examination of haematoxylin and eosin (h&e) stained sections. ethical consideration ethical approval for the research was obtained from ethical committee, nnamdi azikiwe university teaching hospital, nnewi, anambra state, nigeria (nauth/cs/66/vol.2/149). results the histopathological evaluation of the effect of the factory effluents on the liver and kidney tissues of birds reared around the three factories and control were done by microscopic examination of haematoxylin and eosin stained sections. the effect of the factory effluents were evaluated by histological examination of haematoxylin and eosin stained sections of liver tissues of the birds. the control birds showed normal liver structure with minimal fatty change. fig. 1 (a) and (b) show the photomicrographs of control liver tissues from elele and nnewi, respectively, showing normal liver parenchyma cells architecture with a central vein containing no vacuoles and inflammatory processes. fig. 1 a: photomicrographs of the liver of control birds reared in elele; (b) nnewi the photomicrograph of liver tissues around acid battery manufacturing factory birds is presented in fig. 2. the photomicrograph shows widening of the central vein and thickening of the vessels. there is also invasion by chronic inflammatory cells around the central vein with a probable evidence of liver damage. a. n. okpogba et al. assessment of histopathological effect of factory effluents on the liver and kidney…. panacea journal of medical sciences, january-april, 2019;9(1):3-6 5 fig. 2: birds reared around a lead acid battery manufacturing factory (a) in nnewi fig. 3 (a) and (b) show the photomicrographs of liver tissues from birds reared around metal fabricating factory showing liver necrosis involving the peri-central vein and surrounding areas. fig. 3: liver of chickens reared around a metal fabricating factory (b) in nnewi (a) and (b) fig. 4 (a) and (b) present the photomicrographs of liver tissues of birds reared around the metal forging factory (c) showing widening of the central vein and thickening of the vessels with invasion of the surrounding areas by chronic inflammatory cells (and evidence of hepatitis). fig. 4: liver tissues of birds bred around a metal forging factory (c) in nnewi fig. 5 (a) and (b) present the photomicrographs of control kidney tissues from elele and nnewi, respectively, showing normal cellular and physiological characteristics of glomeruli and tubules. fig. 5: photomicrographs of the kidney tissues of control birds in elele (a) and nnewi (b), respectively fig. 6 (a) and (b) show the photomicrographs of kidney tissues from acid battery manufacturing factory (a) birds. the glomeruli showed marked glomerulo-nephritis and hypercellularity with diffuse glomerulosclerosis and tubular necrosis. fig. 6: photomicrographs of tissues of kidney of birds bred around lead acid battery factory (a) in nnewi (a) and (b) the photomicrographs of kidney tissues from metal fabricating factory birds are shown in fig. 7 (a) and (b). the glomeruli show evidence of marked glomerilo-nephritis and hypercellularity with evidence of global sclerosis and hyalinization of the glomeruli. fig. 7: photomicrographs of kidney tissues of a metal fabricating factory (b) in nnewi (a) and (b) the photomicrographs of kidney tissues from metal foundry factory birds are presented in fig. 8 (a) and (b). while the glomeruli show marked glomerulonephritis. there is also diffuse glomerulosclerosis and hyalinization with extensive tubular necrosis. a. n. okpogba et al. assessment of histopathological effect of factory effluents on the liver and kidney…. panacea journal of medical sciences, january-april, 2019;9(1):3-6 6 fig. 8: photomicrographs of kidney tissues of chickens reared around a metal forging factory (c) in nnewi (a) and (b) discussion all birds are vulnerable to the effects of heavy metal poisoning such as pb,18 but their response shows distinct intra-specific and inter-specific differences.19 lead accumulation in tissues is affected by the physiological status of the birds and levels of accumulation differ between species.20 on the other hand, the accumulation of heavy metals varies significantly from one tissue to another within an animal, and varies also between one animal and another.21 the photomicrographs of the histopathological studies of liver of the factory birds around the lead acid battery manufacturing, metal forging and metal fabricating factories showed widening of the liver central vein and thickening of the vessels with invasion of the surrounding areas by chronic inflammatory cells as against the controls which showed fairly normal liver tissues with normal liver parenchyma cells with a central vein containing blood cells. on the other hand, the photomicrographs of the kidney tissues of birds reared around the lead acid battery manufacturing, metal fabricating and metal forging factories showed evidence of marked glomerulo-nephritis and hypercellularity with evidence of glomerulosclerosis and hyalinization of the glomeruli as against the normal glomeruli and tubules found in the control birds. there is paucity of information regarding the histopathological effects of factory effluents on the liver and kidney tissues of chickens reared around factory sites and as a result of which, it was practically difficult comparing the present findings with other studies. however, these results indicate that the environment where these birds are reared is a potential threat to the lives of the birds reared around these factories. conclusion the present study has shown various histological alterations on the liver and kidney tissues of chickens exposed to factory effluents and these indicate that the environment where these birds are reared is a potential threat to the lives of the birds reared around these factories. conflict of interest: none. references 1. barbara y, geraldine o, phillip t. histology of the digestive tract: wheater′s functional histology. 2014; 11th ed. philadelphia: elsevier, churchill living stone, pp. 274-80. 2. singh i. digestive system: textbook of human histology. new delhi, india: jaypee brother′s medical publishers (p) lt. 2014;249-57. 3. guyton ac, hall je. metabolism and temperature control: the liver as an organ. in: hall je, editor. guyton and hall textbook of medical physiology. 2010; vol. 13. 12th ed. philadelphia, pennsylvania: saunders, pp. 536-40. 4. sáez l, zuviæ t, amthauer r, rodríguez e, krauskopf m. fish liver protein synthesis during cold acclimatization: seasonal changes of the ultrastructure of the carp hepatocyte. journal of experimental zoology 2012;230:175-86. 5. emmanuel io, emmanuel io. comparative histologic anatomy of vertebrate liver. ann bioanthropol 2015;3(1):1-5. 6. tim, n. what do the kidneys do?. medical news today 2019;1:15. 7. al-ajeely, ra, fadhil sm. morphohistological study on the development of kidney and ureter in hatching and adulthood racing pigeon (columba livia). domestica j 2012;3(3):665-77. 8. casotti, g., lindberg kk, braun ej. functional morphology of the avian medullar cone. am j physiol, regul, integr comp physiol 2000;279:1722-5. 9. reece wo. dukes’ physiology of domestic animals. 2004; 12th ed. cornell university press, ithaca, pp. 107-113. 10. kaplan o, yildirim nc, yildirim n, cimen n. toxic elements in animal products and environmental health. asian j anim vet advancement 2011;6:228-32. 11. rajaganapathy, v. effect of pollution in livestock production systems. proceedings of the national seminar on recent trends in animal welfare and production 2006;1-3. 12. rajaganapathy v, xavier f, sreekumar d, mandal pk. heavy metal contamination in soil, water and fodder and their presence in livestock and products: a review. j environ sci technol 2011;4(3):234-49. 13. gingerich wh, weber lj. hepatic toxicology of fishes. in: aquatic toxicology, weber, l.j. (ed.). raven press, new york, 1982:55-105. 14. montaser, m., mahfouz, m. e., el-shazly, s. a. m., abdelrahman, g. h. and bakry, s. toxicity of heavy metals on fish at jeddah coast ksa: metallothionein expression as a biomarker and histopathological study on liver and gills. world j fishes mar sci 2010;2:174-85. 15. abdel-baki, a. s., dkhil, m. a. and al-quraishy, s. bioaccumulation of some heavy metals in tilapia fish relevant to their concentration in water and sediment of wadi hanifah. saudi arabian. afri j biotechnol 2011;10:2541-7. 16. miyase, c. a., arzu, y., ilkay, y., ertan, o., ozkan, d. and metin, ar. cadmium induced changes on growth performance, some biochemical parameters and tissue in broilers: effects of vitamin c and vitamin e. asian j anim vet adv 2011;6(9:923-34. 17. luna, l.g. manual of histopathologic staining methods of the armed forces institute of pathology. 1968, 3rd edn. mcgrew-hill book company, london. 18. okpogba, a.n., ogbodo, e.c., ugwu, e.c., oguaka, v.n., dike, c.c., ujowundu, f.n. comparative assessment of heavy metal levels in chickens (gallus gallus domestica) in rural (elele) and urban (nnewi) areas. asian j sci technol 2018;9(11):9056-9. 19. almansour, m.i. inter-species differences between lead concentration in the feathers of bayer, w.n., spann, j.w., sileo, l. and franson, j.c. lead poisoning in six captive avaian species. arch environ contamination toxicol 1988;17:121-30. 20. pycnonotus leucogenys and streptopelia senegalensis from different cities of saudi arabia. int j zoological res 2007;3:200-6. 21. john, h.h and jeanne, i.r. food additives, contaminants and natural toxins in: maurice e.s., james, a.o., moshe, s.l. and febiger, (eds.) modern nutrition in health and disease, 1994; 8th ed., part ii. pp: 15] original research article panacea journal of medical sciences, may-august,2016;6(2): 66-68 66 frequency of gestational diabetes mellitus using diabetes in pregnancy study group of india (dipsi) method preksha jain1,*, savita somalwar2, sulabha joshi3 1junior resident, 2lecturer, 3professor & hod, dept. of obstetrics & gynecology, nkp salve institute of medical sciences & research center, nagpur *corresponding author: email: prekshaenator@gmail.com abstract the purpose of the study was to determine frequency of antenatal women with gestational diabetes mellitus using diabetes in pregnancy study group of india (dipsi) recommended method. total 487 antenatal women were included and administered 75gm glucose. all women who presented before 24 weeks of gestation and found to have pgbs <140mg/dl were tested for gdm again at around 28 to 32 weeks with minimum gap of 6 weeks between the two tests. while, for those who presented for the first time after 24 weeks, test was done only once. out of total 487 antenatal women, there were 52 (10.7%) cases of gestational diabetes mellitus. 5 (9.6%) women out of 52 would have been missed if repeat screening was not done. the frequency of gestational diabetes mellitus was found to be quite high and hence, universal screening is recommended. this study also builds a strong reason for following dipsi guidelines as a single-step method as both screening and diagnostic test for gdm. keywords: diabetes in pregnancy, dipsi test, gestational diabetes mellitus, screening, single step screening method. access this article online website: www.innovativepublication.com doi: 10.5958/2348-7682.2016.00005.1 introduction gestational diabetes mellitus (gdm) is defined as carbohydrate intolerance with onset or recognition during pregnancy(1) which is associated with adverse maternal and fetal outcome. gdm is thought to represent diabetes in evolution, and the increasing prevalence of gdm along with diabetes mellitus confirms this supposition(2). studies by seshiah v et al suggest that the prevalence of gdm in india varied from 3.8 to 21% in different parts of the country, depending on the geographical locations and diagnostic methods used(3). worldwide, its prevalence differs according to race, ethnicity, age, body composition and screening and diagnostic criteria(4). women diagnosed to have gdm are also at increased risk of future diabetes predominantly type 2 diabetes mellitus (dm) as are their children. timely action taken in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition may prevent in all probability, the vicious cycle of transmitting glucose intolerance from one generation to another(5). very few data is available with regard to frequency of gestational diabetes from maharashtra. the present study, therefore, has compiled to serve this purpose. in the present study, the diabetes in pregnancy study group india (dipsi) guidelines have been followed for screening of subjects, so that a uniform protocol followed by similar groups in other parts of the country could enable a fair and judicious correlation with each other. besides, dipsi guidelines also facilitate both economical and feasible mode of evaluation. dipsi diagnostic criterion of 2 h plasma glucose more than 140 mg/dl with 75 g oral glucose load is a modified version of who guidelines in that, who procedure requires women to be in the fasting state, whereas dipsi procedure is performed irrespective of the last meal timing(6). materials and methods the present study was carried out at a tertiary care hospital attached to medical college in the department of obstetrics and gynecology, between november 2013 and october 2015 after approval of the institutional ethics committee. total 487 antenatal women were screened for gdm after obtaining their consent. inclusion criteria included all singleton pregnancies and those willing for regular antenatal check-up while women who were known cases of diabetes mellitus or with multiple pregnancies or with history of pancreatitis and those not willing for any intervention were excluded. demographic data of these women were noted. a detailed history with special reference to previous obstetric outcome, history of abortions, still births, intrauterine deaths, congenital malformations in fetus, preeclampsia, history of gdm in previous pregnancy and positive family history was taken. history of medical disorders like hypothyroidism or treatment for infertility was taken. gestational age at first visit was noted. a thorough clinical and obstetrical examination was done. routine investigations were sent. in addition all antenatal patients screened were preksha jain et al. frequency of gestational diabetes mellitus using diabetes in pregnancy study…. panacea journal of medical sciences, may-august,2016;6(2): 66-68 67 made to drink 75gm glucose dissolved in 200ml of water consumed over a period of 5 minutes, irrespective of whether she is in the fasting or non-fasting state and without regard to the time of the last meal. a venous blood sample was collected at 2 hours for estimating plasma glucose by glucose oxidase peroxidase (godpod) method at central laboratory of the institute. all those women who had 2 hour post glucose blood sugars (pgbs) ≥140 mg/dl were classified as gestational diabetes mellitus and who had <140 mg/dl were classified as non-gdm. all women who presented before 24 weeks of gestation and found to have pgbs <140mg/dl were tested for gdm again at around 28 to 32 weeks with minimum gap of 6 weeks between the two tests. while, for those who presented for the first time after 24 weeks, dipsi test was done only once. the patients with post glucose blood sugars between 140 to 199 mg/dl were advised medical nutrition therapy (mnt) under supervision of dietician and continued for 2 weeks. if mnt failed to achieve control, i.e. fpg ~90 mg/dl and 2hr post-meal glucose ~120 mg/dl, patients were admitted and insulin was initiated and physician opinion was taken. those with initial pgbs ≥ 200 mg/dl were started on insulin along with mnt and were admitted for sugar monitoring. appropriate monitoring and management was done for gdm women. results table 1: frequency of gdm among study population category number % non-gdm 435 89.3 gdm 52 10.7 total 487 100 out of total 487 antenatal women included in the study, there were 52 (10.7%) cases of gestational diabetes mellitus, while remaining 435 (89.3%) cases were classified as non-gdm as depicted in table 1. table 2: distribution of study population according to residential status residential status gdm non-gdm total = n number % number % urban 15 10.8 124 89.2 139 rural 37 10.6 311 89.4 348 total 52 435 487 table 2 provides the distribution of antenatal women as per their residential status. out of 487, number of antenatal women belonging to urban area were 139 (28.5%) while, 348 (71.5%) belonged to rural area. among women belonging to urban area, 15 (10.8%) had gdm and 124 (89.2%) belonged to non-gdm group. among women belonging to rural area, 37 (10.6%) had gdm and 311 (89.4%) belonged to non-gdm group. table 3: distribution of study population according to gestational age at diagnosis of gdm by dipsi test status <24 weeks number (%) ≥24 weeks number (%) total <16 weeks 17-23 weeks 24-28 weeks >28weeks gdm 3 (5.8) 6 (11.5) 23 [20 + 3*] (44.2) 20 [18 + 2*] (38.5) 9 (17.3) 43[38 + 5*] (82.7) 52 *5 gdm women diagnosed after repeat testing after 24 weeks. table 3 shows distribution of study population according to gestational age at diagnosis of gdm by dipsi test. out of 52 gdm women, 3 (5.8%) diagnosed before 16 weeks, 6 (11.5%) women diagnosed between 17 to 23 weeks, 23 (44.2%) women diagnosed between 24 to 28 weeks and 20 (38.5%) women diagnosed after 28 weeks of gestation. thus, 9 (17.3%) women were diagnosed as gdm before 24 weeks and 43(82.7%) women were diagnosed at or after 24 weeks. those woman who were tested negative for gdm before 24 weeks, were again tested after 24 weeks at around 28 to 32 weeks. among these women 5 were diagnosed as gdm in repeat testing. among these 5 women, 3 were diagnosed between 24 to 28 weeks and 2 after 28 weeks. table 4: distribution of women diagnosed as gdm in their first visit before 24 weeks and by repeat dipsi test in second visit dipsi test total tested dipsi positive dipsi negative at first visit <24 weeks 49 9 (17.3%) 40 repeat test >24 weeks 40 5 (9.6%) 35 first visit after 24 weeks 438 38 400 as depicted in table 4, total 52 women were diagnosed as gdm out of 487 women. total 49 women were screened before 24 weeks, among which 9 were diagnosed as gdm. these 9 (17.3%) women would preksha jain et al. frequency of gestational diabetes mellitus using diabetes in pregnancy study…. panacea journal of medical sciences, may-august,2016;6(2): 66-68 68 have been missed if screening was done only at around 24-28 weeks according to older guidelines. remaining 40 women were again screened after 24 weeks, among which 5 women were diagnosed as gdm. these 5 (9.6%) women out of 52 would have been missed if repeat screening was not done. thus, out of 487 women, 49 had first visit before 24 weeks and 438 women had first visit at or after 24 weeks. out of 438 women, 38 were diagnosed as gdm at or after 24 weeks. discussion in present study, the frequency of gestational diabetes mellitus was 10.7% which is quite significant. the frequency in our study is comparable to studies by anjali a (9.5%)(7) and v balaji et al (13.4%)(8), which incorporated dipsi guidelines. thus, taking in account high frequency in study population, there is need for universal screening for gestational diabetes. in our study, 71.4% women belonged to rural area and 28.5% belonged to urban area. out of all gdm women 71.2% belonged to rural area. as the present study was conducted in a tertiary care center attached to medical college situated in rural area, the number of women from rural area was higher than from urban area. similar are the results of the study by kalyani kr et al(9), in which among gdm women 69.4% were from rural area and 64% belonged to urban area. in our study out of 52 gdm women, 3 (5.8%) diagnosed before 16 weeks, 6 (11.5%) women diagnosed between 17 to 23 weeks, 23 (44.2%) women diagnosed between 24 to 28 weeks and 20 (38.5%) women diagnosed after 28 weeks of gestation. those woman who were tested negative for gdm before 24 weeks, were again tested after 24 weeks at around 24 to 28 weeks with gap of about 6 weeks. in present study, total 52 women were diagnosed as gdm out of 487 women. total 49 women were screened before 24 weeks, among which 9 were diagnosed as gdm. these 9 (17.3%) women would have been missed if screening was done only at around 24-28 weeks according to older guidelines. remaining 40 women were again screened after 24 weeks, among which 5 women were diagnosed as gdm. these 5 (9.6%) women out of 52 would have been missed if repeat screening was not done. thus, women who had normal glucose tolerance in the first visit require repeat test in the subsequent visits. thus, out of 487 women, 49 had first visit before 24 weeks and 438 women had first visit at or after 24 weeks. out of 438 women, 38 were diagnosed as gdm at or after 24 weeks. in a study by v. seshiah et al (10), out of the 741 gdm women, 16.3% were within 16 weeks, 22.4% were between 17 and 23 weeks and 61.3% were more than 24 weeks of gestation. 38.7% gdm women were diagnosed before 24 weeks and 28.9% were diagnosed on repeat testing. this difference might be as ours is mainly rural population which is associated with tendency of women to present late in their pregnancy for antenatal checkup. acknowledgement we would like to thank, dr. sunita ghike, professor, dept. of obstetrics and gynecology for her critical suggestions and views related to the study. references 1. expert committee on the diagnosis and classification of diabetes mellitus: report of the expert committee on the diagnosis and classification of diabetes mellitus. diabetes care 2003;26(1):s5-s20. 2. buchanan ta, kjos sl, xiang a, watanbe r. what is gestational diabetes? diabetes care 2007;30:s105-11. 3. seshiah v, balaji v, balaji ms. pregnancy and diabetes scenario around the world: india. int j gynaecol obstet 2009;104:s35-8. 4. cunningham f, leveno k, bloom s, hoffman b. diabetes mellitus. williams obstetrics 24th edition. united states of america: mc graw-hill education; 2014; chap 57. 5. seshiah v, balaji v, balaji ms. scope for prevention of diabetes—‘focus intrauterine milieu interieur’. j assoc physicians india. 2008;56:109-13. 6. seshiah v, das ak, balaji v, joshi sr, parikh mn, gupta s. diabetes in pregnancy study group. gestational diabetes mellitus-guidelines. j assoc physicians india 2006;54:622–8. 7. bhatt aa, dhore pb, purandare vb, sayyad mg, mandal mk, unnikrishnan ag. gestational diabetes mellitus in rural population of western india results of a community survey. indian j endocr metab 2015;19:507-10. 8. balaji v, balaji m, anjalakshi c, cynthia a, arthi t, seshiah v. diagnosis of gestational diabetes mellitus in asian-indian women. indian j endocrinol metab 2011;15:187-190. 9. kalyani kr, jajoo s, hariharan c, samal s. prevalence of gestational diabetes mellitus, its associated risk factors and pregnancy outcomes at a rural setup in central india. int j reprod contracept obstet gynecol 2014;3:219-24. 10. seshiah v, balaji v, balaji ms, paneerselvam a, arthi t, thamizharasi m. gestational diabetes mellitus manifests in all trimesters of pregnancy. diabetes res clin pract 2007 sep;77(3):482-4. original research panacea journal of medical science, september december 2015:5(3);124-129 124 a clinico-pathological profile of primary lung cancer patients presenting in a rural medical college of central india dubey n 1 , julka arti 2 , varudkar hg 3 , agrawat jc 4 , bhandari deepali 5 , mukati sunil 6 , jain anukool 7 abstract: a study of the clinico-pathological profile of cases of lung cancer coming to a rural medical college in the central india. to study the risk factors, the time taken to diagnose and the investigations useful in the diagnosis of lungcancer patients. a prospective, observational and descriptive study was conducted in a rural medical college and hospital for duration of 1 year. statistics analysis was done using the spss version 16. out of 62 cases suspected of lung cancer presented to the medical college, only 47 could be included in the study. out of which 38(80.8%) were males and 9(19.1%) were females, 37(78.7%) were smokers including 34(72.3%) current smokers, 3 (6.3%) ex-smoker and 10 (21.2%) non-smoker. 11 (23.4%) cases of lung malignancy had been misdiagnosed as pulmonary tuberculosis. the onset of symptoms to the confirmation of diagnosis of lung cancer was 5.7 months. maximum diagnostic yield was with fnac 22/30 (73.3%) while results with endobronchial biopsy were 23(63.8%) and percutaneous lung biopsy was 7(63.6%). there were 44 (93.7%) cases of non-small cell lung cancer(nsclc) and 3 (6.3%) of small cell lung cancer (sclc). squamous cell cancer was the predominant cell type 18(38.2%). maximum were diagnosed in the advanced stages of disease. lung cancer remains a male predominant disease with smoking as the most common implicating agent. it continues to be diagnosed very late and presents in very advanced stages of the disease. more needs to be done to educate patients on ill effects of tobacco and to train doctors on early diagnosis especially in the rural areas. keywords: lung, cancer, smoking, cough. 1 senior resident, 2,3 professor, 4 associate professor, 5,6,7 post graduate student, department of pulmonary medicine, rd gardi medical college. ujjain mp. arti_julka@yahoo.co.in introduction lung cancer is one of the commonest malignant neoplasms all over the world (1). this is the leading cause of cancer death in developed countries and is rising rapidly in developing countries(2-3). it is the most commonly diagnosed cancer worldwide accounting for 1.61 million (12.7%) of the total cancer patient sand is also the most common cause of cancer death that is 1.38 million(18.2%) of the total(3). in india too, it is the commonest and most lethal cancer among males accounting for 10.9% of all cancer cases and 13% of cancer related mortality (4).majority of the patients have locally advanced or disseminated disease at presentation and are not candidates for surgery.5-year survival rate for lung cancer has improved only minimally from 5% in the late 1950s to 14% by 1994. this is in sharp contrast to the 5 years survival of 52% in some other type of cancers (1). it is seen that there is an significant increase in the incidence of bronchogenic carcinoma cases seen after the analysis of the records of 15 teaching institutions in india over a period of 10 years. from 16.1 in 1950, it had increased to 26.9 in 1961 per 1000 malignancies(5). the survey conducted in uttar pradesh in 1966 by misra and others showed that the incidence was 4.2 per 10,000 hospital admissions and was 2.1% of all malignancies. according to wig et al (1961), lung carcinoma is a frequent finding amongst all the chest diseases(3). smoking is very rampant in india especially the rural areas. as around 80% of lung cancer patients come from the rural areas(1) there is difficulty in getting proper medical care and diagnosis thereby gets delayed. once diagnosis is made there are monetary constraints as well as inaccessibility of cancer management facilities nearby adding to the problem. this study was designed to evaluate the social, clinicopathological aspects of lung cancer patients coming to the rural medical college. the aim was also to study the time duration for confirming the diagnosis, the relative yield of the investigations in diagnosis of lung cancer and the lung cancer stage in which patients are presenting. materials and methods a prospective, observational and descriptive study was conducted in a rural medical college and hospital (r. d. gardi medical college, ujjain, m. p.) for duration of 1 year(2012-2013) after approval by hospital ethics and research committee. informed consent of all patients was taken. the patients of primary lung cancer mailto:arti_julka@yahoo.co.in dubey n et al. a clinico-pathological profile of primary lung cancer patients presenting in a rural medical… panacea journal of medical science, september december 2015:5(3);124-129 125 diagnosed and evaluated in our hospital were included in the study. patients with malignant metastasis in lung from other sites, primary mediastinal masses, primary pleural malignancy and those cases of lung carcinoma diagnosed elsewhere and those already under treatment were excluded from the study. a detailed medical history of the patients regarding their clinical symptoms, past medical or surgical history, occupational history was taken. the smoking history included the current status, the mode of smoking, and any other mode of tobacco intake. ecog(eastern co-operative oncology group)/who (world health organisation) performance status was also evaluated. a detailed clinical examination of the patient was carried out. the cases of suspected lung cancer were then subjected to the basic haematological, radiological and microbiological investigations. patients who were clinically and radiologically suggestive of primary lung cancer were subjected to fiberoptic bronchoscopy under local anaesthesia. whole tracheobronchial tree was examined and bronchoalveolar lavage (bal) and endobronchial biopsy was collected and evaluated. further relevant investigations like pleural fluid cytology, fnac of lymphnodes / lung mass and trucut biopsy of lung were performed depending upon the lesion. ct head was done in few cases depending as per requirement. results there were 62 clinical and radiological suspects of lung malignancy who presented in our institute during the study period. they were evaluated and 47 pathologically proven patients were finally included in our study. only 47 could be included in the study as the attendants of 15 patients were unwilling for further evaluation on being told about the suspicion of the malignancy and preferred to take the patient home. out of 47 patients, 38 (80.8%) were males and 9 (19.1%) were females. male to female ratio was 4.2:1.patients were in age range of 20-80 years, maximum 22 (46.8%) patients were in age group of 41-60 years and the mean age was 58.6 year. mean age was lower in patients of sclc (51.6 year) than nsclc(59 year). most of our patients were illiterate 34 (72.3%) and farming was the commonest occupation. the commonest risk factor for development of lung cancer found in our study was smoking. majority of the patients i.e. 37 (78.7%) were smokers including 34 (72.3%) current smokers, 3 (6.3%) ex-smoker and 10 (21.2%) non-smoker. most common mode of tobacco intake was bidi in 30(63.8%) cases. significant smoking history of ≥ 20 pack years was present in 29 (78.8%) cases (fig. 1). 11 (23.4%) cases of lung malignancy had been misdiagnosed as pulmonary tuberculosis and were wrongly started on antitubercular treatment(att) by treating physician prior to reporting to the college. the study also revealed that the average duration from the onset of symptoms to the confirmation of diagnosis of lung cancer was 5.7 months. most common symptom of the patients was cough in 38 (80.5%) patients, which was productive in about 35 (74.4%) patients. chest pain was seen in 35(74.4%), dyspnoea in 29(61.7%), decreased appetite in 21 (44.6%), haemoptysis in 17 (36.1%), weight loss in 11(23.4%) and hoarseness of voice in 5(10.6%) patients. other clinical symptoms were fever in 10 (22.2%), swelling over the face in 5(10.6%), dysphagia in 4 (8.5%), vomiting in 2 (4.2%), body ache in 6(12.7%) and weakness in 3 (6.3%) patients (fig. 2). fig. 1: smoking status of patients of lung cancer. 21% 73% 6% smoking status non smoker current smoker ex smoker dubey n et al. a clinico-pathological profile of primary lung cancer patients presenting in a rural medical… panacea journal of medical science, september december 2015:5(3);124-129 126 fig. 2: symptoms of patients of lung cancer most common clinical presentation was mass lesion in 22 (43.1%) cases. associated clinical manifestations were lymphadenopathy in 16(34%), superior vena cava syndrome in 7 (14.8%), pan coast tumor in 3 (6.3%) and horner’s syndrome in 1(2.1%) case. other comorbid conditions present in our patients were copd in 27 (57.4%), hypertension in 4(8.5%), pulmonary tuberculosis in 2 (4.2%) and 1(2.1%) patient had associated interstitial lung disease, optic glioma and inguinal hernia each. most common site of metastases was the lymphnodes and the most common site for extrathoracic organ metastasis was the liver. amongst the paraneoplastic syndromes the hematological findings were of leucocytosis in 18 (38.2%), anemia in 13 (27.6%), monocytosis in 12 (25.5%), eosinophilia in 3 (6.3%) and thrombocytosis in 2 (4.2%). other paraneoplastic syndromes includes clubbing in 13 (27.6%), gynaecomastia in 2 (4.2%) and hypercalcemia in 1 (2.1%) case. maximum diagnostic yield was with fnac 22(73.3%) while results with endobronchial biopsy were 23(63.8%) and percutaneous lung biopsy was 7(63.6%). sputum cell cytology however was not useful in diagnosis of malignancy in our study. the commonest bronchoscopic finding was intrabronchial growth in 25/45 (53.1%) cases out of these in 16 (34%) patients it was associated with intrabronchial obstruction. others findings were stenosis in 19(40.4%), irregular mucosa in 7 (14.8%), vocal cord palsy in 5 (10.6%), pressure effects in 4 (8.5%) and blunt carina in 3 (6.3%) cases. there were 44 (93.7%) cases of nsclc and 3 (6.3%) of sclc. there were 18 (38.2%) cases of squamous cell carcinoma, 15 (31.9%) were adenocarcinoma, 1 (2.1%) was large cell carcinoma, 3 (6.3%) were small cell carcinoma and 10 (21.2%) were ‘not otherwise specified’. thus nsclc was the predominant histopathological type of lung malignancy in our study (fig. 3). fig. 3: histopathological distribution of patients of lung cancer 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 74.40% 36.10% 61.70% 80.50% 74.40% 10.60% 23.40% 44.60% 22.20% 4.20% 10.60% 8.50% 12.70% 6.30% total patients 47 (100%) nsclc 44 (93.6%) squamous cell carcinoma 18 (40.9%) adeno-carcinoma 15 (34%) large cell carcinoma 1 (2.2%) not otherwise specifed 10 (22.7%) sclc 3 (6.3%) dubey n et al. a clinico-pathological profile of primary lung cancer patients presenting in a rural medical… panacea journal of medical science, september december 2015:5(3);124-129 127 ecog / who performance status of ≤ 2 in 30(63.9%) patient’s disease: out of 44 patients of nsclc 29 (65.8%) were having advanced disease with tnm stage iiib and iv at the time of diagnosis. in sclc 2(66.6%) were having limited disease and 1(33.3%) was having extensive disease. fig. 4: tnm stage of non-small cell lung cancer patients at the time of diagnosis discussion the study showed that lung cancer is a male predominant disease, as smoking which is the most important risk factor for lung cancer is more common in males. this is also seen in other indian studies conducted by prasad et al(6) and jindal and behera(7), bhaskarapillai and colleagues (8) and sheema sheikh et al (9). the mean age of lung cancer was 58.6 yr as the disease is usually found in people of elderly age because of prolonged exposure to risk factors (2). most of the lung cancer patients were underweight supporting that weight loss is important symptom of the disease. majority of the patients coming to our medical college were from rural areas and farming was the most common occupation. most of the patients were illiterate. it was found that besides the tobacco smoke there was no significant exposure to any other carcinogenic substance except in female patients who were exposed to chulha smoke and environmental tobacco smoke at home. majority of the patients were ‘bidi’ smokers (either current smokers or exsmoker).thus smoking is the most important risk factor for lung cancer in our study, as also reported by rawat et al (10), kumar et al (11) and koul et al (12). almost one-fourth of the patients had history of att and most of them were misdiagnosed as pulmonary tuberculosis due to incomplete evaluation. there are common clinical symptoms and radiological findings in both tuberculosis and lung cancer leading to misdiagnosis and there is inadequate use of diagnostic modalities like sputum for acid fast bacilli, ct scan and bronchoscopy which is responsible for wrong treatment of the patients(13). another reason for delay in diagnosis is that cough and dyspnoea are usual complaints in most of the copd patients and are neglected alike by the patient and the treating physician. this fact is also reported in studies by r prasad et al (6), arora et al (14), kumar et al (11) and singh etal (15). the average duration in which patients were diagnosed as a case of lung cancer was 5.7 months which is quite late, thereby resulting in the presentation in a more advanced stage which cannot be cured. study revealed that lung cancer shares the common symptomatology as other respiratory diseases. cough was the most common symptom is also reported in other studies (6,16,17,18). change in symptoms of copd patients not relieving with adequate treatment and appearance of symptoms like hoarseness, facial puffiness, chronic chest pain, haemoptysis, excessive weakness and significant weight loss should be further evaluated to rule out malignancy. in majority of the patients the lung mass was the commonest clinical presentation. similarly studies by jindal and behera(7) also found mass with or without collapse as the most common clinical presentation. associated clinical manifestations in our patients were lymphadenopathy, svc syndrome, pan coast syndrome and horner’s syndrome in some patients. these clinical findings should be evaluated with high suspicion of underlying malignancy. copd was the commonest associated co-morbidity in our patients due to sharing of same risk factor that is the smoking. clubbing and monocytosis were important paraneoplastic syndromes found in our study. most common radiological finding was mass lesion in lung. mass as the most common finding on radiology was also reported by hassan & colleagues(16), omer salamoudi(17) and fusun sahin and colleagues(19). hilar prominence and non-resolving pneumonias in high risk group like smokers should raise the suspicion of malignancy and can lead to early diagnosis of patient. most common site of metastasis was the lymph nodes but the most common site for extra thoracic organ metastasis was the liver. lymph nodes are also reported as commonest site of metastasis in studies by arora et al (14), rajesekaran et al (20) and jindal and colleagues (21) and if evaluated can give us earliest diagnosis. maximum diagnostic yield was obtained with fnac while endobronchial biopsy and percutaneous lung biopsy gave almost equal results. so in central lesions tnm stage of nsclc 1 a 2.20% 1 b 6.80% 2a 0% 2 b 6.80% 3 a 18.10% 3 b 6.80% 4 59.00% dubey n et al. a clinico-pathological profile of primary lung cancer patients presenting in a rural medical… panacea journal of medical science, september december 2015:5(3);124-129 128 endobronchial biopsy and in peripheral lesions percutaneous lung biopsy can be done for adequate tissue diagnosis. fnac should be used as the first diagnostic tool wherever possible because it is easy, cheap, outpatient department (opd) procedure which is well accepted by the patients and gives earliest diagnosis. fnac was reported to have maximum yield in study by kumar et al (11)similar to our study but most of the studies reported maximum diagnostic yield by fiberoptic bronchoscopy(7,10,17). sputum cell cytology has not revealed malignancy in any case in our study however it was positive in some studies by prasad et al(6), jindal and behera(7) and hassan and colleagues(16), but yield was very low. intrabronchial, centrally located tumour was the most common finding on fiberoptic bronchoscopy which is common in patients of squamous cell carcinoma and small cell carcinoma. in our study too squamous cell carcinoma(scc) is the predominant histopathological type of malignancy. the cause is most likely due to the fact that the majority of the patients in our study are smokers, this is consistent with the other indian studies (9,20,12,21,22,23), however the predominant type of lung cancer in western world is adenocarcinoma(3,10). almost two-third of the patients were having advanced disease at the time of diagnosis which is also observed in other studies (6,11). this suggests an urgent need of some diagnostic modality for screening and early diagnosis of patients of lung cancer as well as measures to decrease tobacco consumption; the most important etiological factor responsible for lung cancer. conclusion the lung cancer is emerging as a big medical and social problem for our country especially with rampant use of tobacco despite legislation to control it. our patients are presenting in advanced stages of the disease whereby only palliation can be planned. the government should establish more centers for the treatment as affordability is major issue especially in the rural area. the government should strictly implement the rules and regulations for decreasing tobacco consumption. there is a need for strengthening cancer registry system in our country so that exact burden of the disease can be assessed and measures can be taken for planning and management of the disease. there is a need for new research in the field of early diagnosis and management for improvement of survival of the lung cancer patients. so, while awaiting a breakthrough in early diagnosis and effective management it is imperative that doctors keep a high clinical suspicion for it especially in the high risk groups of smokers and copd patients and evaluate them appropriately to avoid misdiagnosis and delayed diagnosis of lung cancer. references 1. behera d and balamugesh t. lung cancer in india. indian j chest dis allied sci.2004;46:269-81. 2. charles s, cruz d, tanoue lt and matthay ra. lung cancer: epidemiology, etiology, and prevention. clinics in chest medicine.2011;32(4):605-644. 3. behera d. lung cancer in india. medicine update. 2012;22:401-07. 4. international agency for research on cancer.(no date). globocan 2008 country fast stats.(online)france iarc.(accessed on: 15.8.2013) available from: http://globocan.iarc.fr/factsheets/populations/factsheet.asp?uno=356 5. viswanathan r, gupta s, iyer pvk. incidence of primary lung cancer in india. thorax 1962;17 : 73-76. 6. prasad r, james p, kesarwani v, gupta r, pant mc et al. clinicopathological study of bronchogenic carcinoma. respirology. 2004; 9:557–60. 7. jindal sk and behera d. clinical spectrum of primary lung cancer-review of chandigarh experience of 10 years. lung india .1990;8(2):94-98. 8. bhaskarapillai b, kumar ss and balasubramanian s. lung cancer in malabar cancer center in kerala – a descriptive analysis. asian pacific j cancer prev.2012;13 (9), 4639-43. 9. sheema sheikh, shah a. arshed a, makhdoomi r, ahmad r. histological pattern of primary malignant lung tumours diagnosed in a tertiary care hospital: 10 year study. asian pacific journal of cancer prevention. 2010;11:1341-46. 10. rawat j, sindhwani g, gaur d, dua r, saini s. clinicopathological profile of lung cancer in uttarakhand. lung india.2009;26(3):74-76. 11. bhattacharyya sk, mandal a, deoghuria d, agarwala a, aloke gg and dey sk. clinico-pathological profile of lung cancer in a tertiary medical centre in india: analysis of 266 cases. journal of dentistry and oral hygiene (serial online). 2011(cited 2013 sept 11);3(3):30 12. koul pa, kaul sk, shiekh mm, tasleem ra, shah a. lung cancer in the kashmir valley. lung india.2010;27:131-7. 13. bhatt m, kant s, bhaskar r. pulmonary tuberculosis as differential diagnosis of lung cancer. south asian j cancer (serial online) 2012 (cited 2013 nov 10);1:36-42. available from: http://journal.sajc.org/text.asp?2012/1/1/36/96507 14. arora vk, seetharaman ml, ramkumar s et al. bronchogenic carcinoma-clinicopathological pattern in south indian population.lung india.1990;7(3):133 36. 15. singh vk, chandra s, kumar s, pangtey g, mohan a, guleria r.a common medical error: lung cancer misdiagnosed as sputum negative tuberculosis. asian pac j cancer prev.2009;10:335-38. 16. hassan mq, ahamad msu, rahman mz, ahmed s, chowdhury maw. clinicopathological profile of bronchogenic carcinoma in tertiary care hospital in bangladesh. jcmcta 2010:21(1): 45-49. 16. alamoudi os. lung cancer at a university hospital in saudi arabia: a four-year prospective study of clinical, pathological, radiological, bronchoscopic, and biochemical parameters. annals of thoracic medicine .2010;5(1):30-36. 17. sánchez de cos escuín j, miravet sorribes l, abalarca j, núñez ares a, hernández hernández j, castañar jover am et al. the epiclicp-2003 study: a multicenter epidemiological and clinical study of lung cancer in spain. arch bronconeumol. 2006;42(9):446-52. 18. sahin f and yildiz p. radiological, bronchoscopic and histopathologic characteristics of patients with primary lung cancer in turkey (2006-2009). asian pacific journal of cancer prevention.2011;12:1947-52. 19. rajeskaran, manickam s, rajasekaran s, vasanthan p, jayachandran c, subbaraman r. pattern of primary lung cancer-a madras study. lung india.1993;11(1&2):7-11. http://journal.sajc.org/text.asp?2012/1/1/36/96507 http://www.ncbi.nlm.nih.gov/pubmed?term=s%c3%a1nchez%20de%20cos%20escu%c3%adn%20j%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=miravet%20sorribes%20l%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=abal%20arca%20j%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=abal%20arca%20j%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=n%c3%ba%c3%b1ez%20ares%20a%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=hern%c3%a1ndez%20hern%c3%a1ndez%20j%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=casta%c3%b1ar%20jover%20am%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.ncbi.nlm.nih.gov/pubmed?term=casta%c3%b1ar%20jover%20am%5bauthor%5d&cauthor=true&cauthor_uid=17040660 http://www.lungindia.com/medlineresult.asp?search=rajasekaran%20s&journal=x&entries=10&pg=0 http://www.lungindia.com/medlineresult.asp?search=vasanthan%20p&journal=x&entries=10&pg=0 http://www.lungindia.com/medlineresult.asp?search=jayachandran%20c&journal=x&entries=10&pg=0 dubey n et al. a clinico-pathological profile of primary lung cancer patients presenting in a rural medical… panacea journal of medical science, september december 2015:5(3);124-129 129 20. jindal sk, malik sk, dhand r, gujral js, malik as, dutta bs. bronchogenic carcinoma in northern india. thorax.1982;37:343-47. 21. notani p and sanghvi ld.a reterospective study of lung cancer in bombay.br. j. cancer.1974;29:477-82. 22. thippanna g, venu k, gopalakrishnaiah v, reddy pn, charan bg.a profile of lung cancer patients in hyderabad. j indian med assoc. 1999;97(9):357-9. 23. malik ps, sharma mc, mohanti bk, shukla nk, deo svs, mohan a et al. clinico-pathological profile of lung cancer at aiims: a changing paradigm in india. asian pacific j cancer prev.2013;14 (1): 489-94. http://www.ncbi.nlm.nih.gov/pubmed?term=thippanna%20g%5bauthor%5d&cauthor=true&cauthor_uid=10638080 http://www.ncbi.nlm.nih.gov/pubmed?term=venu%20k%5bauthor%5d&cauthor=true&cauthor_uid=10638080 http://www.ncbi.nlm.nih.gov/pubmed?term=gopalakrishnaiah%20v%5bauthor%5d&cauthor=true&cauthor_uid=10638080 http://www.ncbi.nlm.nih.gov/pubmed?term=reddy%20pn%5bauthor%5d&cauthor=true&cauthor_uid=10638080 http://www.ncbi.nlm.nih.gov/pubmed?term=reddy%20pn%5bauthor%5d&cauthor=true&cauthor_uid=10638080 http://www.ncbi.nlm.nih.gov/pubmed?term=charan%20bg%5bauthor%5d&cauthor=true&cauthor_uid=10638080 http://www.ncbi.nlm.nih.gov/pubmed/10638080 original research article panacea journal of medical sciences, may-august,2016;6(2): 88-91 88 neck pain in computer users aysha siddiqua kalim khan1,*, mohammed faizan2 1ug student, 2associate professor, dept. of orthopedics, nkp salve institute of medical sciences & research centre & lata mangeshkar hospital, nagpur *corresponding author: email: ayshakhan2493@gmail.com abstract in the modern era of networking, technological advances, particularly, invention of computer revolutionized our way of working. increase in industrialization and urbanization lead to increase in health issue related to it, neck pain in computer users is one of them. 59% of wrmsds (work related musculoskeletal disorder) reported annually by it professionals in india, out of which 30% cases are of neck pain. sickness absenteeism due to neck pain is 41%. the prevalence of neck pain in computer users in our study was 28%. data was collected through questionnaire and analyzed through various statistical methods. 40% of computer users have associated complaint like upper limb pain and parasthesias which are related to neck posture. the prevalence is more in females (60%). the neck pain increased with increase in age, 66% neck pain was found in people between 50 -60 years. the prevalence of neck pain was low among those who do regular exercise, in our study only 30% of computer users do regular exercise out of which only 36% develop neck pain. keywords: neck pain, computer users, paraesthesias, neck posture, upper limb pain. access this article online website: www.innovativepublication.com doi: 10.5958/2348-7682.2016.00010.5 introduction musculoskeletal disorders became increasingly common worldwide during the past few decades. it is common cause of work related disability, among workers with substantial financial consequences due to workers compensation(1). neck pain in particular is considered to one of the major health problem in modern societies. it is also increasing in intensity, frequency, and severity because of more stress and strain on the upper back and neck region(2). neck pain is assumed to be multi factorial in origin, implying that several risk factors can contribute to its development. the long term, lower intensity stress and strain and improper posture are believed to be the most important causative factor for neck pain(3). it is important to consider the public health and financial implication of neck pain. chronic neck pain patient uses the health care system twice as often as the rest of the population. over a decade ago, the national institute for occupational safety and health, estimated that the cost associated with work related musculoskeletal disorder was $13 billion annually; more recently, this was projected to be between $45-54 billion. with children being exposed to computer – related activities at even earlier ages, the health of the future work force deserves contemplation. hence this study about prevalence of neck pain among the computer users. there is general agreement that the frequency of neck pain in particular profession is quite high and its symptoms greatly affect the quality of life and need for health care(4). neck problem also accounts for a large proportion of occupational illness and disability and place a heavy load on the compensation insurance system. the prospective studies on prevalence of neck pain are important to study the size and extent of this problem that would facilitate accurate prediction of the need for preventive measures (fig. 1). neck pain is common among computer workers in our country and contributes importantly to the demand for medical services and the economic burden of absence from work due to sickness. population based studies suggest that life time prevalence of over 70% and a point prevalence of between 12% and 34%(5). fig. 1: annual prevalence of pain among it professionals material and method aysha siddiqua kalim khan et al. neck pain in computer users panacea journal of medical sciences, may-august,2016;6(2): 88-91 89 study design: the aim of the study was to find out the prevalence of neck pain in computer users of our institute. the cross-sectional observational study was conducted. survey research as a method of collecting data was used, which involves the measuring relevant sample variable (often using a questionnaire) without any form of manipulation or systemic intervention. data was used to assess the prevalence of neck pain and other variables in the sample population. sample population: in this study, sample population was selected from the computer users of our tertiary care and medical institute. sampling technique: convenient sampling, 50 computer users who are willing to participate in our study. computer users: in this study computer users are defined as person using computers daily for more than 6 hours, and weekly more than 36 hours. neck pain: neck pain is defined in this study as pain experience from the base of the skull (occiput) to the upper part of the back and extending laterally to the outer and superior bounds of the shoulder blade (6-7). inclusion criteria:  both male and female computer users are selected.  aged between 20-60 years, using computers more than 6 hours a day and weekly more than 36 hours. exclusion criteria:  all other persons who are not fulfilling the above mentioned criteria were excluded.  participants were excluded if they have any specific medical condition affecting the cervical spine (such as ankylosing spondylitis, tumors, infection, and rheumatoid arthritis).  any previous surgery that can cause neck pain. we studied the prevalence of neck pain among computer users and its relationship with following factors:  age  gender  duration of job  daily hours of work  physical exercise information regarding neck pain and computer usage was collected through questionnaires. it included:  individual demographic characteristics.  duration of job.  total duration of daily sitting at work.  physical exercise.  postural care.  other related problems like upper limb pain or paraesthesias. data management and the data analysis: the collected data was descriptive data. we used the graph, tables, bar and pie chart for analyzing data, calculated as percentages, and presented this usage bar and pie charts. informed consent: for this study interested subjects were given consent form and the purpose of the research and consent form was explained to each subject verbally. ethical consideration:  followed the guidelines given by the local ethical committee.  institutional review board approval was taken.  participant were explained the purpose and goals of the study.  strictly maintained the confidentiality.  informed consent was taken. results in our study 50 computer users were taken from our institute and other offices. out of which 25 were male and 25 were female. out of 25 female 15 had history of neck pain, i.e. prevalence of neck pain among female is 60%. and out of 25 male only 10 male computer users had history of neck pain, i.e. prevalence in male is 40%. prevalence according to gender is as follow (fig. 2) fig. 2: prevalence of neck pain according to gender out of 50 computer users the distribution according to age is as follow (table 1) table 1: age-wise distribution age group no of participant 20-30yr 15 30-40yr 23 40-50yr 9 50-60yr 3 neck pain and daily hours of work show the direct relationship (fig. 3) aysha siddiqua kalim khan et al. neck pain in computer users panacea journal of medical sciences, may-august,2016;6(2): 88-91 90 fig. 3: relationship between daily hours of work and neck pain neck pain and duration of job (fig. 4): fig. 4: neck pain and duration of job neck pain and physical exercise show following relation (fig. 5) fig. 5: neck pain and physical exercise discussion the prevalence of neck pain in computer users in this study is 28%. 40% of computer users have associated complaint like upper limb pain and paraesthesias which are related to neck posture. the prevalence is more in females (60%). the neck pain is increased with increase in age, 66% neck pain is found in people between 50 -60 years. the prevalence of neck pain is low among those who do regular exercise, in our study only 30% of computer users do regular exercise out of which only 36% develop neck pain, rest 64% are free of pain. for people who spend a great deal of time using computers, neck pain is a common problem. there has been a great technological advances in computer along with an industrial shift to a more service oriented economy. this has lead to a more sedentary jobs as the downsized of the number of employees is used to minimize looses in corporate profits and resulting increase demands in productivity for those who remain with the company and an increase in sick leave resulting from neck pain. this means more people use computer for work and recreation and we must find better ways of coping with neck pain associated with extended use of computer(4). several literature have specifically studied the work related physical risk factors for the development of neck pain, incidence studies showed that 34.4% annual incident of neck pain among office employees working with computers(5-7). while one year prevalence of neck pain among the full time academic staff hong kong university was 46.7% a significant association was found between gender and neck pain. literatures prove that static loading and repetitive movements on the neck muscles are important risk factors for the development of neck pain also a positive co relation between neck pain and neck flexion. a plausible mechanism for strong relation between prolonged sitting and neck pain as working position will lead to continues static load on the neck muscles. physical fitness and endurance are encouraged for the prevention of neck pain. from this study, we found that there are some modifiable and non-modifiable factors, which are related to neck pain. modifiable factor non modifiable factor daily hours of work age life style gender posture duration of job conclusion neck pain has direct relationship with duration of computer job in years, hours of daily work, age of the person. more the age, duration of computer job, daily hours of work more will be the chance of developing neck pain. we can prevent the neck pain with the help of increasing awareness about life style modification, and few simple arrangements at work place according to ergonomic can reduce the neck pain in workers. taking few seconds break in between and releasing constant stress and strain of muscle can also help in decreasing neck pain. references aysha siddiqua kalim khan et al. neck pain in computer users panacea journal of medical sciences, may-august,2016;6(2): 88-91 91 1. andersson gbj. epidemiologic features of chronic low back pain. lancet 1999;354:5815. 2. binder ai. cervical spondylosis and neck pain. bmj 2007;334(7592):527-31. 3. stupar m, shearer h, cote p. prevalence and factor associated with neck pain in office workers. in: proceeding of the world congress on the neck pain; los angeles. toronto: canadian institute for the relief of pain and disability 2008:154. 4. cote p, cassiy jd, carroll l. the saskatchewan health and back pain survey. the prevalence of neck pain and related disability in saskatchewan adults. spine 1998;23:1689-1698. 5. croft p, johnson sh, velde gv, carroll l, peloso. the burden and determinants of neck pain in workers: result of the bone and joints decade 2000-2010. task force on neck pain and its association disorder. spine j 2008;33(4 suppl):s60-74. 6. tsauo j, jang y, du c, liang h. incidence and risk factor of neck discomfort: 6 month sedentary – worker cohort study. j occup rehabil 2007;17:171-179. 7. cagni b, danneels l, vantiggelens d, deloose v, cambier d. individual and work related risk factor of neck pain among office workers: a cross sectional study. eur spine j 2007;16(5):679-86. original research article doi: 10.18231/2348-7682.2018.0002 panacea journal of medical sciences, january-april 2018;8(1):3-9 3 predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre in central india madhuri holay1, rajashree khot2,*, amit bhatti3, madhuri paithankar4 1,2associate professor, 3senior resident, 4professor, dept. of medicine, government medical college, nagpur, maharashtra, india *corresponding author: email: rajunkmail@yahoo.com abstract cerebral venous sinus thrombosis (cvst) is a less common cause of stroke when compared to arterial thrombosis but its clinical presentation is varied and atypical. early diagnosis may prevent morbidity & mortality which in untreated cases has been reported as 13.8 -48%. materials and methods: this prospective observational study included 40 radiologically diagnosed cases of cvst, to evaluate the predictors of outcome by using modified rankin’s scale (mrs). the primary outcome measure was death or dependency at the end of 12 weeks. results: of 40 patients, 18 cases (45.5%) had mrs 0-3 & 22(55%) had mrs >3. mean age of the cases was 32.22 yrs with m:f= 1: 0.81. purperium was the commonest risk factor. in univariate analysis, age>30(p==0.10), coma (p=0.010) and cheyne stokes breathing (p-<0.001) were statistically significant predictors of poor outcome. on ct imaging haemorrhagic infarct & deep venous sinus thrombosis was a significant predictor of poor outcome (p=<0.001). on multivariate analysis age>30, cerebral haemorrhage and deep venous sinus thrombosis were the predictors of poor outcome. rankin’s score of < 2 had good prognosis at 12 weeks follow up. overall mortality was 15% at 12 weeks follow up. conclusion: cvst is an important cause of stroke in puerperium. neuroimaging plays pivotal role in diagnosis. modified rankin’s scale is a simple score system risk stratification of patients with neurodeficit. low mrs score at hospitalization is associated with better outcome at 12 weeks. keywords: cerebral venous sinus thrombosis (cvst), modified rankin’s scale (mrs) <2, good outcome. introduction cerebral venous sinus thrombosis (cvst) is an uncommon cause of stroke as compared to arterial stroke, but its clinical presentation is varied and often dramatic. it usually affects young and middle-aged patients, and more commonly women. although recognized for more than 100 years,1 it has only in recent years come to be diagnosed ante-mortem, frequently. this is partly due to greater awareness among physicians and neurologists, and partly to improved non-invasive imaging techniques. although it may present with a variety of signs and symptoms, headache is the most frequent and often the earliest manifestation.2 despite the improvements in its diagnosis and treatment, cvst may still cause death or permanent disability. the outcome of the patients with cerebral venous sinus thrombosis may vary from complete recovery to permanent neurological deficits as a natural course of the disease.3 in the acute phase, it is important to identify those patients who have a poor prognosis because this may influence the therapeutic strategy and enable the treating physician to give reliable information to the patient and his/her relatives. in contemporary studies, the reported mortality rate was found to range between 8% and 14%.4 this was in contrast to previous studies in which cause specific mortality was as high as 30% to 50%.5 cvst has an acute case fatality of less than 5% and almost 80% patients recover without sequelae.4 it has been found that early diagnosis of cerebral venous thrombosis is essential because early treatment may prevent morbidity and may even be lifesaving. reliable data on the natural history and the prognosis of cvst are scarce. therefore, this prospective observational study was undertaken to determine the predictors of outcome in cvst. materials and methods institutional ethics committee of govt medical college, nagpur gave clearance for this study. 40 consecutive patients admitted to govt medical college, nagpur, a tertiary care institute, which caters to a large population from central india, over a period of 2 years from 1st january 2015 to 31st december 2016 with a clinical & radiologically confirmed diagnosis of cerebral venous sinus thrombosis within 48 hours after admission were included in the study. the duration between onset of symptoms and hospitalization was less than 7 days. the last case was enrolled on 10th sept 2016 considering their duration of hospital stay & 12 weeks follow up. the patients who were enrolled in the study were evaluated for various risk factors like ear infections, meningitis, malignancy, sickle cell disease, and hyperhomocystinemia. they were followed up throughout their hospital stay and after discharge for 12 weeks & their outcome was assessed according to modified rankins scale. madhuri holay et al. predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre… panacea journal of medical sciences, january-april 2018;8(1):3-9 4 study design and study setting: this prospective observational study was carried out in 40 diagnosed cases of cerebral venous sinus thrombosis in the department of medicine, government medical college, nagpur, a tertiary care center in central india. study population: all the cases with confirmed diagnosis of cvst based on neuro imaging i.e. ct scan head or mri brain. ct machine used was 256 slice tct philip and mri was done on 1.5 tesla (acheiva) philip. patients below 12 years, arterial stroke & critically ill patients with comorbid conditions unrelated to cerebral venous sinus thrombosis were excluded from the study. written consent was obtained from all the cases with normal level of consciousness & from legally acceptable representative (lar) in unconscious patients. all the ct positive cases of cvst were further subjected for mri/mri venography. total duration from onset of symptoms & radiological confirmation of diagnosis was maximum 48 hrs. criteria for diagnosis of cvst on ct/mri imaging: on plain ct, demonstration of hyperdense sinus & non enhancement or typical empty delta sign on contrast ct was considered as thrombus in cerebral venous sinuses. on mri/mri venography, loss of t2w flow void in sinus & noncontrast opacification and post contrast presence of infarcts in their drainage territory was suggestive of cvst. on mri venography non visualization of sinuses, smaller cerebral veins or cortical veins with low flow were also considered for diagnosis of cvst.6 deep cerebral vein thrombosis was diagnosed when involvement of internal cerebral vein, the basal veins of rosenthal & their tributaries resulting into unilateral or bilateral venous congestion and venous infarct in thalami & basal ganglia was seen on neuro imaging.6 demographical, clinical, laboratory, and radiological data was recorded. all investigations like complete blood count, blood sugar, liver function tests, serum creatinine, blood urea nitrogen, serum electrolytes, prothombin time, activated partial thromboplastin time and international normalised ratio were done in all patients. workup for hypercoagulable states including serum homocysteine, antithrombin iii, protein c, protein s deficiency and anticardiolipin antibody, factor v leiden mutation, lupus anticoagulant, hb electrophoresis were also performed. a thorough clinical and neurological examination was done. glasgow coma scale (gcs) was used to assess the severity of neurological dysfunction. the patients were divided into 3 categories according to gcs – 0-8, 9-13 and 14-15. the functional status was assessed on a modified rankin scale (mrs) at admission, discharge and at 12 weeks follow-up. the outcome was dichotomized as good (mrs score of 0–2) or poor (mrs score ≥3). in addition, the in-hospital mortality was recorded separately. during follow up, data regarding disability (according to modified rankin scale [mrs]), death, recurrent symptomatic sinus thrombosis (new symptoms with new thrombus on repeated venogram or mri), other thrombotic events, seizures, headaches requiring bed rest or hospital admission were recorded. the primary outcome used was death or dependency at the end of 12 weeks which was defined as mrs score >3. modified rankin’s scale7,8 score description 0 no symptoms at all 1 no significant disability despite symptoms; able to carry out all usual duties and activities 2 slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance. 3 moderate disability; requiring some help, but able to walk without assistance. 4 moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 severe disability; bedridden, incontinent and requiring constant nursing care and attention 6 dead in addition to the functional status assessement on a modified rankin scale (mrs) at admission, discharge and at 12 weeks follow-up level of consciousness (altered level of consciousness or coma) was assessed on glasgow coma scale.(gcs). gcs between 0-8 were labeled as coma while gcs between 9-13 were labeled as altered level of consciousness (excluding all secondary causes of altered consciousness like electrolytes imbalance, metabolic causes, hypoxia, and infections). all the cases were treated with either inj unfractionated heparin or inj. low molecular weight heparin (lmwh) followed by oral anticoagulants; warfarin, along with supportive treatment and continuing other standard care. statistical analysis the data was analysed by the spss, version 14.0 (spss inc). χ2 tests (or fisher’s exact test whenever appropriate) were performed to analyze the univariate madhuri holay et al. predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre… panacea journal of medical sciences, january-april 2018;8(1):3-9 5 relationship between the possible prognostic factors and the outcome at 12 weeks. as the sample size was small, fischers exact test was used for calculating the p-value. as it was likely that the different prognostic factors were mutually related, the independent effects of the prognostic factors were additionally analyzed by using multivariate logistic regression. subsequently, all the variables with p< 0.05 which were identified in the univariate analysis was presented to a logistic regression model to assess their independent association. the significant prognostic factors were selected with a forward selection strategy by using the likelihood ratio statistic, with p ≤ 0.05 as the criterion level for selection. the effect sizes were expressed as the odds ratios (or). the or can be interpreted as an estimation of the relative risk of a poor outcome. results this prospective observational study comprises total 40 confirmed cases of cerebral venous sinus thrombosis. base line characteristic of these patients revealed, mean age of 31.29 + 8.64 years. males out numbered females marginally with a male: female ratio of 1:0.8. amongst etiological causes, puerperium was the most important cause of cvst in 27.5% cases. the most commonly involved venous sinus was the superior sagittal sinus in 75% cases. apart from the presence of sinus thrombosis, hemorrhagic infarct was seen in 55% cases on ct/mri. there was an overlap of imaging findings. some patients had more than one finding on imaging, eg. 15 patients had haemorrhage out of which 5 had isolated haemorrhage & 10 patients had haemorrhage with haemorrhagic infarct. non haemorrhagic infarct was observed in 13 cases. cerebral oedema was also observed in 19 patients along with haemorrhage and infarction. modified rankins score was between 3-5 in 25(62.5%) cases & 0-2 in 15(37.5%) at the time of hospitalization. in univariate analysis, age >30yrs, and neurological signs like paresis, papilloedema, and coma were significantly associated with poor outcome (p=0.010,p=0.42,p=0.017, p=0.010). no statistically significant association was found between clinical outcome and gender (p value 0.271) and other risk factors. on ct/mri, in addition to dvst, cerebral hemorrhage (p value 0.001) and cerebral oedema (p value 0.002) were associated with poor outcome, which was statistically significant. figure 3 shows mr venography with lateral sinus thrombosis. involvement of deep venous sinuses (dvst) was associated with poor outcome. 6 out of 8 i.e.87.5% cases had a poor outcome at the end of 12 weeks. (p value < 0.001). no significant association was observed between number of sinus involved and outcome. (table 1) table 1: baseline characteristics, imaging features, risk factors and outcome (univariate analysis) baseline characteristics no of patients (%) (n=40) outcome p-value poor (%) (n=10) good (%) (n=30) age <30 yrs 22 (55) 2(20) 20(66.6) 0.010, >30 yrs 18(45) 8(80) 10(33.4) gender male 22 (55) 4 (40) 18 (60) 0.271 female 18(45) 6 (60) 12 (40) clinical features headache 32 (80) 6 (60) 26 (86.6) 0.068 seizure 20 (50) 5 (50) 15 (50) 1.00, vomiting 17 (42.5) 4 (40) 13 (43.4) 0.853, paresis 17 ( 42.5) 7 (70) 10 (30) 0.042, papilloedema 13 (32.5) 8(80) 11(36.6) 0.017, glasgow coma score 3 – 8 (coma) 09 (22.5) 04 (40) 05 (16.7) y2= 3.2339 p =0.199 9-13(altered sensorium) 10(25) 3(30) 7(23.3) 14-15 21(52.5) 3(30) 18(60) fever 09(22.5) 02 (20) 07 (23.3) 0.827 dyspnea 06(15) 05(50) 01(3.3) <0.001 madhuri holay et al. predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre… panacea journal of medical sciences, january-april 2018;8(1):3-9 6 blurring of vision 05 (12.5) nil 05 (16.7) 0.168 ct/mri lesion hemorrhage 15 (37.5) 08(80) 07(23.3) 0.001 hemorrhagic infarct 22(55) 08(80) 14(46.6) 0.067 non-hemorrhagic infarct 13(32.5) 04(40) 09(30) 0.559 cerebral oedema 19 (47.5) 09(90) 10(33.3) 0.002 sinus involvement superior sagittal 30 (75) 09(90) 21(70) 0.206 sigmoid 22 (55) 05(50) 17(56.7) 0.712 transverse 19 (47.5) 05(50) 14(46.6) 0.855 deep venous sinus thrombosis 08 (20) 06(60) 02(6.6) <0.001 inferior sagittal 03 (7.5) nil 03(10) 0.298 cavernous 02 (5) nil 02(6.6) 0.402 internal jugular vein 01(2.5) nil 01(3.3) 0.402 no. of sinus involved 1 12 (30) 01 (10) 11(36.7) 0.1520 2 13 (32.5) 04 (40) 09 (30) >2 15 (37.5) 05(50) 10(33.3) risk factors puerperium 11(27.5) 02(20) 09(30) 0.540 idiopathic 09 (22.5) 02(20) 07(23.3) 0.783 ent infections 07 (17.5) 02 (20) 05(16.7) 0.810 hyperhomocysteinemia 07(17.5) 02(20) 05(16.7) 0.810 sickle cell disease 03(7.5) 01(10) 02(6.6) 1.000 oral contraceptive pills 01(2.5) nil 01(3.3) 0.559 malignancy 01(2.5) 01(10) nil 0.250 meningitis 01(2.5) nil 01(3.3) 0.559 on a multivariate analysis, age >30 years (p value 0.024), cerebral haemorrhage on imaging (p value 0.018) and deep cerebral venous system (p value 0.018) involvement were associated with a poor outcome at 12 weeks of follow-up. (table 2) table 2: mrs and outcome at discharge and at 12 weeks outcome good outcome mrs <3 poor outcome mrs ≥3 at discharge (mean hospital stay 10 days) 22 (55) 18 (45) at 12 weeks 30 (75) 10 (25) functional status of the cases at admission showed 15 cases (37.5%) with 0-2 mrs while 25 case (62.5%) with> 3 mrs (table 3) table 3: outcome at discharge and at 12 weeks follow-up by modified rankin’s scale modified rankin scale functional status on admission n=40 outcome at discharge n=40 outcome at 12 weeks n=35* no. of cases (%) no. of cases (%) no. of cases (%) 0 nil 11 (27.5) 20 (57.14) madhuri holay et al. predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre… panacea journal of medical sciences, january-april 2018;8(1):3-9 7 1 13 (32.5) 05 (12.5) 08 (22.85) 2 02 (5) 06 (15) 02 (5.71) 3 03 (7.5) 07 (17.5) 03 (8.57) 4 08 (20) 05 (12.5) 01 (2.85) 5 14 (35) 01 (2.5) 6 (death) nil 05 (12.5) 01 (2.85) total 40 (100) 40 (100) 35* (100) death or dependency 25 (62.5) 18 (45) 10 (25) * five patients died during the hospital stay overall mortality was (15%) i.e. 6 out of 40 cases. five patients died during their hospital stay and one during follow up. mrs score of >3 showed more disability & mortality. in hospital mortality in 5 cases was primarily due to cvst attributed to involvement of deep cerebral vein thrombosis, cerebral edema and gcs < 8, while 1 patient died at home and exact cause could not be ascertained. thus 45% cases (n=18) had poor outcome (mrs >3) at the time of discharge but at the end of 12 weeks there was functional improvement and this figure was reduced to 25% (n=10) (table 4). table 4: multiple logistic regression analysis for factors associated with poor prognosis of cvst at 12 weeks variable adjusted odds ratio 95% confidence interval p-value age >30 yrs 32.23 1.12 – 92.08 0.042, s gcs 0.68 0.09 – 4.75 0.703, ns papillodema 2.34 0.11 – 49.93 0.585, ns cerebroedema 0.47 0.014 – 15.84 0.677, ns cerebral haemorrhage 23.95 1.07 – 53.67 0.045, s dvt 6.35 1.57 – 19.13 0.028, s p<0.5 is significant, other variables were dropped because of linearity discussion cvst is a great masquerader as it can present in various forms and confuse the clinician. it manifests as a stroke with seizures confusing it with arterial strokes. one of the greatest advances in the field of cvst is the change in outcome and prognosis of the disease throughout the years. it may be helpful in the acute stage to identify those patients who are likely to have a poor outcome, as this provides useful prognostic information for relatives and possibly influence the use of more invasive treatment. in early series of cerebral venous thrombosis (largely diagnosed by angiography) and largely related to sepsis, mortality was 30–50%. recent studies have shown a mortality rate closer to 10%.4 predisposing causes of cvst are multiple. the risk factors for venous thrombosis in general are linked classically to the virchow triad of stasis of the blood, changes in the vessel wall, and changes in the composition of the blood. amongst the risk factors, purperium emerged as the commonest risk factor for cvst in the present study. a study from south india also observed same risk factor as reported by us.9 but the results of the western studies are different, where oc pills consumption & hrt were the commonest risk factors seen.4,10 oral contraceptive use was not a major risk factor in our setting which was implicated in majority of western female patients. this could be attributable to better obstetric facilities in west along with awareness of contraception resulting in higher number of female opting for hormonal contraceptives as compared to indian women. in the past, cvst was associated with a dismal prognosis and high mortality rate, reaching 30–50%.10 the outcome of cvst has improved tremendously in the past few decades. the decreased mortality rates over the last 30 years may be the consequence of: (i) the development of brain mri allowing an early diagnosis of benign cases of cvt, which may have remained undiagnosed before the era of mri, and (ii) early anticoagulation even in the hemorrhagic cases.12 this study is one of the few studies where mrs is used as a prognostic indicator in cvst patients. mrs is usually applied to patients with arterial stroke. we found it to be a significant predictor of outcome in cvst. patients of cvst having mrs score between 36 showed poor outcome in the form of death or functional dependency at 12 weeks, similar to that reported by few authors 14,17. the period of follow up was variable from 16-36 months. overall mortality reported in earlier studies was 6.67%, 4.39% & 15%.10,15 in the present study overall madhuri holay et al. predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre… panacea journal of medical sciences, january-april 2018;8(1):3-9 8 mortality was noted in 15% of cases having mrs score between 3-6 which is slightly higher. high mortality may be attributed to involvement of deep cerebral vein thrombosis in 8 (20%) cases which is a risk factor for death as reported in previous literature. the deep cerebral veins (internal cerebral veins, the basal veins of rosenthal) & their tributaries are involved in approximately 10% of patients of cvst. it may result in unilateral or more typically bilateral venous congestion and venous infarction of the thalami and basal ganglia.6 involvement of deep veins has been shown to be risk factor for death & long term sequelae.17,18 the less mortality reported in previous studies might be due to less involvement of deep cerebral veins4,9 (< 10%). overall prognosis for survival and functional independence is better than it was believed. mortality usually ranges from 4-15%.15,16 the extent of functional recovery in survivors of cvst is better as compared to patients with arterial thrombosis in which the proportion of permanent dependent patients ranges between one third and two third of survivors which is in contrast to cvt in which an independent survival of around 80% is commonly found. identifying patients who are at a high risk for unfavourable outcomes may provide an opportunity for the development of novel therapeutic paradigms including thrombolysis (systemic versus endovascular) and early neurosurgical interventions.8 the predictors of mortality in multivariate analysis were age>30 yrs, haemorrhagic infarcts, predisposing haemorrhagic disorders, cns infections & malignancy as reported in literature.9,12,13,15 in present study the predictors of poor outcome were age > 30, intracranial hemorrhage at the time of hospitalisation and deep cerebral venous system thrombosis. in multivariate analysis. other factors did not show statistically significant association with poor outcome, probably because of the small number of patients in our study, leading to a lack of statistical power. conclusion thus we conclude that age > 30 years, deep venous sinus involvement, and intracerebral haemorrhage are predictors of poor outcome. modified rankins scale is a simple score system for categorization of clinical status of patients with neurological impairement in venous stroke also. low mrs at hospitalization is associated with better outcome in terms of survival and functional disabilities. study limitation small sample size may be a limitation of the study and studies with larger sample size are needed to validate the findings of present study. source of funding: self and institute conflicts of interests: nil references 1. bousser mg cerebral venous thrombosis: nothing heparin or local thrombolysis. stroke, 1999;30:481-3. 2. ameri a,bousser mg: cerebral venous thrombosis. neurol clini,1992;10:87-111. 3. einhaupl km, villringer a, habert rl, pfister w, deckert m, steinhoff h, et al. clinical spectrum of sinus venous thrombosis. in: einhaupl km, kempski o, baethmann a, editiors. cerebral sinus thrombosis;experimental and clinical aspects. new york: plenum press; 1990;149-56. 4. ferro jm,canhao p stam j,bousser mg barinagarrementeria f for the iscvt investigators:prognosis of cerebral vein and dural sinus thrombosis : results of the international study on cerebral vein and dural sinus thrombosis(iscvt). stroke;2004;35:664-70. 5. bousser mg, ferro jm. cerebral venous thrombosis: an update. lancet neurol. 2007;6:162-70. 6. j linna.t pfefferkorn,k.lvanicova, s.muller, s chunk,et al. noncontrast ct in deep cerebral venous thrombosis and sinus thrombosis comparison of its diagnostic value for both entities. american journal of neuro radiology 2009;30:728-35. 7. rankin j. cerebral vascular accidents inpatients over the age of 60 & prognosis. scott med j 2(5) may 1957; 20015 pmid13432835 8. farrell b,godwin j,richards s,warlow c: the united kingdom trasient ischemic attack( uk-tia) aspirin trial final results .j neurol neurosurg psychiatry 1991:54(12)1044-1054 doi:10,1136/jnnp.5412.1044.pmc1014676.pmid 1783914. 9. halesha br,chennaveerappa pk, vittak bg, jayashree n: a study of the clinical features and the outcome of cerebral venous and sinus thrombosis ina tertiary care centre in south india. j.of clinical and diagnostic research (serial online)2011 june(cited 2011 sep29);5’443-7. 10. stolz e,rahimi a,gerriets t,kraus j,kaps m: cerebral venous thrombosis an all or nothing disease? prognostic factors and long term outcome. clini neurol neurosurg 2005;107(2)99-107. 11. gustavo saposnik, aha/asa scientific statement diagnosis and management of cerebral thrombosis; a statement for health care professionals from american heart association/american stroke association. stroke 2011;42:1158-92. 12. de leys, breteau g. cerebral venous and sinus thrombosis 3 years clinical outcome in 55 cosecutive patients. j neurol 2003 jan,250(1)29-35. 13. de bruijn s,stam j,koopmam m, vandenbrouk j:casecontrol etudy of risk of cerebral venous thrombosis in oral contraceptive users who are carriers of hereditary prothrombotic conditions br med j,1998;316:589-92. 14. khealani ba; cerebral venous and sinus thrombosis a descriptive multicenter study of patients in pakistan and middle east stroke 2008 oct 39(10);2707-11. 15. haghighi: mortality of cerebral venous and sinus thrombosis in a large national sample. stroke 2011; print issn : 0039-2499. onlineissn 1524-4628. 16. mahashur f, mehreain s,einhaupal k: cerebral venous and sinus thrombosis. j.neurol 2004;251:11-23. 17. patil vc1, choraria k1, desai n1, agrawal s1. clinical profile and outcome of cerebral venous sinus thrombosis at tertiary care center. j neurosci rural https://www.ncbi.nlm.nih.gov/pubmed/?term=patil%20vc%5bauthor%5d&cauthor=true&cauthor_uid=25002759 https://www.ncbi.nlm.nih.gov/pubmed/?term=choraria%20k%5bauthor%5d&cauthor=true&cauthor_uid=25002759 https://www.ncbi.nlm.nih.gov/pubmed/?term=desai%20n%5bauthor%5d&cauthor=true&cauthor_uid=25002759 https://www.ncbi.nlm.nih.gov/pubmed/?term=agrawal%20s%5bauthor%5d&cauthor=true&cauthor_uid=25002759 https://www.ncbi.nlm.nih.gov/pubmed/25002759 madhuri holay et al. predictors of outcome of cerebral venous sinus thrombosis at a tertiary care centre… panacea journal of medical sciences, january-april 2018;8(1):3-9 9 pract. 2014 jul;5(3):218-24. doi: 10.4103/09763147.133559. 18. gunes hn1, cokal bg1, guler sk1, et al. clinical associations, biological risk factors and outcomes of cerebral venous sinus thrombosis. j int med res. 2016 dec;44(6):1454-1461. doi: 10.1177/0300060516664807. epub 2016 nov 10. https://www.ncbi.nlm.nih.gov/pubmed/25002759 https://www.ncbi.nlm.nih.gov/pubmed/?term=gunes%20hn%5bauthor%5d&cauthor=true&cauthor_uid=28222615 https://www.ncbi.nlm.nih.gov/pubmed/?term=cokal%20bg%5bauthor%5d&cauthor=true&cauthor_uid=28222615 https://www.ncbi.nlm.nih.gov/pubmed/?term=guler%20sk%5bauthor%5d&cauthor=true&cauthor_uid=28222615 https://www.ncbi.nlm.nih.gov/pubmed/28222615 name: original research article doi: 10.18231/2348-7682.2018.0013 panacea journal of medical sciences, may-august, 2018;8(2):51-53 51 serological profile of rheumatoid arthritis in a tertiary care hospital p.k surendran1 1assistant professor, p.k das institute of medical science, vaniyamkularn, kerala, india *corresponding author: email: surendranpkdr@gmail.com abstract rheumatoid arthritis (ra) is an autoimmune based inflammatory pathology with involvement of joints that show early morning stiffness alongwith pain resulting in loss of function. it usually affects females aged 30 years or above. a total of 150 patients of rheumatoid arthritis were included in the present study of which 120 were females and 30 males (f:m=4:1). serological tests were carried out in these patients. these test were analyzed for their sensitivity as well as specificity. combination of various test were also assessed for their results. in the present, study age and sex of patient affected by rheumatoid arthritis was analysed. combination of serological tests provided a high specificity as can be seen from the present study. quantitative rheumatoid factor estimation and anti rheumatoidantibodies assay gave the maximum specificity of 89.8%. a combination of serological tests is advisable rather than a single diagnostic test.this allows for the early diagnosis of rheumatoid arthritis so as to prevent complications by the disease. keywords: investigations, rheumatoid arthritis, serology, specificity, sensitivity. introduction rheumatoid arthritis (ra) has a prevalence of about 0.5% to 1% and an incidence of about 30 per 100 000 inhabitants, making it one of the commonest chronic inflammatory autoimmune disease.1-3 rheumatoid arthritis (ra) is an inflammatory autoimmune pathology involving joints mainly leading to pain, early morning stiffness and restriction of movements. cartilages, synovium, and certain systems of the body are affected with autoimmunity and inflammatory processes of ra. early diagnosis and aggressive treatment are the best means of avoiding joint destruction, damage to organs and disability. studies on the spectrum and expression of ra in asian population are limited in the literature.5-7 this prospective study was carried out to determine the relationship between ra and laboratory tests used in the diagnosis of ra.traditionally females are affected about three to four times more often than men. materials and methods this prospective study was carried out over a period of one year in a tertiary care teaching hospital between january 2017 and dec 2017. all patients who were clinicallysuspected to be suffering from ra were included in the present study. approval of the institutional ethical committee was taken.written consent was taken from all the patients who were included in the study. a total of 150 patients with 30 males and 120 females were included with a m:f ratio of 1:4. the age ranged from 23 years to 74 years. patients undergoing any treatment or previously diagnosed cases of ra were excluded from the study. all patients included in the study were subjected to all the investigations such as complete haemogram, esr, quantitative c-reactive protein (crp), rheumatoid factor (latex as well as quantitative), and anti ccp antibodies (anti-cyclic citrullinated peptide). esr was estimated using automated analyzer. crp and ra factor latex test was carried out using kits from tulip diagnostics. quantitative assays were performed using automated analysers as per the manufacturer’s instructions and protocol. statistical analysis was done using spss (statistical package for the social sciences) version 17.0 for windows software. p value of <0.05 was considered as statistically significant. results a total of 150 cases were included in the present study. the age and sex distribution of the cases is shown in table 1. table 1: age and sex distribution of patients with rheumatoid arthritis s. no. age group males females total n(%) 1 20 29 3 28 31(20.7%) 2 30 39 8 34 42(28.0%) 3 40 49 6 29 35(23.3%) 4 50 59 6 15 21(14.0%) 5 60 69 4 12 16(10.7%) 6 70 79 3 2 5(3.3%) total 30 120 150(100%) p.k surendran serological profile of rheumatoid arthritis in a tertiary care hospital panacea journal of medical sciences, may-august, 2018;8(2):51-53 52 the male: female ratio was 1:4. majority of the cases were in the age group of 30-39 years, followed closely by 40-49 years.the mean age was 45.2 years. results of the serological tests carried out in the patient are depicted in table 2. table 2: distribution of patients as per the results of the serological tests (n = 150) s. no. n % 1 raised esr 126 84.0 2 increased crp 132 88.0 3 anti ccp positive 112 74.7 4 ra factor positive 139 92.7 5 high quantitative ra factor 143 95.3 quantitative ra factor was raised in 143 of the 150 patients (95.3%). anti ccp antibodies were present in only 112 of the 150 patients (74.7%).there has been an observed overlap between the serological tests also. in some patients multiple parameters were positive or their values were more than the normal. we also studied the sensitivity and specificity of different serological markers as well as their combinations (table 3). table 3: sensitivity and specificity of different serological tests in the present study sensitivity specificity esr 92.1% 68.2% crp 84.1% 70.4% anti ccp antibodies 74.2% 88.5% r a factor (latex) 38.2% 87.8% quantitative r a factor 71.8% 64.6% anti ccp + q r a 71.4% 94.1% anti ccp + latex r a 52.4% 89.8% combination of test increases the specificity rates significantly. it was further observed that patients with multi joint involvement if tested negative for both latex ra factor as well as anti ccp antibodies indicate that the patient is not having rheumatoid arthritis. there was a positive correlation between anti-ccp antibodies and higher esr, crp. also there was a positive correlation between rf and increased esr and crp.in this study fifty percent of the patients were both anti-ccp and rf positive. the study (p<0.05) revealed significant positive correlation between rf and anti-ccp antibodies. discussion rheumatoid arthritis is a systemic disease, accompanied by progressive joint destruction and deformity. depending on the severity, there may also be extra-articular manifestations, involving skin, vascular channels, and internal organs as well. if inadequately treated, ra leads in the long term to a significant impairment of the quality of life; morbidity and increase in mortality. early diagnosis and suitable therapy are therefore of great importance in determining the prognosis of ra. the three pillars for the diagnosis of rheumatological disease are a good medical history, clinical findings (including radiological investigations) and serological laboratory tests. serological diagnostic testing is of growing importance in the early detection and differentiation of rheumatoid arthritis. apart from the traditional detection of rheumatoid factor, new specific autoantibodies to citrullinated antigens have made a crucial contribution to the diagnosis of ra. the rheumatoid factor is an autoantibody, which may be igm, igg or iga, and which was first mentioned in 1922.1 it recognizes domains ch2 and ch3 of the fc segment of human igg and is a component of the classification criteria for ra published by the american college of rheumatology.2 the classification criterion to define ra that is used internationally was defined by the american college of rheumatology (acr) in 1987. new criteria for rheumatoid arthritis classification were introduced in 2010.1 ra sera contained antibodies that reacted to the keratinized layer of epithelial cells. these were called antikeratin antibodies, and were reported only in ra patients. anti-ccp was included in the acr/eular (european league against rheumatism) ra classification criteria in 2010. erythrocyte sedimentation rate (esr), c-reactive protein (crp), and rheumatoid factor (rf) are the other serological tests used in the ra classification criteria. assessment of anti-ccp, rf, esr and crp in the serum was included in the acr/eular ra classification criteria in 2010. several studies have questioned the importance of anti-ccp antibody testing in distinguishing ra from other inflammatory diseases.1-2 joints that showed erosion or destruction showed strong association with anti ccp antibodies.3 ra has been associated with several autoantibodies, including rheumatoid factors (rf), anti‐perinuclear factor (apf), anti‐keratin antibodies (aka) and anti‐filaggrin antibodies (afa).4 p.k surendran serological profile of rheumatoid arthritis in a tertiary care hospital panacea journal of medical sciences, may-august, 2018;8(2):51-53 53 these autoantibodies bind antigenic determinants that contain the unusual amino acid citrulline, formed by a post‐transcriptional modification of arginine residues by peptidylarginine deiminase. to detect these autoantibodieselisa is used. this method uses as antigen a cyclic variant of a citrullinated peptide (ccp) derived from the sequence of human filaggrin. the anti‐ccp antibody test is now commercially available and its diagnostic accuracy is comparable with that of the rf test5. the diagnostic accuracy of this test in the detection of ra is still unclear, as sensitivities ranging from 41 to 68% have been reported.3,6,7 in the present study a comparison of the sensitivity and specificity of the anti‐ccp antibody test with those of other tests commonly used in the diagnosis of ra. role of these autoantibodies in assessing the severity of the disease is unknown.8-10 the present study establishes the value of anti‐ccp antibodies in the diagnosis of ra both singly as well as in combination. the specificity obtained for the anti‐ccp test (88.5%) was almost similar to that found by other groups: 91–98%.1,8-10 however, although there is consensus by different authors regarding specificity, there is significant variation in the sensitivity, rates ranging from 41–68%. this variation may be attributed to the different dilutions of serum used or, to the different cut‐off values as per the diagnostic test employed. the anti‐ccp antibody test has moderate sensitivity and excellent specificity, the aka test has poor sensitivity but excellent specificity, and the igm rf test has moderate sensitivity and specificity11-15. a positive test for anti‐ccp antibodies or aka practically establishes this diagnosis. hence these tests, may prove more useful in selected cases in clinical practice especially in cases where significant disagreement between these tests exist, true positives among ra patients and false positives among controls, suggests that there is considerable room for improvement in the serological diagnosis of ra.16 whether these tests are able to predict the occurrence of clinical or radiological manifestations of ra remains a mystery. the present study was cross‐sectional and therefore liable to possible selection bias. prospective studies would probably have produced more information than a cross‐sectional study of patients with definite ra. however, in prospective studies, it is mandatory to predict that treatments have not affected the results.17 conclusion in conclusion, our results suggest that anti‐ccp antibodies, aka and igm rf reflect clinically relevant disease processes in ra patients. however, in clinical practice, both igm rf and anti‐ccp antibodies may be useful, igm rf for their good sensitivity and as a marker of disease severity and anti‐ccp antibodies for their high specificity and their presence in some ra‐seronegative patients. references 1. tennakoon tmis, nissanka tm, bandaranayake bmvc. the spectrum of rheumatoid arthritis. a single unit experience. anuradhapura medical journal. 2015;9(2supp):s38. 2. aletaha d, neogi t, silman aj, funovits j, felson dt, bingham co, et al. an american college of rheumatology/ european league against rheumatism collaborative initiative 2010 rheumatoid arthritis classification criteria. arthritis rheum. 2010;62:25692581. 3. visser h, le cessie s, vos k, breedveld fc, hazes jmw. how to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. arthritis rheum. 2002;46:357-365. 4. goldbach‐mansky r, lee j, mccoy a. rheumatoid arthritis associated autoantibodies in patients with synovitis of recent onset. arthritis res. 2000;2:236–43. 5. schellekens ga, visser h, de jong ba. the diagnostic properties of rheumatoid arthritis antibodies recognizing a cyclic citrullinated peptide. arthritis rheum. 2000;43:155–63. 6. bizzaro n, mazzanti g, tonutti e, villalta d, tozzoli r. diagnostic accuracy of the anti‐citrulline antibody assay for rheumatoid arthritis. clin chem. 2001;47:1089–93. 7. gupta r, thabah mm, aneja r, chandrasenan pj. usefulness of anti-ccp antibodies in rheumatic diseases in indian patients. indian j med sci. 2009;3:92. 8. kashyap b, tiwari u, garg a, kaur ir. diagnostic utility of anti-ccp antibodies and rheumatoid factor as inflammatory biomarkers in comparison with c-reactive protein and tnf-y in rheumatoid arthritis. trop j med res. 2015;18:5-9. 9. lee dm, schur ph. clinical utility of the anti-ccp assay in patients with rheumatic disease. ann rheum dis. 2003;62:870-874. 10. swedler w, wallman j, froelich cj, teodorescu m. routine measurement of igm, igg and iga rheumatoid factors: high sensitivity, specificity and predictive value for rheumatoid arthritis. j rheumatol. 1997;6:1037-44. 11. arnett fc, edworthy sm, bloch da. the american rheumatism association 1987 revised criteria for the classification of rheumatoid arthritis. arthritis rheum. 1988;31:315-24. 12. schellekens ga, visser h, de jong ba. the diagnostic properties of rheumatoid arthritis antibodies recognizing a cyclic citrullinated peptide. arthritis rheum. 2000;43:155-63. 13. ahmad a, singh tb, usha. an epidemiological study on clinical suspected rheumatoid arthritis rural patients of eastern uttar pradesh, india. irmjcr. 2014;2(1):48-54. 14. bharathi kv, sobharani yn, sridhar c. epidemiological study on rheumatoid arthritis. indian journal of multidisciplinary research. 2009;5(1):17-24. 15. malaviya a, kapoor s, singh r, kumar a, pande i. prevalence of rheumatoid arthritis in the adult indian population. rheumatol int. 1993;13:131-4. 16. ropes mw, bennett ga, cobb s, jacox r, jessar ra. revision of diagnostic criteria for rheumatoid arthritis. bull rheum dis. 1958;9:175. 17. vliet vlieland tp, buitenhuis na, van zeben d, vandenbroucke jp, breedveld fc, hazes jm. sociodemographic factors and the outcome of rheumatoid arthritis in young women. ann rheum dis. 1994;53(12):803-6. https://www.ncbi.nlm.nih.gov/pubmed/?term=vliet%20vlieland%20tp%5bauthor%5d&cauthor=true&cauthor_uid=7864687 https://www.ncbi.nlm.nih.gov/pubmed/?term=buitenhuis%20na%5bauthor%5d&cauthor=true&cauthor_uid=7864687 https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20zeben%20d%5bauthor%5d&cauthor=true&cauthor_uid=7864687 https://www.ncbi.nlm.nih.gov/pubmed/?term=vandenbroucke%20jp%5bauthor%5d&cauthor=true&cauthor_uid=7864687 https://www.ncbi.nlm.nih.gov/pubmed/?term=breedveld%20fc%5bauthor%5d&cauthor=true&cauthor_uid=7864687 https://www.ncbi.nlm.nih.gov/pubmed/?term=hazes%20jm%5bauthor%5d&cauthor=true&cauthor_uid=7864687 https://www.ncbi.nlm.nih.gov/pubmed/7864687 review article doi: 10.18231/2348-7682.2016.0002 panacea journal of medical sciences, september-december,2016;6(3): 117-124 117 focusing on psychiatric aspects of cancer: a need of the day? abhijeet dhawalram faye1,*, sushil gawande2, rahul tadke3, vivek kirpekar4, sudhir bhave5 1assistant professor, 2,3associate professor, 4professor & hod, 5professor, dept. of psychiatry, nkp salve institute of medical sciences, nagpur *corresponding author: email: abhijeetfaye12@gmail.com abstract psychiatric aspects of cancer are increasingly being considered important. emotional and behavioral consequences are common phenomena in patients with cancer and family members. anxiety, depressive features, delirious behavior, pain and somatic symptoms (fatigue) are encountered during the treatment of cancer. lifestyle changes have been considered as important aspect to reduce the risk of cancer. managing emotional issues are integral part of palliative care of a patient with cancer. besides this care giver’s burden and professional difficulties/burnout while treating a cancer patient are also discussed in this article. keywords: psychiatric aspects, cancer, care giver’s burden, professional burnout. introduction a good mental health has always been considered as an integral component of total health of an individual along with physical and social wellbeing. thus psychiatric aspects become important while approaching any disorder or disease. cancer, as a disease also has psychiatric aspects associated with it. the term psycho-oncology refers to “diverse psychological, social, behavioral and psychiatric aspects related to cancer prevention, cancer illness & treatment and cancer survivorship”.(1) in other words it is a study of psychological and psychosocial factors related to the diagnosis, management & prognosis of cancer and psychiatric disorders associated with it.(2) a primary goal of psychosocial treatment and care is to identify/address how cancer and its treatment affect mental state and emotional well-being of cancer patients and their family members. along with improving the mental health,(3) psychosocial care also improves common disease-related symptoms and adverse reactions of treatment, like pain(4) and fatigue.(5) historical aspects over last 25 years, psycho-oncology has been evolved as a sub-specialty of oncology. the field today includes care of cancer patients and their family members, training of staff in psychiatric & psychological management and collaborative research ranging from the behavioral aspects in preventing the cancer to the treatment of psychiatric/psychological problems associated with cancer, including the end-oflife care.(6) the concept of psycho-oncology might have had its roots in twentieth century later part when the fear of word cancer got reduced and the diagnosis could be discussed with the patient. however, another stigma i.e. negative attitude attached with the mental illness, even in relation to the medical illnesses has contributed to delayed development of interest in psychological domains of cancer.(7) in recent era, many studies have been done on psychiatric aspects in cancer patients (like anxiety, depression, delirium and behavioral disturbances) for early detection, assessment and treatment. clinical practice guidelines given by the national comprehensive cancer network are also available for psychiatric disorders common among cancer patients.(8) today psycho-oncology is considered as clearly defined sub-specialty of consultation-liaison psychiatry requiring multi-disciplinary approach. now-a-days psycho-oncology subunit exists in almost every cancer center and many cancer hospitals have mental health professionals available for consultation.(7) psychiatric aspects of cancer psychiatric aspects include: 1. psycho-social issues 2. psychiatric disorders a. psycho-social issues in cancer patients psychological/emotional reactions to cancer: cancer usually referred as “a killing disease” is affecting people in increasing frequency. it can impair the living of not only elders but also children and their family members. it can affect the physical, emotional, social as well as financial life of the affected. it is difficult for a person to cope with the disease at any stage whether it’s a stage of diagnosis, treatment or complications. many a time, lack of knowledge, unexpected diagnosis, poor financial stability, limited social support, severity of a disease are the deciding factors for emotional breakdown and psychiatric consultation or counselor’s help becomes mandatory to help patient handle the stress in healthy and positive way. the common psychological responses in cancer arise from knowledge about life-threatening diagnosis, prognostic uncertainty and fear of death. the emotional reactions can also be due to adverse effects of medical/surgical/radiation therapies (e.g. loss of hairs, http://www.indianjpsychiatry.org/article.asp?issn=0019-5545;year=2012;volume=54;issue=2;spage=111;epage=118;aulast=chaturvedi#ref1 abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 118 skin pigmentation, etc). the stigma of cancer and its sequel adds to the negative emotional reactions.(9) most common emotions are fear, anger, anxiety, feelings of helplessness and dependency. commonly used coping styles in indian people are turning to religion, denial, attributing everything to fate or past deeds and helplessness. however with these types of coping, resolution is noted in <40% of the cases.(10) though not every person with cancer encounters the losses, the different levels at which a sense of loss may be encountered are 1) relationship losses: adjusting to being a person unable to function to his or her original capacity and living a life with limitations and precautions can lead to less socialization and intimacy in relationship.(11) additionally limited employment options, restrictions in activities, emotional distance from loved ones i.e. difficulty in having conversation, blaming, guilt about past behaviors or actions and disruption of sexual life may have significant impact. 2) practical losses: include loss of physical independence, mobility, hygiene, self-care, driving, declining fitness levels, economic losses, altered living conditions and financial hardship. 3) emotional and/or spiritual losses: lack of self-confidence and self-belief, uncertainty, body image concerns may affect the intimate relationships and emotional issues related to career or ambitions. impact of diagnosis of cancer: diagnosis of cancer produces marked emotional reaction compared to other diseases, regardless of mortality or treatment options. this includes a wide range of reactions like grief from denial, anger, bargaining, depression and acceptance. the severity and duration of emotional disturbances and the extent to which it affects patient's life seems to determine normal and abnormal emotional response. some people fear cancer itself, while others are afraid about cancer treatments and worry how they will get through it. cancer patients and their relatives anticipate the suffering through which they will be passing through and that can be the greatest fear for them. feeling of guilt is common and patients blame themselves for not paying attention or not noticing the symptoms earlier. they also worry that other members of family may also suffer the same. this can cause even more concerns for the person newly diagnosed with malignancy. b. psychiatric disorders in cancer patients: psychiatric comorbidity is known to be associated with chronic and life threatening medical illnesses and cancer is no exception. there is a co-existence of various psychiatric disorders in cancer patients including adjustment disorders, depression, anxiety, reduced self-esteem, etc. patients can also suffer non-specific stress and worries which if not handled carefully can affect patient’s ability to face the cancer and its complications significantly. short term treatment of psychiatric disorders in cancer patients is very useful in overall management and prognosis. adjustment disorder: this is the most common psychiatric disorder seen in cancer patients.(9) studies have found prevalence of adjustment disorder in cancer patients as high as 68%.(12) many adjustment disorder patients have depressed/anxious mood or mixed emotional disturbances. patients with cancer usually have some level of psychological distress that is often considered a natural reaction. studies shown adjustment disorder as the most common psychiatric diagnosis in cancer patients followed by major depression, delirium and anxiety disorders. in indian studies, 38 to 53% of patients with cancer were found having identifiable psychiatric disorders with adjustment disorder & depression being common. in some studies on cancer patients attending a general hospital, hospice and neurosurgery department, psychiatric disorders were identified in 48%, of which 44% had adjustment disorders. in a study carried out at cancer hospital, the psychiatric disorders were found in 53% of the patients with depressive disorder being common.(13,14) major depression: symptoms of depression can arise by disease process directly or by the anti-cancer drugs. depression can be a functional response to disabilities and impairments secondary to cancer. worthlessness, hopelessness and guilt are important differentiating symptoms between usual sadness seen in cancer patients and major depression. studies have reported prevalence of depression ranging from 1.5% to 50%. the prevalence is also dependant on cancer site, course, prognosis, type of treatment, presence of pain & its severity. on an average, prevalence of major depression ranges from 13% to 40%. there are certain diagnostic problems to detect depression in cancer patients as depressive symptoms tend to appear in the context of the severe stress associated with any serious medical illness like cancer; secondly, many physical or vegetative symptoms of depression are similar to those because of cancer, for example, loss of appetite, decreased weight, insomnia, loss of concentration and energy. lastly, diagnostic and classification systems have used different methods to diagnose depression to overcome the problems raised due to symptoms overlap of depression and cancer, like substitution of somatic symptoms with psychological ones, removing somatic symptoms, changing the number of criteria to be met, or trying to differentiate if the symptoms are due to the disease or due to psychological factors.(15,16) various risk factors that can increase the proneness of cancer patients to develop depression are young age, female gender, palliative treatment, severe somatic symptoms or persistent uncontrolled pain, advanced stage of disease and marked disability/discomfort. other risk abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 119 factors are social isolation, recent life events or losses, pessimism and history of substance use. in advanced cancer, prevalence estimates of major mental illness vary widely depending on the criteria used & sample size or non-dsm instruments and can result in rates up to five times those found using more rigorous criteria. one study with strict criteria found that approximately 12% of patients met the criteria for at least one major mental illness. rates of depression were 6.8%, panic disorder 4.8%, and generalized anxiety disorder 3.2%.(17) caregivers were equally affected; panic disorder was the most common (8%), followed by major depressive disorder (4.5%), posttraumatic stress disorder (ptsd) (4%) and generalized anxiety disorder (3.5%). if adjustment disorder is included, the prevalence of mental illness may be as high as 50% of all patients with advanced cancer.(12,18,19) sub-syndromal disorders are quite prevalent, with high rates of significant anxiety symptoms, especially posttraumatic ones.(20) recently the prevalence of depression in cancer patients has decreased due to changes in outcomes, stigma, palliative care and screening & treatment options.(21) less symptomatic disease might have greater rate and severity than symptomatically progressive one.(22) however, this finding has been disputed by other researchers who stated that metastasis increases the risk of depression.(23,24) its effect on severity of symptoms is unclear: nearing death, existential distress increases with increased physical symptom burden, not with closeness to death.(25) the prevalence of anxiety disorders might marginally increase as compared to the depressive spectrum disorders in the terminal phases of cancer.(18) the patients with younger age and those having poor social support have a greater risk.(19) delirium: delirium is also a common complication with advanced stages of cancer, occurring in 28%— 44% of hospital admissions and in 90% of patients before death.(26) in the palliative care setting, hypoactive delirium is most prevalent and has a worse prognosis(27) whereas hyperactive delirium occurs in 13%—46% of the patients.(28) a reversible or treatable cause is found in less than fifty percent of the patients of advanced cancer with delirium. mortality rate may be high in these patients. bipolar disorder: prevalence of bipolar disorder in cancer patients is same as that in general population. antidepressants, corticosteroids, stimulants and interferon used in cancer patients can cause or exacerbate mania in bipolar disorder patients.(18) schizophrenia: prevalence of schizophrenia is 1% worldwide. there is a evidence in literature for an increased overall cancer risk in patients with schizophrenia.(25,29) this increased risk is attributable to factors like tobacco smoking and alcohol consumption. schizophrenic patients have impaired insight into the illness and poor memory for medical recommendations. cancer may be diagnosed at late stages in these patients because of not paying attention or not recognizing the symptoms. in addition, psychotic patients may not verbalize pain/discomfort and may tolerate even infected lesions without complaint.(30) substance use disorders: substance like tobacco and alcohol increase the risk of lung, oral and head/neck cancer significantly. prevalence of alcohol dependence in cancer patients is more than that in non-cancer patients.(31) alcoholism is associated with increased need for opioids(31,32) and poor outcome in some cancers. the highest rate of alcohol dependence is found in head/neck cancers.(33) suicidality: it has been observed that thoughts about suicide may be present in up to 17% of patients with cancer.(33) compared to the prevalence in general population (16.7) adjusted rates of suicide in patients with cancer are 31.4/100,000 person-years.(34) hopelessness has been considered as a strong contributor to suicidal ideation.(35) the presence of hallucinations and/or delusions can also be the significant risk factor for suicidal attempts. suicidal ideation differs from a death wish i.e. a desire for hastened death. ten to thirty percent terminally ill patients of cancer express death wishes(36) which can be considered as a wish to relief from pain. early reports suggest that the family members of cancer patients with severe anticipatory grief are also at risk for contingent suicide after the death of their loved one.(37) cancer is the only non-psychiatric condition independently associated with completed suicide; and spreading of cancer to other organs i.e. metastasis further raises the risk.(38) 0.2% of all deaths in patients with cancer are due to suicide.(39) lung cancer is associated with the highest rate of suicide, followed by stomach and oropharyngeal/ laryngeal cancers.(34) the risk of suicide is highest in first five years of diagnosis and remains high for at least 15 years. a mood disorder is present in 80% of completed suicides among those with cancer.(40) others fatigue: more than 80% of outpatients undergoing chemotherapy or radiation treatment experience fatigue. it can persist even for months or years after the cancer treatment.(41) treatment of fatigue includes management of anemia and other nutritional deficiencies, activating antidepressants like stimulants, bupropion and modafinil.(42) non-pharmacologic interventions include exercise and psychosocial support, education and stress management programs. there is also a evidence to http://focus.psychiatryonline.org/article.aspx?articleid=52922#b24 abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 120 support the role of yoga and stress management programs in reducing the fatigue.(43) personality changes: the prevalence of personality disorders has been found to be similar to that in general population.(12) narcissistic, borderline and histrionic personality disorders tend to cause most difficulties in medical settings. chemotherapy-induced cognitive dysfunction: possible reasons include direct cytotoxic effects on nervous system, anemia, menopause and secondary depression. risk factors may include advanced age and dose & type of chemotherapy (high-dose and cyclophosphamide/methotrexate have more risk). treatment of psychiatric disorders associated with cancer depression: treatment of depression is important for improving the quality of life.(43) depression (usually secondary to hopelessness) can affect the outcome of cancer treatment. self-neglect and poor compliance to cancer treatment may result in grave consequences leading to poor outcome and impaired quality of life. it is therefore important to intervene early if cancer patients show signs of depression. pharmacotherapy: selective serotonin reuptake inhibitors, tricyclic anti-depressants and psychosocial interventions are all evidence-based interventions for depression in cancer.(44,45) with respect to interactions and side effects, escitalopram and sertraline are preferred selective serotonin reuptake inhibitors (ssri). the serotoninnor-epinephrine reuptake inhibitors (venlafaxine and duloxetine) have some advantage in pain management. mirtazapine is frequently used because of its side effect profile including increased appetite and a mild hypnotic effect at lower doses. tolerability and drug interactions with tricyclic agents limit their use. often low doses are effective.(18) psychostimulants like methylphenidate and dextroamphetamine are frequently used for low energy and withdrawal; the onset of effects can be within 1-2 days. modafinil has also been used.(46) various modalities are available for symptom control.(47) electroconvulsive therapy can be effective but not specifically studied in oncologic settings. spaceoccupying intracranial lesions are relative contraindication, although the literature suggests that safe electroconvulsive therapy is possible(48) even in this setting. psychosocial interventions: psycho-education and relaxation training are useful. the core symptoms related to cancer need to be managed promptly without which just psychological or psycho-pharmacological treatment modalities may not be effective.(49) anxiety: evidence-based psychosocial interventions include cognitive behavior therapy, relaxation training, preventative psychosocial interventions and perhaps music therapy.(50) pharmacological treatment includes benzodiazepines, shorter-acting agents such as lorazepam are used for those with hepatic impairment. etilzolam can also be used. progressive muscle relaxation has efficacy equivalent to that of benzodiazepines in patients with good functional status.(51) low dose ssris are needed in some cases. delirium: treatment includes correcting dehydration, treating infections, addressing hypoxia & metabolic derangements and discontinuing unnecessary medications such as benzodiazepines (that are independent risk factors for delirium in icu patients).(52) non-pharmacologic interventions(53) include frequent reorientation, cognitively stimulating activities, limiting noise stimuli, nighttime medications, establishing sleep routines and using visual & hearing aids. small comparison trials in various medical patients’ population revealed almost equal efficacy of haloperidol, olanzapine and risperidone in reducing the symptoms.(54,55) schizophrenia: early psychiatric evaluation before surgery is important, as is communication with family members. in patients with breast cancer, prolactin elevation doesn’t increase the recurrence risk, so treatment with first-generation antipsychotics or risperidone can be continued if the patient is taking it previously.(56) clozapine should be used with caution in patients on chemotherapeutic agents as this can cause myelo-suppression, although there are published cases of patients receiving clozapine and chemotherapy without agranulocytosis, despite expected neutropenia.(57) for agranulocytosis, prescribing lithium or (gsf) granulopoiesis-stimulating factors and discontinuation of bone marrow suppressing medications (carbamazepine, valproate or risperidone) may help.(58) treatment of schizophrenia in cancer patients is important as it can have a significant impact on treatment adherence, compliance with the regimen and overall prognosis. substance use disorders traditional substance use treatment modalities may be difficult cancer patients with advanced disease. some guidelines for management of substance abuse in psycho-oncology setting(59) focus on following aspects. 1. involving a multi-disciplinary team 2. setting the realistic goals of therapy (harm reduction) as relapse rate is high in setting of cancer-related stress. 3. evaluation of co-morbid psychiatric symptoms. abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 121 4. preventing or minimizing the withdrawal symptoms. 5. applying appropriate pharmacologic principles (e.g. qid rather than daily dosing of methadone for pain). 6. relying on long acting drugs if possible 7. doing urine toxicology screening. 8. providing relaxation therapy and non-drug coping strategies. carer’s burden: family carers (fcs) are the main source of emotional support for cancer patients and play a major role in helping patients face their illness in a positive way.(60,61) family members may play a key role in keeping patient optimistic especially in children. a family is considered as a social system and if one member has a illness like cancer, the rest of the family is likely to suffer significantly. the challenges faced by family start right from the stage of diagnosis to continue later and can have shattering effect on even a very strong family member. it is important to communicate openly and express the feelings within the family to create a healing environment and help them gain the strength needed to deal with the crisis of cancer. feelings of over-responsibility, change of priorities, physical exertion during the treatment of patient, constant efforts to instill hope in patients and give them support are overwhelming to most of the carers. they may get the feelings of anger, frustration and burnout. many blame their and patient’s “doing or non-doing” of past existence for the suffering and face the events passively as they happen. family members of cancer patients experience social, emotional as well as health-related problems along with significant burdens related to responsibilities of giving care.(62) women face more difficulties as they have to look after the household, finances, children and many other matters along with the care of a patient. family carers, thus should be integrated in the treatment programs.(63) studies found that carers usually experience more depression and anxiety compared to non-caregivers.(63) they also experience feelings of fear, uncertainty, powerlessness and hopelessness.(64,65) some have reported the emotional reactions of family members as both challenging & positive experiences(66,67) and described time they spent with their patients as ‘quality time’. some reported the experiences of care giving as meaningful and satisfying. in some studies carers reported the care giving process as if riding an emotional roller coaster.(66) professional burnout: doctors, along with other health workers, are believed to be at risk of a work-related distress, termed 'burnout'. it is common manifestation resulting from distress in professionals dealing with cancer patients and characterized by a loss of enthusiasm to do work, cynicism and a reduced sense of personal accomplishment.(68) it is usually seen in terms of emotional exhaustion, depersonalization (treating patients and others as if they were objects) and low productivity accompanied by feelings of low achievement.(69) the importance of 'burnout' and psychiatric disorder lies not only in personal suffering of doctors, but in the risk they carry for impairing the delivery of health care also. it is accepted that workrelated distress and more pervasive psychiatric disorders are likely to occur when the demands of working environment exceed the individual's resources to meet those demands.(70) some studies showed that 28% of cancer clinicians had psychiatric disorders.(71) among cancer clinicians, oncologists appear to experience the most distress and low satisfaction from work-related sources. palliative care clinicians describe the low levels of 'burnout' and stress, together with high levels of satisfaction from work. nursing staff is also found to be significantly vulnerable for occupational stress and burnout, however hospice nurses were found to have comparatively lesser burnout than critical care nurses.(72) central factors responsible for burnout are high workload, loss of autonomy and lack of meaning in work and inefficiency.(73) additional factors include facing frequent situations that need life and death decisions, administering therapies having toxic effects and narrow therapeutic windows, guarded prognosis in many cancer patients and need of keeping oneself updated with scientific and treatment advances related to the disease.(74) other factors like less fruitful interventions, expectations of being more empathetic, dealing with the suffering of fatal illness, dying, treatment toxicities and error, etc are overwhelming for treating clinicians. these occupational risk factors can precipitate 'burnout' and psychiatric disorder in vulnerable individuals. family psychiatric history, childhood experiences of illness, emotional neglect and particular personality traits have all been described as causal factors for distress among doctors. unconscious and experiential factors determine the emotional and psychological responses of a medical professional.(75) conclusion addressing psychiatric issues is important in patients with cancer as it can have variable impact on patient’s, carer’s and professional’s psyche. adjustment disorder, major depression, anxiety and delirium are important and common psychiatric disorders associated with cancer. stress associated with cancer and additional psychiatric co-morbidities may result in poor response and increase the chances of relapse of the disease. addressing the psychological issues in family members is equally important to keep them involved in patient’s care with a hope and stand with strength during the course of cancer and its consequences. psycho-social interventions along with pharmacological abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 122 treatment are useful in managing the psychological or psychiatric manifestations of cancer. it can improve the overall quality of life in patients and their family members. psychiatrist’s role in multi-disciplinary management of cancer has been well appreciated now a days and it is necessary to screen all the patients of cancer for any psychiatric or psychological signs or symptoms in all the setting of cancer management. specific focus and interventions are needed for carer’s burden and professional burnout. future perspectives with the fact of higher risk of psychiatric problems in cancer patients and significant improvement in quality of life & overall outcome after its treatment, it can be postulated that every patient diagnosed with cancer should be evaluated for psychiatric symptoms. there can be a mandatory protocol to assess all the patients with cancer periodically for emergence of psychiatric symptoms throughout the course of the disease. psychiatric services should be the integral part of any cancer institute with psychiatrist on panel. more research is required to reconfirm how the management of psychiatric disorders in cancer patients can modify the prognosis and improve their quality of life. addressing carer’s psychological, social, financial and moral issues with their preparation to accept the fact and helping them to cope with the stress can be of significant importance and has to be incorporated in treatment plan. anti-neoplastic drugs should be chosen (if possible) considering the psychiatric profile of the patients. regular counseling, stress management and strengthening the coping of professionals working with the cancer patients is also a crucial intervention. it is also recommended that mental health issues and its management should be incorporated in the curriculum and training of medical professionals to meet the demands of cancer and palliative care patients. references 1. breitbart w, chochinov hm. psycho oncology research: the road traveled the road ahead. journal of psychosomatic research 1998;45:185-9. 2. chaturvedi sk. psychiatric oncology. in: vyas jn, nathawat ss, ediotrs. psychiatry by ten teachers. new delhi: aditya medical publishers; 2003. p. 420-33. 3. andrykowski ma, manne sl. are psychological interventions effective and accepted by cancer patients? i. standards and levels of evidence. ann behav med 2006;32:93-97. 4. gorin ss, krebs p, badr h, janke ea, jim hs, spring b, et al. meta-analysis of psychosocial interventions to reduce pain in patients with cancer. j clin oncol 2012;30:539-547. 5. kangas m, bovbjerg dh, montgomery gh. cancerrelated fatigue: a systematic and metaanalytic review of non-pharmacological therapies for cancer patients. psychological bulletin 2008;134:700-741. 6. holland jc, editor. psycho-oncology. new york: oxford university press; 1998. 7. holland jc. history of psycho-oncology: overcoming attitudinal and conceptual barriers. psychosomatic medicine 2002;64:206–221. 8. holland jc. update. nccn practice guidelines for the management of psychosocial distress. oncology 1999;13(11a):459–507. 9. chaturvedi sk. psychiatric oncology: cancer in mind. indian j psychiatry 2012;54:111-8. 10. chaturvedi sk, shenoy a, prasad km, senthilnathan sm, premlatha bs. concerns, coping and quality of life in head and neck cancers. support care cancer 1996;4:186-90. 11. block k. cancer’s impact on social roles (editorial). integrative cancer therapies 2008;7(1):3-4. 12. derogatis lr, morrow rg, fetting j, penman d, piasetsky s, schmale am, et al.the prevalence of psychiatric disorders among cancer patients. jama 1983;249:751-5. 13. chaturvedi sk, chandra p, channabasavanna sm, beena mb, pandian rd. detection of depression and anxiety in cancer patients. nimhans journal 1994;12:141-4. 14. chaturvedi sk. report of the terry fox project on quality of life of cancer patients. nimhans, bangalore 2003. 15. holland jc. managing depression in the patient with cancer. clin oncol 1986;1:11-3. 16. rapp sr, vrana s. substituting non somatic for somatic symptoms in the diagnosis of depression in elderly male medical patients. am j psychiatry 1989;146:1197-2000. 17. kadan-lottick ns, vanderwerker lc, block sd, zhang b, prigerson hg. psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study. cancer 2005;104:2872—2881. 18. miovic m, block s. psychiatric disorders in advanced cancer. cancer 2007;110:1665-1676. 19. wilson kg, chochinov hm, skirko mg, allard p, chary s, gagnon pr, et al. depression and anxiety disorders in palliative cancer care. j pain symptom manage 2007;33:118-129. 20. gurevich m, devins gm, rodin gm. stress response syndromes and cancer: conceptual and assessment issues. psychosomatics 2002;43:259-281. 21. spiegel d, giese-davis j. depression and cancer: mechanisms and disease progression. biol psychiatry 2003;54:269-282. 22. lichtermann d, ekelund j, pukkala e, tanskanan a, lönnqvist j. incidence of cancer among persons with schizophrenia and their relatives. arch gen psychiatry 2001;58:573-578. 23. ciaramella a, poli p. assessment of depression among cancer patients: the role of pain, cancer type and treatment. psychooncology 2001;10:156-165. 24. evans dl, staab jp, petitto jm, morrison mf, szuba mp, ward he, et al. depression in the medical setting: biopsychological interactions and treatment considerations. j clin psychiatry 1999;60(suppl 4):40-55. 25. lichtenthal w, nilsson m, zhang b, trice ed, kissane dw, breitbart w, et al. do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches? psychooncology 2009;18:50-61. 26. lawlor pg, gagnon b, mancini il, pereira jl, hanson j, suarez-almazor me, et al. occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. arch intern med 2000;160:786-794. http://www.ncbi.nlm.nih.gov/pubmed/?term=sheinfeld%20gorin%20s%5bauthor%5d&cauthor=true&cauthor_uid=22253460 http://www.ncbi.nlm.nih.gov/pubmed/?term=krebs%20p%5bauthor%5d&cauthor=true&cauthor_uid=22253460 http://www.ncbi.nlm.nih.gov/pubmed/?term=badr%20h%5bauthor%5d&cauthor=true&cauthor_uid=22253460 http://www.ncbi.nlm.nih.gov/pubmed/?term=janke%20ea%5bauthor%5d&cauthor=true&cauthor_uid=22253460 http://www.ncbi.nlm.nih.gov/pubmed/?term=jim%20hs%5bauthor%5d&cauthor=true&cauthor_uid=22253460 http://www.ncbi.nlm.nih.gov/pubmed/?term=spring%20b%5bauthor%5d&cauthor=true&cauthor_uid=22253460 http://www.ncbi.nlm.nih.gov/pubmed/?term=spring%20b%5bauthor%5d&cauthor=true&cauthor_uid=22253460 abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 123 27. spiller ja, keen jc. hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care. palliat med 2006;20:17-23. 28. ross ca, peyser ce, shapiro i, folstein mf. delirium: phenomenologic and etiologic subtypes. int psychogeriatr 1991;3:135-147. 29. pandiani ja, boyd mm, banks sm, johnson at. elevated cancer incidence among adults with serious mental illness. psychiatric services 2006;57:1032-1034. 30. talbott ja, linn l. reactions of schizophrenics to lifethreatening disease. psychiatr q 1978;50:218-227. 31. bruera e, moyano j, seifert l, fainsinger rl, hanson j, suarez-almazor m. the frequency of alcoholism among patients with pain due to terminal cancer. j pain symptom manage 1995;10:599-603. 32. parsons ha, delgado-guay mo, el osta b, chacko r, poulter v, palmer jl, et al. alcoholism screening in patients with advanced cancer: impact on symptom burden and opioid use. j palliat med 2008;11:964-968. 33. kugaya a, akechi t, okuyama t, nakano t, mikami i, okamura h, et al. prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. cancer 2000;88:28172823. 34. misono s, weiss ns, fann jr, redman m, yueh b. incidence of suicide in persons with cancer. j clin oncol 2008;26:4731-4738. 35. chochinov hm, wilson kg, enns m, lander s. depression, hopelessness, and suicidal ideation in the terminally ill. psychosomatics 1998;39:366-370. 36. breitbart w, rosenfeld b, pessin h, breitbart w. depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. jama 2000;284:2907-2911. 37. gutheil tg, schetky d. a date with death: management of time-based and contingent suicidal intent. am j psychiatry 1998;155:1502-1507. 38. miller m, mogun h, azrael d, solomon dh. cancer and the risk of suicide in older americans. j clin oncol 2008;26:4720-4724. 39. rodin g, zimmermann c, rydall a, jones j, shepherd fa, moore m, et al. the desire for hastened death in patients with metastatic cancer. j pain symptom manage 2007;33:661-675. 40. ganzini l, goy er, dobscha sk. prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. bmj 2008;337:a1682. [pmid18842645] 41. hofman m, ryan jl, figueroa-moseley cd, jean-pierre p, morrow gr. cancer-related fatigue: the scale of the problem. oncologist 2007;12(suppl 1):4-10. 42. carroll jk, kohli s, mustian km, roscoe ja, morrow gr. pharmacologic treatment of cancer-related fatigue. oncologist 2007;12(suppl 1):43-51. 43. strong v, waters r, hibberd c, murray g, wall l, walker j, et al. management of depression for people with cancer (smart oncology 1): a randomised trial. lancet 2008;372:40-48. 44. lorenz ka, lynn j, dy sm, shugarman lr, wilkinson a, mularski ra, et al. evidence for improving palliative care at the end of life: a systematic review. ann intern med 2008;148:147-159. 45. carr d, goudas l, lawrence d, pirl w, lau j, devine d, et al. management of cancer symptoms: pain, depression, and fatigue. evid rep technol assess (summ) 2002;7:15. 46. kumar r. approved and investigational uses of modafinil: an evidence-based review. drugs 2008;68:1803-1839. 47. rao a, cohen hj. symptom management in the elderly cancer patient: fatigue, pain, and depression. j natl cancer inst monogr 2004;32:150-157. 48. rasmussen kg, perry cl, sutor b, moore km. ect in patients with intracranial masses. j neuropsychiatry clin neurosci 2007;19:191-193. 49. block sd. psychological issues in end-of-life care. j palliat med 2006;9:751-772. 50. luebbert k, dahme b, hasenbring m. the effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: a meta-analytical review. psychooncology 2001;10:490-502. 51. holland jc, morrow gr, schmale a, derogatis l, stefanek m, berenson s. a randomized clinical trial of alprazolam versus progressive muscle relaxation in cancer patients with anxiety and depressive symptoms. j clin oncol 1991;9:1004-1011. 52. pandharipande p, shintani a, peterson j, pun bt, wilkinson gr, dittus rs. lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. anesthesiology 2006;104:21-26. 53. inouye sk, bogardus stj, charpentier pa, leosummers l, acampora d, holford tr. a multicomponent intervention to prevent delirium in hospitalized older patients. n engl j med 1999;340:669676. 54. han cs, kim yk. a double-blind trial of risperidone and haloperidol for the treatment of delirium. psychosomatics 2004;45:297-301. 55. skrobik yk, bergeron n, dumont m, gottfried sb. olanzapine vs haloperidol: treating delirium in a critical care setting. intensive care med 2004;30:444-449. 56. massie mj.in handbook of psycho-oncology .edited by holland jc. new york, oxford university press, 1989, pp320-323. 57. rosenstock j. clozapine therapy during cancer treatment. am j psychiatry 2004;161:175. 58. esposito d, rouillon f, limosin f. continuing clozapine treatment despite neutropenia. eur j clin pharmacol 2005;60:759-764. 59. passik sd, portenoy rk, ricketts pl. substance abuse in cancer patients. part 2: evaluation and treatment. oncology (williston park) 1998;12:729-734; discussion 736,741-722. 60. bultz bd, speca m, brasher pm, geggie ph, page sa. a randomized controlled trial of a brief psychoeducational support group for partners of early stage breast cancer patients. psycho-oncology 2000;9(4):303–313. 61. carlson le, ottenbreit n, st-pierre m, bultz bd. partner understanding of the breast and prostate cancer experience. cancer nurs 2001;24(3):231–239. 62. carter pa. family caregivers’ sleep loss and depression over time. cancer nurs 2003;26(4):253–259. 63. stenberg u, ruland cm, miaskowski c. review of literature on the effects of caring for a patient with cancer. psycho-oncology 2009;19:1013-1025. 64. dumont s, turgeon j, allard p, gagnon p, charbonneau c, vezina l. caring for a loved one with advanced cancer: determinants of psychological distress in family caregivers. j palliat med 2006;9(4):912–921. 65. mystakidou k, tsilika e, parpa e, galanos a, vlahos l. caregivers of advanced cancer patients: feelings of hopelessness and depression. cancer nurs 2007;30(5):412–418. abhijeet dhawalram faye et al. focusing on psychiatric aspects of cancer: a need of the day? panacea journal of medical sciences, september-december,2016;6(3): 117-124 124 66. grbich c, parker d, maddocks i. the emotions and coping strategies of caregivers of family members with a terminal cancer. j palliat care 2001;17(1):30–36. 67. kim y, baker f, spillers rl. cancer caregivers’ quality of life: effects of gender, relationship, and appraisal. j pain symptom manage 2007;34(3):294–304. 68. maslach c, jackson s, leiter m. the maslach burnout inventory: manual (ed 3). palo alto, ca, consulting psychologists press, 1996. 69. cherniss, c. staff burnout: job stress in the human servic es. beverly hills, ca: sage. 1980. 70. lazarus rs, folkman s. stress, appraisal, and coping. new york, ny: springer; 1984. 71. ramirez aj, graham j, richards ma, cull a, gregory wm, leaning ms, et al. burnout and psychiatric disorder among cancer clinicians. br j cancer 1995;71:1263-1269. 72. mallett k, price jh, jurs sg, slenker s. relationships among burnout, death anxiety, and social support in hospice and critical care nurses. psychol rep. 1991;68:1347–1359. 73. shanafelt t, dyrbye l. oncologist burnout: causes, consequences, and responses. j clin oncol 2012;30(11):1235-41. 74. shanafelt t, adjei a, meyskens fl. when your favorite patient relapses: physician grief and well-being in the practice of oncology. j clin oncol 2003;21:2616-2619. 75. johnson wd. predisposition to emotional distress and psychiatric illness amongst doctors: the role of unconscious and experiential factors. br j med psychol. 1991;64:317–329. julydecember 2012 pdf for website synchronous bilateral invasive breast carcinoma 1 2 2 chikhlikar kasturi , wilkinson anne , bothale kalpana abstract: bilateral breast carcinomas are uncommon lesions, with most evidence supporting them to be independent tumours and not metastatic tumours. synchronous breast carcinomas are carcinomas which arise within 3 months from the diagnosis of the first tumour. we report a case of synchronous bilateral breast cancer in a 32-year-old lady. keywords: synchronous, breast carcinoma. case history: a 32year-old lady presented with a 4 x 3 cm right breast hard lump of 4 months duration, with palpable right axillary lymph nodes. the left breast was apparently normal. there was no family history of breast cancer. fnac of the right breast lump diagnosed a ductal carcinoma and the subsequent right mastectomy specimen showed infiltrating duct carcinoma nos, grade ii with areas of mucinous carcinoma and metastases to five axillary lymph nodes (fig. 1 and 2). after surgery a week later while still in the hospital, she noticed a small lump in the contralateral left breast, which was a mobile 1 x 1 cm lump. no left axillary lymph nodes were figure 4: photomicrograph showing left breast infiltrating duct carcinoma figure 1: gross photograph of right mastectomy specimen showing a white infiltrative growth with mucinous areas (left) figure 2: photomicrograph showing right breast infiltrating duct carcinoma and mucinous carcinoma areas figure 3: gross photograph of left mastectomy specimen showing a white infiltrative growth 31 1 2 pathology resident, associate professor, department of pathology, nkpsims & rc, digdoh hills, hingna road, nagpur -440019. anne_cerry@yahoo.co.in pjmsvolume 2 number 2: julydecember 2012 case report palpable. fnac of this mass showed presence of benign ductal cells, and cells with suspicion of malignancy. a lumpectomy was done which showed areas of intraductal and lobular hyperplasia and a small focus of intraductal carcinoma. the subsequent mastectomy specimen showed infiltrating duct carcinoma nos, grade ii with metastasis in two left axillary lymph nodes (fig. 3 and 4). the patient was referred to the oncologist for further treatment. discussion: breast cancer is one of the most important health problems in the world and affects a great number of women over the entire globe (1). bilateral breast carcinoma is a rare clinical entity. these are of two typessynchronous and metachronous. majority are metachronous with an incidence of 5-6% whereas synchronous have an incidence rate of 0.2-2 % (2). synchronous breast carcinomas are carcinomas which arise within 3 months from the diagnosis of the first tumour (3). most evidence supports bilateral breast carcinomas to be independent tumours and not metastatic tumours. when cancer is detected in the opposite breast, however, the question arises whether this tumour is a second cancer or a metastatic spread from the ? rst breast cancer. a differentiation based on clinical and histopathological parameters de?nes a second primary, when either in situ lesions, a different histological type or a higher degree of histological differentiation can be demonstrated in the second cancer (4). in our case the fact that the second tumour also showed areas of hyperplasia and intraductal carcinoma in addition to invasive malignancy, supports the fact that this was an independent tumour and not a metastasis. the gradual increase in the incidence of synchronous disease during the 1970s coincides with the introduction of routine and bilateral mammography as part of the diagnostic work-up in women with unilateral cancer (2). such work-up may entail that some preclinical bilateral cancers are detected early and classi?ed as synchronous disease (perhaps in an earlier and more favourable stage) rather than diagnosed later as metachronous disease (5). family history plays an important role in the pathogenesis of bilateral breast carcinoma. women with a first-degree relative whose breast carcinoma was diagnosed at an early age have a higher risk of developing bilateral breast carcinoma. there are numerous reports in the literature purporting to document the occurrence of unilateral and bilateral breast carcinomas in young women treated with irradiation for postpartum mastitis, hodgkin disease, tuberculosis, and others diseases(6). there are high rates of distant metastases for synchronous bilateral breast cancer and the prognosis is worse than metachronous breast carcinomas (7). however contradictory data exists concerning the prognosis of patients with synchronous bilateral breast cancer (sbbc). schmid et al (8) found that the prognosis of sbbc (synchronous bilateral breast cancer) was determined by the reference lesion; the contralateral second tumor had no additional impact on outcome. however solh et al (9) found synchronous breast cancer to be more aggressive than metachronous breast cancer with a poorer outcome. importance: the early presentation and detection of the second malignancy while the patient was still recovering from the first surgery makes this a very interesting case of synchronous bilateral invasive breast carcinoma. references: 1. de'mello r, figueiredo p, marques m, sousa g, carvalho t, gervasio h. concurrent breast stroma sarcoma and breast carcinoma: a case report. journal of medical case reports 2010; 4: 414. 2. dalal ak, gupta a, singal r, dala u, attri ak, jain p, et al. bilateral breast carcinoma– a rare case report. j med life 2011; 4(1): 94–96. 3. shi yx, xia q, peng rj, yuan zy, wang ss, an x, et al. comparison of clinic-pathological characteristics and prognoses between bilateral and unilateral breast cancer. j cancer res clin oncol 2012; 138(4):705-14. 4. janschek e, eckersberger dk, ludwig c, kappel s, wolf b, taucher s, et al. contralateral breast cancer: molecular differentiation between metastasis and second primary cancer. breast cancer research and treatment 2001; 67:1–8. 5. hartman m, czene k, reilly m, adolfsson j, bergh j, adami h, et al. incidence and prognosis of synchronous and metachronous bilateral breast cancer. journal of clinical oncology 2007; 25 (27): 4210-4216. 6. heron de, komarnicky lt, hyslop t, schwartz gf, mansfield cm. bilateral breast carcinoma. cancer 2000; 88 (12): 27392750. 7. vuoto hd, garcía am, candás gb, zimmermann ag, uriburu jl, isetta ja, et al. bilateral breast carcinoma: clinical characteristics and its impact on survival. breast j 2010; 16(6): 625-32. 8. schmid sm, pfefferkorn c, myrick me, viehl ct, obermann e, schötzau a, et al. prognosis of early-stage synchronous bilateral invasive breast cancer. eur j surg oncol 2011 jul; 37(7):623-8. 9. solh m, ali hb, mittal v, bergsman k. synchronous versus metachronous breast cancer: characteristics of the second tumour. j clin onco 2008; 26 may (suppl): 1107. 32 pjmsvolume 2 number 2: julydecember 2012 case report page 35 page 36 429 too many requests you have sent too many requests in a given amount of time. review article doi: 10.18231/2348-7682.2018.0022 panacea journal of medical sciences, september-december, 2018;8(3):96-99 96 biochemical and clinical impact of reduced methylene tetrahydrofolate reductase enzyme activity samapika bhaumik1,*, suprava patel2 1final year mbbs student, 2associate professor, dept. of biochemistry, all india institute of medical sciences, raipur, chhattisgarh, india *corresponding author: email: samapikabhaumik@gmail.com abstract methylene tetrahydrofolate reductase (mthfr) enzyme is a crucial enzyme involved in the pathway of tetrahydrofolate inter-conversion and one-carbon metabolism. though there are 24 reported polymorphisms associated to mthfr gene, the two most investigated are c677t (ala222 val) and a1298c (glu429 ala) single nucleotide polymorphisms (snps). the metabolic impact in the form of hyperhomocysteinemia, redistribution of different forms of folates, altered methylation process and accumulation of unmetabolised folic acid have been reported in individuals with reduced or deficient mthfr activity. these biochemical alterations have been associated with coronary artery diseases, various thromboembolic phenomenon, infertility and reproductive failures, cancers and inflammatory diseases. folic acid supplementation may further worsen the case in these individuals by increasing the unmetabolised forms. supplementation of 5mthf could be a better alternative for therapeutic and preventive purposes. keywords: mthfr, structure, c677t, a1298c, biochemical impact. introduction methylene tetrahydrofolate reductase (mthfr) enzyme is a crucial enzyme involved in the pathway of tetrahydrofolate inter-conversion and one-carbon metabolism. the prime role of the enzyme is catalyzing the conversion of 5, 10-methylenetetrahydrofolate to 5methyltetrahydrofolate, the major circulatory form of folate that acts as a co-substrate for homocysteine remethylation to methionine by methionine synthase. this homodimer flavoprotein is about 75 kda consisting of 656 amino acids. each monomer of the enzyme has 4 important domains: 1) n-terminal catalytic domain, 2) c-terminal regulatory domain, 3) tryptic cleavage site and 4) conserved domain. each n-terminal catalytic domain consists of two noncovalently bound flavin adenine dinucleotide (fad) as prosthetic group and binds to nicotinamide adenine dinucleotide phosphate (nadph) as reducing agent. the cterminus of each monomer has an s-adenosylmethionine binding site which regulates the enzyme activity by allosteric inhibition. the catalytic and regulating domains can be separated by trypsin digestion at the tryptic cleavage site. the enzyme also has a phosphorylation site and phosphorylation reduces enzyme activity by nearly 20%.1,2 this cytosolic enzyme is involved in many biological processes of cellular amino acid metabolism, folic acid metabolic process, homocysteine-methionine cycle, one carbon metabolism, tetrahydrobiopterin and nitric oxide metabolism, blood circulation, neural tube closure, histone methylation and heterochromatin maintenance and various other metabolic activities.3 mthfr polymorphism: mthfr is encoded by the mthfr gene on chromosome 1 location p36.3 in humans and acts as a rate limiting enzyme. human mthfr gene is composed of 11 exons and does not have a tata box but has cpg islands and multiple potential sp1 binding sites.4,5 though there are 24 reported polymorphisms associated to mthfr gene, the two most investigated are c677t (rs1801133) and a1298c (rs1801131) single nucleotide polymorphisms (snps).6 c677t snp: this is also coined as ala222val. c at position 677 (leading to an alanine at amino acid 222) is the normal allele. the 677t allele (leading to a valine substitution at amino acid 222) encodes a thermolabile enzyme with reduced activity. persons with two copies of 677c (677cc) have the most common genotype. 677tt individuals (homozygous) have lower mthfr activity than cc or ct (heterozygous) individuals. about 10% of the north american population are t-homozygous for this polymorphism. ethnic variability in the frequency of the t allele can be seen viz. frequency is greater in mediterranean or hispanics than in caucasians and africans or african-americans.7 in persons with 677tt, the degree of enzyme thermolability is more than persons with 677ct and 677cc.8 owing to less active mthfr available to produce 5-methyletetrahydrofolate, the persons with 677tt are predisposed to mild hyper-homocysteinaemia. this can also be as a result of low dietary intake of folic acid. however, low folate intake affects individuals with 677tt to a greater extent than those 677cc or 677ct. hence, persons with 677tt with lower plasma folate levels are at high risk for elevated plasma homocysteine levels.4 677tt persons are at an increased risk for acute lymphoblastic leukemia9 and colon cancer.10 non-caucasian persons with 677ct genotype are at increased risk of recurrent pregnancy loss.11 similarly, 677ct polymorphism is associated with risk of myocardial infarction in african, north american and elderly populations.12 according to cortese and motti (2001), homozygosity for the val allele there appears to be a relative deficiency in the re-methylation process of homocysteine which lead to a samapika bhaumik et al. biochemical and clinical impact of reduced methylene tetrahydrofolate…. panacea journal of medical sciences, september-december, 2018;8(3):96-99 97 mild to moderate hyper-homocysteinaemia. this condition can be a possible risk factor for atherosclerosis. the genetic influence of the mthfr polymorphism on homocysteine levels is reduced in females in premenopausal age and persons with higher serum levels of folate or vitamin b12. the independent role of mthfr polymorphism in cardiovascular risk is still not well established. mutations in the mthfr gene could be one of the factors leading to increased risk of developing schizophrenia.13 similarly, there is also reported link between mthfr mutations and dementia14 and alzheimer’s disease in asians.15 a1298c snp (glu429 ala) there are two possibilities either a or c at nucleotide 1298 of the mthfr. 1298a (leading to a glu at amino acid 429) is the most common while 1298c (leading to an ala substitution at amino acid 429) is less common. 1298 aa is the ‘normal’ homozygous, 1298 ac the ‘heterozygous’ and 1298 cc the homozygous for the ‘variant’. the c mutation does not affect the mthfr protein, homocysteine levels and does not result in thermolabile mthfr. it, however, affects the conversion of mthf to tetrahydrobiopterin, an important cofactor in the production of neurotransmitters and the synthesis of nitric oxide. a maternal mthfr 1298ac polymorphism is associated with down syndrome pregnancy particularly in asian population.5 1298ac polymorphism may also play a role in the development of major depressive disorder.16 hyper-homocysteinemia is also associated with high blood pressure, glaucoma, and ischaemic stroke.17 this condition is also linked to migraines and mental disorders like bipolar disorder, and depression is linked to inadequate methylation resulting from mthfr polymorphism.18,19 severe mthfr deficiency is rare but can be caused by mutations resulting in 0-20% residual enzyme activity.6 the affected persons exhibit developmental delay, motor and gait dysfunction, seizures and neurological impairment and have extremely high levels of plasma and urine homocysteine and low plasma methionine levels. biochemical impact of mthfr deficiency 1. hyper-homocysteinemia: the mutated genotype is linked to low serum folate levels and hyperhomocysteinemia and homocysteinuria. this is associated with toxic effects on vasculature leading to thromboembolic phenomenon, premature atherosclerosis and coronary artery disease.8,20 2. dysregulation in methionine and s-adenosylmethionine formation: reduced or deficient activity of mthfr enzyme disrupts s-adenosylmethionine synthesis rather conversion of homocysteine to sadenosylhomocysteine might interfere with many other methyltransferases. transfer of methyl groups are an important aspect in dna and histone methylation processes, involved in the process of epigenesis and imprinting. alteration in these processes could be one of the major influencing factors for neural tube defects, increased chromosomal anomalies, early fetal loss or habitual first trimester abortions.21,22 3. alteration in folate metabolism: low methytetrahydrofolate levels and an increase in other forms of folate like methylenetetrahydrofolate and nonmethylated and formylated forms, have been associated with redistribution of active folates. this might limit the bioavailability of purines and pyrimidines required for dna synthesis and repair during cell cycle. this could be a potential factor for oncogenesis, psoriasis and developmental delay in children. this could also be a contributory factor for neurological and psychiatric diseases associated with mthr diseases.21-24 4. accumulation of unmetabolised folic acid: accumulation of other forms of folate and unmetabilosed folic acid (umfa) in red blood cells (rbc) and lymphocytes have been associated with altered immunity and inflammatory diseases. folic acid supplementation in mthfr deficient individuals could significantly elevate umfa levels having deleterious effect on natural killer (nk) cells decreasing natural immunity.24 clinical impact of mthfr deficiency mthfr polymorphism has been associated with various diseases as given below: 1. vascular disease: hyper-homocysteinemia has been marked as an independent factor for coronary artery disease (cad) and ischemic stroke. few studies have reported regarding hemorrhagic stroke, essential hypertension, retinal vein occlusion and venous thromboembolism.8,25 the low serum folate levels and hyper-homocyteinemia and homocysteinuria can be linked to this mutated genotype. toxic effects on the vasculature lead to thromboembolic phenomenon and coronary artery disease. 2. infertility and reproduction: a strong impact of mthfr polymorphism has been reported in patients with habitual abortions. hyper-homocysteinemia leading to hypercoaguable state could be the most possible cause for the first trimester fetal loss. repeated assisted reproductive (art) failures have been observed. mthfr isoforms also have an impact on the sperm quality and quantity and also on low ovarian reserve.21,24 first trimester fetal abortions are the results of alterations in the process of epigenesis and imprinting related to dna and histone methylation process (reduced or deficient activity of mthfr enzyme). 3. neural tube defects: chromosomal abnormalities and neural tube defects have been well recognised with folate deficiencies and as well as mthfr polymorphisms.11,20 reduced activity of mthfr enzyme disrupts s-adenosylmethionine synthesis which in turn might interfere with many other methyltransferases. significant changes in these biochemical processes could be an etiological factor for neural tube defects. samapika bhaumik et al. biochemical and clinical impact of reduced methylene tetrahydrofolate…. panacea journal of medical sciences, september-december, 2018;8(3):96-99 98 4. neurological and psychiatric diseases: neurotoxic effects of hyper-homocysteinemia leading to hyperexcitibility have been related to parkinsonism and alzheimer’s diseases. risk of schizophrenia and bipolar disorders are also associated with mthfr polymorphism.13,19 decreased methytetrahydrofolate levels accompanied by increased methylenetetrahydrofolate and non-methylated and formylated forms, affect redistribution of active folates thus limiting the bioavailability of purines and pyrimidines required for dna synthesis and repair during cell cycle. neurological and psychiatric diseases could be a result of this process involving mthr diseases. 5. inflammatory diseases: elevated homocysteine and accumulation of non-methylated and formyl tetrahydrofolates in neuronal tissues have been reported in individuals with mthfr polymorphism and multiple sclerosis or sporadic amyotropic lateral sclerosis. high levels of serum inflammatory markers like il-1β, tnfα and crf were reported in these patients.26 6. cancer: altered methylation processes required for dna synthesis and repair could be the possible mechanism for oncogenesis. psoriasis, altered epithelial repair have been seen in mthfr polymorphism individuals.9,10 studies have revealed that low methytetrahydrofolate levels and an increase in other forms of folate limit the bioavailability of purines and pyrimidines required for dna synthesis and repair during cell cycle. this disturbed biochemical condition could lead to oncogenesis. conclusion mthfr enzyme is a key enzyme for folate metabolism. numerous polymorphisms have been reported for the gene coding for the enzyme. reduced or deficient activity of the enzyme results in hyperhomocysteinemia. mthfr polymorphism has been associated with various diseases like vascular disease, infertility, reproductive failure, neurological diseases, cancers and inflammatory diseases. folate supplementation in mthfr deficient individuals might result in accumulation of umfa leading to immune deficiency. supplementation of active folate, 5mthf could be a better alternative as compared to folic acid supplementation. conflict of interest: none. references 1. shahzad k, hai a, ahmed a, kizilbash n, aruwaili j. a structured-based model for the decreased activity of ala222val and glu429ala methylenetetrahydrofolate reductase (mthfr) mutants. bioinformation 2013;9(18):929-936. 2. froese ds, kopec j, rembeza e, bezerra ga, oberholzer ae, suormala t, et al. structural basis for the regulation of human 5,10-methylenetetrahydrofolate reductase by phosphorylation and s-adenosylmethionine inhibition. nat commun 2018;9(1):2261. 3. bellamy mf, mcdowell if. putative mechanisms for vascular damage by homocysteine. j inherit metab dis 1997;20(2):307–315. 4. reilly r, mcnulty h, pentieva k, strain jj, ward m. mthfr 677tt genotype and disease risk: is there a modulating role for b-vitamins? proc nutr soc 2014;73(1):47–56. 5. rai v, yadav u, kumar p. null association of maternal mthfr a1298c polymorphism with down syndrome pregnancy: an updated meta-analysis. egypt j med hum genet 2017;18(1):9–18. 6. sibani s, christensen b, o’ferrall e, saadi i, hiou-tim f, rosenblatt ds, et al. characterization of six novel mutations in the methylenetetrahydrofolate reductase (mthfr) gene in patients with homocystinuria. hum mutat 2000;15(3):280– 287. 7. schneider ja, rees dc, liu yt, clegg jb. worldwide distribution of a common methylenetetrahydrofolate reductase mutation. am j hum genet 1998;62(5):1258–1260. 8. frosst p, blom hj, milos r, goyette p, sheppard ca, matthews rg, et al. a candidate genetic risk factor for vascular disease: a common mutation in methylenetetrahydrofolate reductase. nat genet 1995;10(1):111–113. 9. ojha rp, gurney jg. methylenetetrahydrofolate reductase c677t and overall survival in pediatric acute lymphoblastic leukemia: a systematic review. leuk lymphoma 2014;55(1):67–73. 10. bailey lb. folate, methyl-related nutrients, alcohol, and the mthfr 677c-->t polymorphism affect cancer risk: intake recommendations. j nutr 2003;133(11 suppl 1):3748s-3753s. 11. wu x, zhao l, zhu h, he d, tang w, luo y. association between the mthfr c677t polymorphism and recurrent pregnancy loss: a meta-analysis. genet test mol biomark 2012;16(7):806–11. 12. alizadeh s, djafarian k, moradi s, shab-bidar s. c667t and a1298c polymorphisms of methylenetetrahydrofolate reductase gene and susceptibility to myocardial infarction: a systematic review and meta-analysis. int j cardiol 2016;217:99–108. 13. zhang y, yan h, tian l, wang f, lu t, wang l, et al. association of mthfr c677t polymorphism with schizophrenia and its effect on episodic memory and gray matter density in patients. behav brain res 2013;243:146–152. 14. nishiyama m, kato y, hashimoto m, yukawa s, omori k. apolipoprotein e, methylenetetrahydrofolate reductase (mthfr) mutation and the risk of senile dementia--an epidemiological study using the polymerase chain reaction (pcr) method. j epidemiol 2000;10(3):163–172. 15. hua y, zhao h, kong y, ye m. association between the mthfr gene and alzheimer’s disease: a meta-analysis. int j neurosci 2011;121(8):462–471. 16. cho k, amin zm, an j, rambaran ka, johnson tb, alzghari sk. methylenetetrahydrofolate reductase a1298c polymorphism and major depressive disorder. cureus 2017;9(10):e1734. 17. li p, qin c. methylenetetrahydrofolate reductase (mthfr) gene polymorphisms and susceptibility to ischemic stroke: a meta-analysis. gene 2014;535(2):359–364. 18. azimova je, sergeev av, korobeynikova la, kondratieva ns, kokaeva zg, shaikhaev go, et al. effects of mthfr gene polymorphism on the clinical and electrophysiological characteristics of migraine. bmc neurol 2013;13:103. 19. gilbody s, lewis s, lightfoot t. methylenetetrahydrofolate reductase (mthfr) genetic polymorphisms and psychiatric disorders: a huge review. am j epidemiol 2007;165(1):1–13. samapika bhaumik et al. biochemical and clinical impact of reduced methylene tetrahydrofolate…. panacea journal of medical sciences, september-december, 2018;8(3):96-99 99 20. matthews rg, sheppard c, goulding c. methylenetetrahydrofolate reductase and methionine synthase: biochemistry and molecular biology. eur j pediatr 1998;157(s2):s54–59. 21. liew s-c, gupta ed. methylenetetrahydrofolate reductase (mthfr) c677t polymorphism: epidemiology, metabolism and the associated diseases. eur j med genet 2015;58(1):1–10. 22. leclerc d, sibani s, rozen r. molecular biology of methylenetetrahydrofolate reductase (mthfr) and overview of mutations/polymorphisms [internet]. landes bioscience; 2013 [cited 2019 jan 26]. available from: https://www.ncbi.nlm.nih.gov/books/nbk6561/ 23. mthfr methylenetetrahydrofolate reductase homo sapiens (human) mthfr gene & protein [internet]. [cited 2019 jan 26]. available from: https://www.uniprot.org/uniprot/q5snw5 24. servy e, menezo y. the methylene tetrahydrofolate reductase (mthfr) isoform challenge. high doses of folic acid are not a suitable option compared to 5 methyltetrahydrofolate treatment. clin obstet gynecol reprod med 2017;3(6). 25. selzer rr, rosenblatt ds, laxova r, hogan k. adverse effect of nitrous oxide in a child with 5,10methylenetetrahydrofolate reductase deficiency. n engl j med 2003;349(1):45–50. 26. alatab s, hossein-nezhad a, mirzaei k, mokhtari f, shariati g, najmafshar a. inflammatory profile, age of onset, and the mthfr polymorphism in patients with multiple sclerosis. j mol neurosci mn 2011;44(1):6–11. original research article doi: 10.18231/2348-7682.2016.0011 panacea journal of medical sciences, september-december,2016;6(3): 159-163 159 complementary and alternative medicine: hidden presence among doctors and patients, an explorative study rs solanki assistant professor, dept. of community medicine, mahatma gandhi institute of medical sciences, wardha, maharashtra email: drranjansolanki@gmail.com abstract the term "alternative medicine" is used to describe healing treatments that are not part of conventional medical training. when alternative treatments are used along with conventional therapies then it is known as complementary medicine. this together is known as complementary alternative medicine (cam). the purpose of our study was to determine the prevalence of complementary and alternative medicine (cam) and perception about cam and cultural beliefs among doctors and patients attending primary care at kem hospital in mumbai.a cross-sectional study was carried out in primary care clinics in at gs seth medical college and kem hospital. a random sample of 100 doctors and patients was used. convenience sampling has been used. doctors and patients were interviewed by a pretested semi structured questionnaire including cam use, satisfaction with care, ailment for which cam used and cultural health beliefs about the same.all the doctors were aware of ayurveda, homeopathy and yoga. 40% doctors were also aware of siddha, unani, naturopathy, acupressure and acupuncture. 82% doctors and 58% patients have tried complementary and alternative medicine at least once in the past. chronic conditions like skin ailments asthma, arthritis, body aches are most commonly sought after. amongst different cam therapies, 52% doctors and 41% patients consulted for ayurveda which is highest in frequency. this is followed by homeopathy and yoga. 63% doctors and 69% patients were relieved of the symptoms for which they had consulted the cam therapy. dissatisfaction from conventional treatment, philosophical and spiritual orientation, friendlier approach of cam therapist and affordability of cam therapies were chief reasons to seek cam modalities. ayurveda is most consulted for. and maximum consultations to cam therapies were done for skin ailments. 84% patients reported that they had tried some form of home remedies before visiting doctor. and 70% of them found these home remedies to be effective. as seen in this study, use of cam is much prevalent among health care providers and seekers. the results of this study suggest doctors should be in a better position to make informed choices about cam modalities. further research and studies needed to determine the mechanism of action of many of the popular cam modalities. keywords: complementary alternative medicine, prevalence, tertiary care hospital. introduction the term "alternative medicine" is used to describe healing treatments that are not part of conventional medical training. many patients and health care providers use alternative treatments together with conventional therapies. this is known as complementary medicine. this together is known as complementary alternative medicine(cam). current estimates indicate that at least 50% of the population in the united states is using some form of alternative therapy and that, furthermore, very few of these persons will tell their primary care physician of their use of these therapies for fear of criticism and humiliation. many americans—more than 30 percent of adults and about 12 percent of children use cam modalities.(1) in developing countries, where more than one-third of the population lacks access to essential medicines, the provision of safe and effective complementary and alternative medicine therapies could become a critical tool to increase access to health care. with the increase in cost of conventional medical treatment, the incidence of self-medication has increased and many families prefer to try home remedies and alternative therapies before consulting a qualified medical practitioner.(2) many physicians believe in the usefulness of alternative medicine, especially in cases where conventional medicine cannot provide a cure. often there seems to be no effective therapy for chronic back or joint pain, depression, gastrointestinal disorders, skin problems or diseases categorized as "allergic" or "autoimmune".(3) as part of its global strategy for health for all in the 21st century, the world health organization (who) has supported the integration of conventional and alternative medicine to improve the quality of health care. in india ayush department, has been created in ministry of health and family welfare in november 2003. central council of industrial research has prepared guidelines about use of ayush, which are being used under national health mission. the government of india in association with csir has developed traditional knowledge digital library (tkdl) loaded with ancient medical knowledge. the online database contains translations of manuscripts and textbooks in five languages including english. patency for traditional medicine has been registered as per international protocol using advanced information technology. on the same ground, this study is an attempt to know the frequency of the use of complementary and rs solanki complementary and alternative medicine: hidden presence among doctors…. panacea journal of medical sciences, september-december,2016;6(3): 159-163 160 alternative medicine by health care providers and health care seekers. the present study also attempts to understand the perception of doctors and patients regarding complementary and alternative therapies at tertiary care hospital in mumbai. material and methods the present study has been conducted at general out patient department at gs seth medical college and kem hospital, mumbai in state of maharashtra. the present study is a cross sectional study done from 1/05/1015/05/10. convenience sampling has been used for this study. the patients attending general outpatient department were chosen by systematic random sampling. fifty patients who consented to spare time and filling proforma were selected. 50 residents doctors who consented to participate were also selected for the study. critically ill patients and patients below 18 years of age were excluded from the study. a socio demographic profile that included age, name sex, educational status, residence and socioeconomic status were administered. in addition to above stated questions the self-administered questionnaire semi structured questionnaire administered to doctors also included questions regarding cam use the most common reasons for using cam and patient perceptions of cam therapy ailments for which patients are referred to cam and their opinion regarding safety of use of cam. these were derived from the current literature and listed as choices referral of patients to cam. the questionnaire for patients consists of 15 direct questions on the use and attitudes towards alternative medicine. the questionnaire for doctors consists of 20 direct questions on perception and their view about incorporating alternative medicine into the health care system. the questions also dealt with awareness about possible harmful effects of alternative medicine. results 50 patients and 50 doctors approached for the study completed the questionnaire. the study participants’ demographics are outlined in table1.the mean age of doctors who participated in the study was 26 yrs whereas for patients it was 34years. 66% (n=33) patients and 56% (n=29) doctors were males.44% (n=21) doctors and 34% (n=17) patients were females. 51% (n=26) doctors were from department of community medicine. none of the patient is illiterate. 62% (n=31) of the patients have completed their secondary schooling. 18% (n=9) patients have completed higher secondary education. only 12% (n=6) patients are graduates. table 1: socio demographic profile of study participants doctors n=50 patients n=50 17-22yrs 9(18%) 22-40yrs 50(100%) 25(50%) >40yrs 16(32%) male 29(56%) 33(66%) female 21(44%) 17(34%) psm 26(51%) medicine 15(30%) pediatrics 9(18%) illiterate nil primary pursuing m.d. 4(8%) secondary 31(62%) higher secondary 9(18%) graduation 6(12%) table 2: attitude and perception of doctors and patients about complementary and alternative medicine the frequency of therapies known by patients (multiple responses) p value complementary and alternative medicine % of patents aware of it 1 ayurveda 44(88%) 2 homeopathy 40(80%) 3 yoga 42(84%) 4 unani 5(10%) 5 others 4(8%) 6 nil 6(12%) frequency of doctors and patients who have tried complementary and alternative therapies p=0.0088 cam tried (n=50) 1 doctors 41(82%) 2 patients 29(58%) ailments for which cam were tried by doctors and patients doctors(n=41) patients(n=29) 1 skin 8(19%) 5(17%) 2 urti 9(21%) 3(10%) rs solanki complementary and alternative medicine: hidden presence among doctors…. panacea journal of medical sciences, september-december,2016;6(3): 159-163 161 3 arthritis 3(7%) 7(24%) 4 hepatitis 3(7%) 2(6%) 5 bodyache 7(24%) 6 others 18(43%) 5(17%) frequency of cam tried by doctors for themselves and tried by patients p=0.0869 therapy doctors(n=41) patients(n=29) 1 ayurveda 21(52%) 12(41%) 2 homeopathy 12(29%) 8(27%) 3 yoga 8(19%) 9(32%) frequency of doctors and patients who reported relief from symptom after use of cam doctors(n=41) patients(n=29) p = 0.8209 symptoms got relieved 26(63%) 20(69%) reasons for going for cam by doctors and patients doctors(n=41) patients(n=29) 1 dissatisfied with conventional treatment 11(26%) 13(44%) 2 cam more effective 9(22%) 8(27%) 3 due to philosophical and spiritual orientation 7(17%) 1(3%) 4 therapist is more friendly 6(14%) 6(20%) 5 cam is cheaper 2(4%) 6(20%) frequency of cam therapies referred for by doctors n=22 1 ayurveda 12(54%) 2 homeopathy 5(22%) 3 yoga 4(18%) 4 unani 1(4%) frequency of ailments for which the patients are being referred frequency of reference (n=22) 1 skin ailments 8(36%) 2 arthritis 4(18%) 3 anxiety and depression 3(15%) 4 backache 2(12%) 5 others 2(10%) all the doctors were aware of ayurveda, homeopathy and yoga. 40% doctors were also aware of siddha, unani, naturopathy, acupressure and acupuncture. only 6% doctors were aware of chiropractic, aromatherapy, gem therapy and tibetan medicine. 88% patients are aware of aurveda, 84% patients are aware of yoga 80% patients are aware of homeopathy. 10% patients are also aware of unani. out of 84% patients who are aware about yoga, 14% patients are also practicing it regularly.82% (n=41) doctors and 58% (n=29) patients have tried complementary and alternative medicine at least once in the past. significantly higher number of doctors have sought complementary and alternative therapies than patients (p=0.0088). for skin ailments 19% (n=8) doctors and 17%(n=5) patients sought cam therapies. 21% (n=9) doctors and 10% (n=3)patients consulted cam practitioners for urti. 7% (n=3) doctors and 24% (n=7) patients sought cam practitioners for arthritis. for hepatitis 24% (n=7) patients and none of the doctors went for cam consultation. for body ache 43% (n=18) doctors and 17% (n=5) took consultation from cam practitioners. amongst different cam therapies, 52% (n=21) doctors and 41% (n=12) patients consulted for ayurveda which is highest in frequency. this is followed by homeopathy for which 29% (n=12) doctors and 27% (n=8) patients took consultation from.19% (n=8) doctors and 32% (n=9) patients consulted for yoga. as table suggest, 63% (n=26) doctors and 69% (n=20) patients were relieved of the symptoms for which they had consulted the cam therapy. so, 26% (n=11) doctors 44% (n=13) patients consulted cam therapies because they were dissatisfied by conventional treatment. 22% (n=9) doctors and 27% (n=8) patients thought that cam was rs solanki complementary and alternative medicine: hidden presence among doctors…. panacea journal of medical sciences, september-december,2016;6(3): 159-163 162 more effective for certain ailments like skin ailments, arthritis, myalgia, anxiety and depression than conventional therapy. 17% (n=7) doctors and 3% (n=1) patients had tried cam due to philosophical and spiritual orientation whereas 14% (n=6) doctors and 20% (n=6) patients have found cam therapist more friendly.4% (n=2) doctors and 20% (n=6) patients found cam therapies cheaper than conventional therapies. maximum referrals to cam therapies by doctors are done for ayurveda(54%) this is followed by homeopathy referral that amounts to 22% followed by yoga upto 18%. least referrals are done towards unani that measured upto 4%. the ailments for which maximum referrals were done by doctors to cam therapies were skin ailments (36%) that was followed by arthritis (18%) followed by anxiety and depression (15%). during history taking from patients, 78% doctors reported that they usually took history regarding use of cam therapies by patients. 78% doctors opined that complementary and alternative therapies should be incorporated in mainstream medicine whereas 92% doctors felt that sanitization about cam therapies should be introduced in mbbs curriculum. 64% doctors thought that complementary and alternative therapies could be harmful, if used without supervision and at unskilled hands. 24% doctors expressed their concern regarding presence of heavy metals and steroids in some cam drugs which come in market without clinical trial. 12% doctors think that the cam medicines should be standardized and should undergo clinical trial for safety measures. as per 14% of doctors, cam therapist also should be brought under supervision and monitoring by respective councils. they also expressed need of evaluation of affectivity of cam and need of standardization of cam drugs. whereas only 6% patients viewed cam therapies as harmful. 32% (n=16) doctors had attended some conference or read some article about cam. out of 16(32%) doctors who have attended conference or read some article about cam, 52% (n=9) said that they got positive about cam after attending the conference. 84% (n=42) patients reported that they had tried some form of home remedies before visiting doctor. and 70% (n=59) of them found these home remedies to be effective (table 2). discussion the results of the study indicate that alternative medicine has an significant hidden presence and influence within the health care system. the results showed considerable use of alternative medicine among doctors and patients. this is surprising finding that more doctors (82%) than patients(58%) have indicated personal use of cam for different ailments. amongst different cam therapies, majority of doctors and patients took consultation for ayurveda which is highest in frequency. this is followed by homeopathy and yoga. most of the doctors and patients were relieved of the symptoms for which they had consulted the cam therapy. the various reasons cited by doctors and patients for which they sought cam therapies were dissatisfied by conventional treatment, perceived more effectiveness of cam modalities for chronic ailments, due to philosophical and spiritual orientation, friendlier approach of cam therapist and affordability of cam therapies. maximum referrals to cam therapies by doctors were done for ayurveda. (54%) which was followed by homeopathy and yoga. maximum patients were referred for chronic ailments like by doctors to cam therapies. less than half (32%)doctors had attended some conference or read some article about cam. majority of patients had used some form of home remedies before visiting doctor and most of them found these home remedies to be effective. a considerable number of patients are also reportedly satisfied by using home remedies. this necessitates research in the effectiveness of home remedies. the conditions for which patients were referred were chronic ailments, such as asthma, arthritis, backache and skin disorders, and a variety of nonspecific disorders, including headache, backache, joint pain, and depression. it is found that for the similar ailments cam is consulted for in many other studies.(2,4)a study by jump et al. demonstrated that the majority of physicians in the united states viewed many of cam therapies as not part of legitimate medical practice.(5-7)in addition, milden et.al found that while a random sample of california physicians demonstrated an overall positive attitude toward cam, 61% still found themselves discouraging cam therapies because they are not knowledgeable enough about the safety or efficacy of cam treatments. a less than quarter patients even practice yoga regularly which shows receptivity of the patients for cam. the fact that a fairly large number of the doctors even suggested patients to approach practitioners of alternative medicine shows that doctors not only acknowledge the existence of unconventional therapies, but also support them, even if they are viewed as a last resort. in this study, most of the doctors have made referral to indigenous medicine ayurveda and yoga. ayurveda is the most consulted cam by both doctors and patients followed by yoga and homeopathy. in this study, most of the residents suggested that cam were effective and should be incorporated in mainstream of medicine and further added that m.b.b.s. students should be sensitized regarding cam. doctors and patients both have tried cam for skin ailment, arthritis and bodyache, hepatitis and asthma have experienced a considerable degree of contentment. majority of doctors and patients have not experienced any side effect of cam. majority of doctors and patients said that they would recommend it to others. majority of doctors and patients had tried allopathic before going for cam. most of the doctors have indicated that they rs solanki complementary and alternative medicine: hidden presence among doctors…. panacea journal of medical sciences, september-december,2016;6(3): 159-163 163 always take history of use of cam from their patients. furlow ml et al(8) also suggest that, 83% of physicians surveyed routinely query their patients about cam use. marian f et al 2008(9) suggests that in a primary care setting, patient satisfaction seems to be higher with homeopathic treatment compared to conventional treatment. and also indicated that homeopathic treatment is perceived as a low-risk therapy with less side effects than conventional treatment. these findings are consistent with our study. present study indicates than a less than quarter number of doctors never asks their patients about use of cam therapies. this could also be harmful, as many herbal medicines have been found to have strong drug interaction with conventional medicines.(10-11) considering the high prevalence of use of home remedies, evidence base needs to be generated for them. qualified practitioners of alternative medicine should be integrated in health team so that they can share their knowledge and skills with and develop their understanding of holistic approach towards health. cam panels need to be introduced in health system, to take integrated decision about management of many chronic conditions. the involvement of qualified practitioners of alternative medicine will also help the participants to assess each other's strengths, limitations and practice patterns and provide an opportunity to discuss solutions for individual and community health. this will also reduce misunderstandings and resistance between so-called conventional and unconventional therapists. communication between students, doctors and practitioners of alternative medicine will promote research in neglected areas and further develop health care providers' ability to deal with uncertainties. our studies primary limitation was its small sample size. with larger sample size more useful perspectives could be sought on part of doctors and patients as well. conclusion as seen in this study, use of cam is much prevalent among health care providers and seekers. the results of this study suggest doctors should be in a better position to make informed choices about cam modalities. further research and studies needed to determine the mechanism of action of many of the popular cam modalities. acknowledgements the author would like to thank department of community medicine, seth gs medical college and kem hospital, mumbai for support provided to conduct this study. author is also grateful to all study participants who spared their valuable time to fill the self-administered questionnaire required for the study. references 1. eisenberg dm, kessler rc, forster c, norlock fe, calkins dr, deldano tl. unconventional medicine in the united states; prevalence, costs and patterns of use. n engl j med 1993;328:246-252. 2. lam cl. self-medication among hong kong chinese. social science and medicine 1994;39(12):1641-7. 3. eisenberg dm. unconventional medicine in the united states. prevalence, costs and patterns of use. new england journal of medicine 1993;328(4):246-52. 4. regulatory situation of herbal medicines: a worldwide review. geneva, world health organization, 1998. 5. wharton r, lewith g. complementary medicine and the general practitioner. british medical journal 1986;292:1498-500 6. jump j, yarbrough l, kilpatrick s, cable t. physicians' attitudes toward complementary and alternative medicine. integrative medicine 1998;1:149–153. 7. milden sp, stokols d. physicians' attitudes and practices regarding complementary and alternative medicine. behav med 2004;30:73–82. 8. mandi l furlow, divya a patel, ananda sen, j rebecca liu. physician and patient attitudes towards complementary and alternative medicine in obstetrics and gynecology. bmc complement alternative med 2008;8:35. 9. marian f, joost k, saini kd, von ammon k, thurneysen a, busato a. patient satisfaction and side effects in primary care: an observational study comparing homeopathy and conventional medicine. bmc complement altern med 2008 sep 18;8:52. 10. laura shane-mcwhorter, patti geil. interactions between complementary therapies or nutrition supplements and conventional medications cde. diabetes spectrum october2002;15(4):262-266. 11. brazier nc, levine ma. drug-herb interaction among commonly used conventional medicines: a compendium for health care professionals. american journal of therapeutics 2003;10(3):163-169. https://www.ncbi.nlm.nih.gov/pubmed/?term=marian%20f%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/?term=joost%20k%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/?term=saini%20kd%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/?term=von%20ammon%20k%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/?term=thurneysen%20a%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/?term=thurneysen%20a%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/?term=busato%20a%5bauthor%5d&cauthor=true&cauthor_uid=18801188 https://www.ncbi.nlm.nih.gov/pubmed/18801188 https://www.ncbi.nlm.nih.gov/pubmed/18801188 original research article http://doi.org/10.18231/j.pjms.2019.007 panacea journal of medical sciences, january-april, 2019;9(1):23-28 23 platelet indices in type 2 diabetes mellitus and their association with microvascular complications ravindra m. kshirsagar1*, shilpa deoke2, shamim akhtar3 1assistant professor, 2,3associate professor, 1,2dept. of medicine, 3dept. of pathology, nkp salve institute of medical sciences and research centre, nagpur, maharashtra, india *corresponding author: ravindra m. kshirsagar email: rmk11.ngp@gmail.com abstract the platelets play a vital role in the pathological changes in diabetes leading to micro-vascular complications. platelet indices being indicators of platelet activity, may be useful predictive markers of these complications. the aim of this study was to evaluate the platelet indices in diabetic patients and correlate them with micro-vascular complications of the disease. we included 60 patients of type 2 diabetes and 60 non-diabetics in this case-control study. detailed clinical history including duration of diabetes and presence of microvascular complications was noted. platelet indices (platelet count-plt, mean platelet volume-mpv, platelet distribution width-pdw and plateletcrit-pct) were obtained using automated cell counter. fasting blood glucose and hba1c were also obtained. diabetics were further categorized into patients with complications and without complications. statistical analysis was performed by epi info software version 7, student's t-test and anova test. the study showed that mpv was significantly higher in diabetics than non-diabetic controls (p<0.05). hba1c (p<0.05) and duration of diabetes (p<0.05) were statistically significantly higher in diabetics with microvascular complications as compared to diabetics without microvascular complications. mpv showed statistically significant difference between diabetics with and without complications and nondiabetics (p < 0.05). pdw and mpv were positively correlated with duration of diabetes. duration of diabetes was significantly higher in diabetics with retinopathy (<0.05) and neuropathy (p<0.05). diabetics have higher mpv. mpv and pdw are predictive biomarkers of diabetic micro-vascular complications. keywords: diabetes, platelet indices, platelet count, mean platelet volume, platelet distribution width, plateletcrit. introduction diabetes mellitus (dm) has become a global health crisis with 422 million people suffering from it and its incidence is rapidly rising in middleand low-income countries.1 over 80% of cases of dm are type 2 diabetes, which is characterised by either deficiency of insulin or resistance to action of insulin or both.2 diabetes is a complex disease with chronic hyperglycemia, metabolic abnormalities, and long-term macroand micro-vascular complications involving the blood vessels, eyes, kidneys, and nerves.3 diabetes and uncontrolled hyperglycemia contribute to increased morbidity and mortality including development of cardiovascular disease.4 microvascular complications are predictors of coronary heart events.5 the hyperglycemia, dyslipidemia, and insulin resistance in diabetes causes endothelial and pericyte injury, making it a prothrombotic state. platelets are known to play a vital role in thrombosis. platelets with altered morphology are found in diabetics.6 they are larger with denser granules which are enzymatically and functionally hyperactive and contribute to this prothrombotic state. mean platelet volume (mpv) is a blood parameter used for measuring platelet size.7 larger platelets have higher mpv. hence increased mean platelet volume (mpv) and platelet distribution width (pdw) might be associated with increased thrombotic potential.8 diabetic patients have shown significantly higher mpv than the nondiabetic subjects.9 larger platelets with altered morphology could be associated with increased risk of vascular complications in diabetes.10 in recent years, there has been renewed interest in hematological parameters such as white blood count (wbc), mean platelet volume (mpv), platelet distribution width (pdw), plateletcrit (pct), platelet count, platelet to lymphocyte ratio (plr) and neutrophil to lymphocyte ratio (nlr) and they are designated as predictors of endothelial dysfunction and inflammation. the newer hematological analyzers can give us various platelet parameters which help in easy detection of change in platelet structure, which may help in early detection of prothrombotic state of the platelets. platelet indices may serve as useful tools, being simple, quick, effective and routinely available at a relatively low cost, to detect early vascular complications in patient with dm, aiding in better patient care.11-13 thus they can act as an alarm for diagnosis, initiation or progression of diabetic complications. hence, in view of this, we aimed to study platelet parameters in type 2 diabetes and its association with the microvascular complications of diabetes. materials and methods patient population and study design this cross-sectional analytical study was conducted in a tertiary care hospital and research centre catering services to central india. the study included 60 diabetic patients and 60 nondiabetics as controls without cad. all cases of diabetes type 2 were recruited from the inpatient department of medicine and the non-diabetic controls from the inpatient department of eye over a period of 2 years from june 2015 to may 2017. institutional ethical committee clearance was obtained before the start of study. informed and written consent of all the subjects was taken. we included diabetic patients who were already on treatment either oral and / or insulin injection for previously diagnosed dm or newly diagnosed in accordance with the mailto:rmk11.ngp@gmail.com ravindra m. kshirsagar et al. platelet indices in type 2 diabetes mellitus and their association with microvascular… panacea journal of medical sciences, january-april, 2019;9(1):23-28 24 american diabetes association.14 the control group was obtained from individuals without dm, as obtained from their medical records. females with hb <10gm% and males hb <12 gm%, nondiabetic subjects with cad, pregnant women, patients on antiplatelet drugs such as aspirin or clopidogrel and subjects with any diagnosed malignancy were excluded from the study. also patients with hematologic diseases, hepatic or renal or cardiac failure, acute illness, chronic diseases like chronic infections, alcohol abuse, that are on medication altering the platelet function, and atherosclerotic diseases except for arterial hypertension were not included in the study. evaluation of demographical and clinical specifications all the diabetic and nondiabetic subjects had a complete clinical examination including details of medical history and medications. blood pressure, height and weight measurements, waist and hip circumference were recorded and body mass index (bmi) was calculated by using quetlet index with weight in kgs / height in mt² formula and waist circumference and waist/hip ratio was calculated by the readings obtained. diabetics were evaluated for presence of microvascular complications i.e. retinopathy, nephropathy, and neuropathy. retinopathy diagnosis was made based on the findings of proliferative or non-proliferative changes in the fundus examination by a trained ophthalmologist. nephropathy was diagnosed by doing urine analysis by dipsticks method. diabetic neuropathy symptom and signs, such as hypoaesthesia or anaesthesia or absent ankle jerks, were used to determine the presence of diabetic peripheral neuropathy. biochemical and hematologic evaluation the blood investigations performed were complete blood count including platelet indices i.e. platelet count (plt), mean platelet volume (mpv), platelet distribution width (pdw) and plateletcrit (pct); fasting (fbs) and postmeal (pmbs) blood sugar and hba1c in diabetic subjects and random blood glucose in non-diabetic controls. blood sample was taken under all aseptic precautions from the antecubital vein by a clean puncture avoiding bubbles and froth. about 2 ml of blood sample each was collected in edta, fluoride bulb, and 4ml in plain bulb. the testing of the blood samples was done within 2 hours of collection of blood to avoid changes due to aging of the blood sample. complete hemogram was performed by using automated haematology cell counter abx micross 60 from edta bulb. hb, platelet count, mpv, pdw, and pct were also recorded. plasma glucose levels were measured by the glucose oxidase method. hba1c level was analyzed by immunoturbidometric inhibition method. statistical analysis statistical analysis was performed by epi info software version 7. student's t-test was used to find the significant difference of fbs, hba1c, plt, mpv, pdw, pct according to complications. diabetics were subdivided in 2 groups depending on presence or absence of microvascular complication/s and anova test was used to find the significance of platelet indices between these two groups and the controls. correlations of platelet indices with individual microvascular complications were obtained using pearson’s formula. data were expressed as mean ± standard deviation. a p < 0.05 was considered statistically significant. results in this study total 124 subjects were evaluated, out of which 63 were cases of diabetes and 61 were non-diabetic controls. 3 cases and 1 control were excluded due to haemoglobin less than 10 gm%. in both the groups males were 33 and females were 27 in number respectively. the average age of diabetes subjects was 57.05±9.39 years (males 57±9.0; females 56.6±8.94) while that of control group 56.75±8.59 9 years (males 57±9.1; females 56.56±8.13). there was no significant difference in age and gender distribution. however diabetic group showed significantly higher bmi, waist circumference, systolic (sbp) and diastolic blood pressure (dbp), and mpv than the controls. but the plt, pct and pdw were not significantly different between the two groups (table 1). table 1: demographic and biochemical parameters in diabetic subjects vs controls s. no. parameter diabetes group (n = 60) control group (n = 60) ‘p’ value 1 age (years) 57.05±9.39 56.75±8.59 0.896 2 gender f/m 27/33 27/33 --- 3 bmi (kg/m 2) 23.40±2.88 21.75±3.52 <0.001* 5 waist circumference (cms) 90.67 ± 6.18 76.68 ± 9.52 <0.001* 5 sbp (mm of hg) 135.53±14.35 127.87±13.69 0.004* 6 dbp (mm of hg) 83.43±8.58 79.60±7.16 0.009 7 plt (x103/ul) 2.93±1.00 3.05±0.76 0.469 8 mpv (fl) 8.07±1.00 7.70±0.61 0.016* 9 pct(%) 0.23±0.08 0.24±0.09 0.393 10 pdw (fl) 13.82±1.80 13.49±1.64 0.303 *significant p value ravindra m. kshirsagar et al. platelet indices in type 2 diabetes mellitus and their association with microvascular… panacea journal of medical sciences, january-april, 2019;9(1):23-28 25 the duration of diabetes was 4.0 ± 3.23 years. the fasting blood glucose in diabetes group was 171±65.17 and post meal blood glucose was 264.15 ± 81.53 mg% while hba1c was 8.63 ±1.42%. out of 60 subjects of diabetes, 30 (50%) had one or more of the 3 microvascular complications, namely retinopathy, neuropathy and nephropathy, while 30 subjects were without complications. among the microvascular complications, retinopathy was seen in 11(18.33%) subjects, neuropathy in 13(21.67%) and nephropathy in 18(30%) subjects respectively. 21 subjects had at least 1 microvascular complication while 6 had 2 complications and 3 subjects had all the 3 complications. 20 subjects in diabetic group also had hypertension and 1 had ischemic heart disease. the platelet indices, fbs, hba1c, and duration of diabetes in diabetic subjects with microvascular complications when compared with that of diabetic subjects without complications, showed that there was no significant difference in platelet indices, fbs and pmbs between the two groups but the hba1c and the duration of diabetes were found to be significantly higher in diabetics with complications than in diabetics without complications. (table 2). table 2: platelet indices, control and duration of diabetes in diabetics with microvascular complications vs. diabetics without complications parameters diabetics with microvascular complications (n = 30) diabetics without microvascular complications (n = 30) p value plt 2.9 9 ± 0.87 2.87 ± 1.12 0.666 mpv 8.19 ± 1.17 7.95 ± 0.79 0.357 pct 0.23 ± 0.07 0.23 ± 0.09 0.964 pdw 13.98 ± 1.60 13.56 ± 1.97 0.372 fbs 175.30 ± 67.08 167.87 ± 64.13 0.662 hba1c 9.02 ± 1.64 8.24 ± 1.05 0.031* duration of dm 4.83 ± 3.17 3.24 ± 2.60 0.045* *significant p value we divided the subjects in 3 groups namely dm with microvascular complications, dm without complications and normal controls and analysed through one way anova to find the significance of platelet indices between the 3 groups. it showed significant value with respect to mpv and not with other platelet parameters. (table 3) table 3: comparison of platelet indices in diabetics with complications, without complications and non-diabetic controls group n plt mpv pct pdw mean s.d. mean s.d. mean s.d. mean s.d. dm with complication 30 2.99 0.87 8.19 1.17 0.23 0.07 13.98 1.60 dm without complication 30 2.87 1.12 7.95 0.79 0.23 0.09 13.56 1.97 controls 60 3.05 0.76 7.70 0.61 0.24 0.09 13.49 1.64 p value 0.68 0.03* 0.69 0.43 *significant p value table 4: comparison of platelet count (plt) and mean platelet volume (mpv) according to the complications in diabetic group complication yes / no n plt (x103/ul) mpv(fl) mean ± s.d. ‘p’ mean ± s.d ‘p’ retinopathy yes 11 2.66 ± 0.66 0.33 8.37 ± 0.93 0.28 no 49 2.99 ± 1.05 8.01 ± 1.01 neuropathy yes 13 2.94 ± 1.02 0.98 8.54 ± 1.08 0.06 no 47 2.93 ± 1.00 7.95 ± 0.95 nephropathy yes 18 3.08 ± 0.82 0.45 8.13 ± 1.32 0.76 no 42 2.86±1.07 8.05 ± 0.84 platelet count was found to be decreased in diabetic subjects with retinopathy as compared to those without retinopathy whereas it was more in those with neuropathy and nephropathy groups but these differences were not statistically significant. mpv, although was found to be higher in all the 3 complications but was insignificant (table 4). similarly, pdw and hba1c although were found to be higher in all the 3 complications but failed to achieve significant level (table 5 and 6). ravindra m. kshirsagar et al. platelet indices in type 2 diabetes mellitus and their association with microvascular… panacea journal of medical sciences, january-april, 2019;9(1):23-28 26 table 5: comparison of plateletcrit (pct) and platelet distribution width (pdw) according to the complications in diabetic group complication yes / no n pct (%) pdw (%) mean ± s.d. ‘p’ mean ± s.d ‘p’ retinopathy yes 11 0.21 ± 0.04 0.26 14.58 ± 1.18 0.10 no 49 0.24 ± 0.08 13.60 ± 1.88 neuropathy yes 13 0.22 ± 0.07 0.70 13.85 ± 2.10 0.87 no 47 0.07± 0.08 13.76 ± 1.74 nephropathy yes 18 0.24 ± 0.06 0.53 14.02 ± 1.15 0.52 no 42 0.23 ± 0.08 13.68 ± 2.02 table 6: comparison of fasting blood sugar (fbs), hba1c and duration of diabetes according to the complications in diabetic group complication yes / no n fbs hba1c duration of dm mean ±s.d. ‘p’ mean ± s.d ‘p’ mean ± s.d ‘p’ retinopathy yes 11 192.82± 89.29 0.235 8.76 ± 1.83 0.73 6.27 ± 4.54 0.01* no 49 166.82 ± 58.591 8.60 ±1.34 3.49 ± 2.66 neuropathy yes 13 161.31 ± 75.40 0.53 8.93 ± 1.60 0.39 5.77 ± 3.86 0.02* no 47 174.43 ± 62.66 8.55 ± 1.38 3.51 ± 2.90 nephropathy yes 18 183.00 ± 69.06 0.38 9.02 ± 1.62 0.17 3.35 ± 0.79 0.44 no 42 166.69 ± 63.66 8.46 ± 1.32 3.20 ± 0.49 *significant p value there was no significant difference of fbs between the two groups in all the 3 microvascular complications. higher duration of diabetes was associated significantly with presence of retinopathy and neuropathy but not with nephropathy (table 7). table 7: pearson’s correlation of platelet indices with duration of dm, fbs and hba1c platelet indices  plt mpv pct pdw other parameters↓ r' p r' p r' p r' p dm –duration -0.23 0.08 0.34 0.01* -0.22 0.65 0.43 0.00* fbs -0.19 0.15 -0.06 0.65 -0.26 0.04* 0.03 0.82 hba1c -0.03 0.82 -0.06 0.65 -0.06 0.65 -0.10 0.45 * significant p value on correlation analysis mpv and pdw were found to be positively corelated with the duration of diabetes while plateletcrit showed significant negative correlation with fbs. discussion diabetes mellitus is a chronic and complex metabolic syndrome with hyperglycemia and various complications such as microvascular (retinopathy, neuropathy and nephropathy) and macrovascular (coronary heart disease, cerebrovascular episodes, peripheral vascular disease etc.3 the microvascular complications occur due to increased prothrombotic and atherosclerotic potential in diabetes especially when it is prolonged and / or poorly controlled.5 these complications are predictive markers of macrovascular complications, notably cardiovascular disease, that are responsible for increased morbidity and mortality in diabetes.15 diabetes and its complications result into a heavy burden on our health services and economy.16 survey by nanditha et al revealed increased prevalence of diabetes in rural india.17 previous studies have suggested that platelet indices may be useful to predict the microvascular complications in diabetes.18 good control of dm type 2 has shown to decrease the severity and prolong the onset of vascular complications and hence decrease the morbidity and mortality.19,20 platelet indices that we studied included – platelet count, mpv, pdw, and pct which are quickly available at affordable costs in routinely done peripheral blood counts and can be monitored repeatedly. previous studies have mostly studied mpv in various conditions including diabetes but very few of them have included other of these parameters.21-23 hence in this study we aimed to find out the platelet indices in type 2 dm and their association with the presence of microvascular complications, and with the regulation and duration of hyperglycemia in patients predominantly from periurban villages and rural population in central india. in our study amongst the platelet indices we found that mpv was significantly higher in diabetics than controls. pdw though also higher yet was not statistically significant. plt and pct were found to be decreased but were not significant. considering the microvascular complications, in our study none of the platelet indices showed significant difference between diabetics with and without complications. however, the duration of diabetes and the hba1c were significantly higher in diabetics with ravindra m. kshirsagar et al. platelet indices in type 2 diabetes mellitus and their association with microvascular… panacea journal of medical sciences, january-april, 2019;9(1):23-28 27 microvascular complications than in diabetics without complications. the study reinforced the fact that poor glycemic control and longer duration may increase the risk of diabetic complications. previous studies have shown altered platelet indices in diabetic patients and its complications9,21,22,24,25. most of the previous studies have shown that diabetics have higher plt 9,21,24,25 while our study revealed lower plt in dm group as compared to non diabetic controls which is similar to that observed by hekimsoy et al and buch a.et al. it was postulated that this may be because of various factors such as high production and turnover rate in t2dm with diminished mean platelet survival. the platelet function and its size are said to be related to each other. larger platelets are highly active and have more dense granules, secrete more prothrombotic factors e.g. thromboxane a2, thromboxane b2, platelet factor 4, serotonin, and platelet-derived growth factor than smaller sized platelets and hence cause increased tendency to thrombotic events.26-30 platelet hyperactivity in dm is also attributed to hyperglycemia as it is postulated that large sized platelets may form because of persistent and unregulated blood sugar levels.26 this seems to occur through certain mechanisms such as nonenzymatic protein glycation of these platelets and also osmotic effect of glucose and protein kinase c activation.26 our study revealed that the mpv was significantly higher in diabetics than non diabetics which is similar to the observation of most of the previous other studies9,18,21,27,28 which indicates that larger and hence hyperactive platelets are due to the chronic hyperglycemia but this was not seen in the study by akinbami akinsegun et al.29 some authors obtained significantly higher mpv in dm with vascular complications than without complications.22,31,32 our study although found higher mpv in dm with complications as compared to dm without complications but the difference was not statistically significant which was similar to kodiatte ta et al. our study revealed that there is significant positive correlation of mpv with the duration of diabetes, but there was no such observation in regards to fbs, and hba1c. hekimsoy z, also did not find a significant correlation in mpv vs fbs. we found that mpv was not correlated with fbs and hba1c. hekimsoy z, et al also did not find a significant correlation in mpv vs fbs. some studies have reported positive association of mpv with elevated fbs and hba1c levels.9,21,24,27 however, it is proposed that fsg is not directly associated with increased cardiovascular events in patients with type 2 dm.33 in our study pdw also showed significant positive correlation with the duration of dm similar to k l, sushma et al. pdw is a measure of the platelet size variability, and it increases when there is increased production of larger reticulated platelets.22 the platelets which are activated are different in size than nonactivated ones because of pseudopodia formation and change in shape from discoid to spherical giving rise to increased pdw.34 on analysing pdw in diabetics we found that although it was higher in diabetics than controls and also in diabetics with complications than diabetics without complications yet the differences were not significant statistically. other authors have shown pdw to be significantly higher in diabetics.21,35 study by alhadas kr et al showed higher pdw in diabetics with complications and found a positive correlation between fbs and pdw in diabetics; between hba1c and pdw as well as mpv and pct. these changes were attributed to the osmotic effect due to hyperglycemia and some of its metabolites in blood.35 however present study showed no significant difference of pdw between diabetics with complications, diabetics without complications and nondiabetic groups. this was similar to that of buch a. et al, while k l, sushma et al have reported positive correlation between pdw with fbs and hba1c level which is discordant to our study. many other factors like platelet number and reactivity along with the cardiovascular comorbidities such as hypertension; dyslipidemia, obesity, cigarette smoking, albuminuria contribute to the progression of diabetes and its effect on platelet indices which may account for the thrombotic potential of diabetics with time.22 regarding pct few studies are available in the literature. in the present study no significant difference of pct levels was seen between the diabetics and the controls and there was no significant correlation of pct with the microvascular complications. however pct was negatively correlated to increase in fbs. to maintain constant platelet mass or pct, the platelet count tends to decrease as the platelet volume increases. however alhadas kr, et al obtained higher pct in diabetics and also in diabetics with chronic complications. it is explained by the observation that in diabetic patients the platelets is larger and more reactive, due to which the platelet mass increases, thus increasing the pct. conclusion among the platelet indices mean platelet volume (mpv) and platelet distribution width (pdw) are associated with diabetes and its microvascular complications and hence they may be considered as markers of platelet activation. however, the increased mpv as the cause or the result of vascular complications needs to be further explored. but being cost effective, simple to obtain, and easily available in peripheral blood counts can be used to monitor the progression and control of dm and its cardio-vascular complications. limitations in this study because of the cross-sectional design, we cannot establish a causal relationship between platelet indices and microvascular complications of diabetes. another limitation is that qualitative platelet disorders could not be assessed. acknowledgements we express our sincere thanks and gratitude to the departments and the heads of medicine, ophthalmology, ravindra m. kshirsagar et al. platelet indices in type 2 diabetes mellitus and their association with microvascular… panacea journal of medical sciences, january-april, 2019;9(1):23-28 28 pathology and met of nkpsims and rc and lmh, digdoh, hingna road, nagpur for their guidance and support. conflict of interest: none. references 1. colin d mathers, dejan loncar. public library of science plos medicine projections of global mortality and burden of disease from 2002 to 2030 published: november 28, 2006. available at: https://doi.org/10.1371/journal.pmed.0030442. 2. world health organization (who) diabetes who fact sheet updated 30 october 2018 available at: https://www.who.int/news-room/fact-sheets/detail/diabetes. 3. powers ac. diabetes mellitus. in: longo dl, fauci as, kasper dl, hauser sl, jameson jl, loscalzo j, editors. harrison's principles of internal medicine. 18th ed. new york: mcgraw-hill; 2012:2968–3002. 4. laakso m. hyperglycemia and cardiovascular disease in type 2 diabetes. diabetes 1999;48:937–42. 5. avogaro a, giorda c, maggini m, mannucci e, raschetti r, lombardo f, et al. incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location. diabetes care 2007;30:1241–7. 6. ferroni p, basili s, falco a, davì g. platelet activation in type 2 diabetes mellitus. j thromb haemost 2004;2:1282–91. 7. chu sg, becker rc, berger pb, bhatt dl, eikelboom jw, konkle b, et al. mean platelet volume as a predictor of cardiovascular risk: a systematic review and meta-analysis. jsj thromb haemost 2010;8(1):148-56. 8. endler g, klimesch a, sunder-plassmann h, schillinger m, exner m, mannhalter c, et al. mean platelet volume is an independent risk factor for myocardial infarction but not for coronary artery disease. br j haematol 2002;117:399–404. 9. kodiatte ta, manikyam uk, rao sb, jagadish tm, reddy m, lingaiah hm, et al. mean platelet volume in type 2 diabetes mellitus. j lab physicians 2012;4:5-9. 10. jindal s, gupta s, gupta r. platelet indices in diabetes mellitus: indicators of diabetic microvascular complications. hematol 2011;16(2):86-9. 11. hekimsoy z, payzin b, ornek t, kandoğan g. mean platelet volume in type 2 diabetic patients. j diabetes complications 2004;18(3):173-6. 12. kaveeshwar sa, cornwall j. the current state of diabetes mellitus in india. amj 2014;7(1):45-8. 13. vijaya c, archana shetty, parikshith. comparative study of significance of lipid profile, platelet count and mpv-diabetics and non-diabetics. sch j app med sci 2014;2(5b):1584-8. 14. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care 2004;27:5–10. 15. rosenson rs, fioretto p, dodson pm. does microvascular disease predict macrovascular events in type 2 diabetes? atheroscler 2011;218(1):13-8. 16. van dieren s, beulens jw, van der schouw yt, grobbee de, neal b. the global burden of diabetes and its complications: an emerging pandemic. eur j cardiovasc prev rehabil 2010;17 suppl 1:s3-8. 17. nanditha a, snehalatha c, satheesh k, susairaj p, simon m, vijaya l, et al. secular trends in diabetes in india (stridei): change in prevalence in ten years among urban and rural populations in tamil nadu. diabetes care 2019;42(1):18. 18. levent demirtas, husnu degirmenci, emin murat akbas, adalet ozcicek, aysu timuroglu, ali gurel, et al. association of hematological indicies with diabetes, impaired glucose regulation and microvascular complications of diabetes. int j clin exp med 2015;8(7):11420–7. 19. andersson c, van gaal l, caterson id, weeke p, james wp, coutinho w, et al. relationship between hba1c levels and risk of cardiovascular adverse outcomes and all-cause mortality in overweight and obese cardiovascular high-risk women and men with type 2 diabetes. diabetologia 2012;55:2348-55. 20. boos cj, lip gy. assessment of mean platelet volume in coronary artery disease what does it mean? thromb res 2007;120:11-3. 21. alhadas kr, santos sn, freitas mm, viana sm, ribeiro lc, costa mb. are platelet indices useful in the evaluation of type 2 diabetic patients? j bras pathol med lab 2016;52:96-102. 22. buch a, kaur s, nair r, jain a. platelet volume indices as predictive biomarkers for diabetic complications in type 2 diabetic patients. j lab physicians 2017;9:84-8. 23. sushma kl, rangaswamy m. study of platelet indices in type 2 diabetic patients and its correlation with vascular complications. ann pathol lab med 2017;4:a591-a8. 24. demirtunc r, duman d, basar m, bilgi m, teomete m, garip t. the relationship between glycemic control and platelet activity in type 2 diabetes mellitus. j diabetes complications. 2009;23:89–94. 25. zuberi bf, akhtar n, afsar s. comparison of mean platelet volume in patients with diabetes mellitus, impaired fasting glucose and non-diabetic subjects. singapore med j 2008;49:114-6. 26. kakouros n, rade jj, kourliouros a, resar jr. platelet function in patients with diabetes mellitus: from a theoretical to a practical perspective. int j endocrinol 2011;2011:742719. 27. ulutas k, dokuyucu r, sefil f. evaluation of mean platelet volume in patients with type 2 diabetes mellitus and blood glucose regulation: a marker for atherosclerosis?. int j clin exp med 2014;7(4):955-61. 28. jabeen f, fawwad a, rizvi h. role of platelet indices, glycemic control and hs-crp in pathogenesis of vascular complications in type-2 diabetic patients. pak j med sci 2013;29(1):152-6. 29. akinsegun a, akinola olusola d, sarah jo, olajumoke o, adewumi a, majeed o, et al. mean platelet volume and platelet counts in type 2 diabetes: mellitus on treatment and non-diabetic mellitus controls in lagos, nigeria. pan afr med j 2014;18:42. 30. gasparyan ay, ayvazyan l, mikhailidis dp, kitas gd. mean platelet volume: a link between thrombosis and inflammation? curr pharm des 2011;17:47–58. 31. zuberi bf, akhtar n, afsar s. comparison of mean platelet volume in patients with diabetes mellitus, impaired fasting glucose and non-diabetic subjects. singapore med j 2008;49:114-6. 32. papanas n, symeonidis g, maltezos e, mavridis g, karavageli e, vosnakidis t, et al. mean platelet volume in patients with type 2 diabetes mellitus. platelets 2004;15:475-8. 33. yeboah j, bertoni ag, herrington dm, post ws, burke gl. impaired fasting glucose and the risk of incident diabetes mellitus and cardiovascular events in an adult population: mesa (multi-ethnic study of atherosclerosis). j am coll cardiol 2011;58:140-6. 34. vagdatli e, gounari e, lazaridou e, katsibourlia e, tsikopoulou f, labrianou i. platelet distribution width: a simple, practical and specific marker of activation of coagulation. hippokratia 2010;14(1):28–32. 35. dalamaga m, karmaniolas k, lekka a. platelet markers correlate with glycemic indices in diabetic, but not diabeticmyelodysplastic patients with normal platelet count. dis markers 2010;29(1):55-61. https://www.ncbi.nlm.nih.gov/pubmed/?term=snehalatha%20c%5bauthor%5d&cauthor=true&cauthor_uid=30659076 https://www.ncbi.nlm.nih.gov/pubmed/?term=satheesh%20k%5bauthor%5d&cauthor=true&cauthor_uid=30659076 https://www.ncbi.nlm.nih.gov/pubmed/?term=susairaj%20p%5bauthor%5d&cauthor=true&cauthor_uid=30659076 https://www.ncbi.nlm.nih.gov/pubmed/?term=simon%20m%5bauthor%5d&cauthor=true&cauthor_uid=30659076 https://www.ncbi.nlm.nih.gov/pubmed/?term=vijaya%20l%5bauthor%5d&cauthor=true&cauthor_uid=30659076 https://www.ncbi.nlm.nih.gov/pubmed/30659076 http://www.ncbi.nlm.nih.gov/pubmed/?term=demirtas%20l%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=degirmenci%20h%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=akbas%20em%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=ozcicek%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=timuroglu%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=gurel%20a%5bauth%5d original research article doi: 10.18231/2348-7682.2017.0019 panacea journal of medical sciences, may-august,2017;7(2): 65-67 65 correlation between middle ear risk index (meri) and tympanoplasty-a prospective study rameshbabu kalyanasundaram1,*, geetanjali narendran2 1assistant professor, 2senior resident, dept. of ent, thanjavur medical college, thanjavur, tamil nadu. *corresponding author: email: drbalagi7@gmail.com abstract tympanoplasty results depend on the severity of middle ear disease present preoperatively. various grading systems were developed for this. the present study was carried out to determine the middle ear risk index (meri) score and categorise the patients into mild, moderate and severe meri and study the relation between meri and outcome of tympanoplasty. the study consisted of 50 patients undergoing tympanoplasty for mucosal or squamous type of csom. the meri score was calculated. the patients were categorised into those with mild, moderate and severe meri. the graft uptake status was assessed. the relation between meri score and graft status was assessed by t test. the overall graft uptake was 76%. patients with a high meri score had low graft uptake. this study shows that meri score is a prognostic indicator of tympanoplasty results. it is inverserly proportional to graft uptake. keywords: middle ear risk index, tympanoplasty, graft uptake, chronic suppurative otitis media. introduction tympanoplasty results depend on the severity of middle ear disease present preoperatively. various grading systems were developed for this such as belluci grading, wullstein and austin five part system, spite system of black,(1) kartush's factors.(2) the middle ear risk index developed by the above authors were numerical values which were evaluated with the help of the above factors. each patient is assigned a numerical score based on the risk factors. the total score is 12. based on meri score, the patients are classified as mild disease (1-3), moderate disease (4-6) and severe disease (712). it was modified in 2001. smoking was added as a risk factor.(3) aims and objectives 1. to predict the result of tympanoplasty with the aid of meri. 2. based on meri score the patient can be categorised as mild, moderate and severe. 3. to study the interdependence between meri score and success of tympanoplasty. the objective of our study is to segregate the patients based on their meri scores and assess the results of tympanoplasty. each risk parameter was given a numerical value: meri ear discharge: 0-3, perforation: 0-2, cholesteotoma: 02, ossicular chain status: 0-4, middle ear granulation and history of previous surgery: 0-2. now newly, smoking is also included as a risk parameter. materials and method this clinical study which was conducted in the ent department of tmch, from july 2013 to june 2015.the group under study comprises 50 patients of the age group 20-45 years with chronic suppurative otitis media (csom), both mucosal and squamous type with hearing loss planned for tympanoplasty. patients with systemic diseases, otomycosis, septic foci such as sinusitis which can influence the outcome of tympanoplasty were excluded from the study. history of ear discharge, hearing loss, previous ear surgery and use of ototoxic drugs were taken into consideration. otoscopic examination was done to find the presence or absence of perforation, granulation tissue and cholesteatoma. examination of nose and paranasal nasal sinuses and throat was done to rule out septic foci. basic investigations such as cbc, aural culture sensitivity, pta and ct temporal bone were taken. otoendoscopy and otomicroscopy were done to confirm the otoscopic findings. the meri was evaluated. the patients were segregated into those with mild(0-3), moderate(4-6) and severe(≥7) meri. the type of tympanoplasty and mastoidectomy was decided intraoperatively based on the extent of disease in middle ear and mastoid. temporalis fascia graft was used for all patients. graft status was analysed by otoscopy, such as healed graft/atelectatic graft/perforation of the graft. results this study was conducted in the department of ent department, thanjavur medical college and hospital, thanjavur, tamil nadu for a period of two years from july 2013 to june 2015. the group under study consisted of 50 patients csom of both mucosal and squamous type (table 1). rameshbabu kalyanasundaram et al. correlation between middle ear risk index and tympanoplasty panacea journal of medical sciences, may-august,2017;7(2): 65-67 66 table 1: demographic data age no. of patients percentage 20-25 years 5 18 25-30 years 18 36 30-45 years 16 32 35 40 years 9 18 the study comprises 19 males and 31 females (fig. 1). fig. 1: sex distribution 29 patients belong to mucosal or tubotympanic type of csom and 21 patients belong to the squamous type or the atticoantral type. the study group comprises 14 patients with mild (1-3) meri score, 19 patients with moderate (4-6) meri score and 17 patients with severe (≥ 7) meri score (table 2). table 2: distribution of cases mild moderate severe taken up 13 15 10 rejected 1 4 7 the data in the table indicates that when the meri score is mild graft is taken up by 13 patients and rejected for only 1 patient. when the meri score is moderate the graft is taken up by 15 patients and rejected for only 4 patients when the meri score is high the chances of graft taken up among patients is low & rejection rate is high. it may be noted from the above table that the p value of .031 is lower than alpha value at 5% level of significance by doing the t test. therefore higher the meri score, lower the graft uptakein patients under study. fig. 2: graft status vs meri score the graft is taken up for 38 patients (72%) and rejected for 12 patients (28%). thus the overall success rate of tympanoplasty is 74%. among those with mild meri, graft is taken up for 13 patients and rejected only for 1 patient. similarly, among those with severe disease, there is higher graft rejection rate (7 patients) (fig. 2). discussion csom is a quite common ent problem worldwide, especially in developing countries. it is more common in rural areas than urban areas and is associated with poor hygiene, illiteracy and is common among the middle and low income groups. in spite of the availability of wide range of antibiotics, better surgical techniques and newly developed prosthetic materials we are still not able to reach 100% successful outcomes in tympanoplasty. hence these risk parameters are summarised and assigned a numerical value corresponding to the meri index, which helps us to identify the extent of disease and thereby predict the outcome of surgery. in our study, the overall success rate of tympanoplasty is 74% according to graft status. manpreet kaur et al did studies on comparison of graft uptake between tympanoplasty alone and tympanoplasty combined with simple mastoidectomy in noncsom (mucosal type) in patients with sclerotic bone. they concluded that graft uptake was 76% in patients who underwent tympanoplasty and 88% in tympanoplasty combined with simple mastoidectomy.(4) veysel yurttafl et al stated that the presence of middle ear with granulation tissue had a negative effect on the hearing improvement after reconstructive surgery. his study concluded that graft uptake rate was about 44% in patients with extensive middle ear granulation tissue.(5) he suggested mastoidectomy with tympanoplasty for all patients with active middle ear infection to remove granulation tissue from middle ear and mastoid cavity. success of hearing reconstructive surgery depends on the preoperative ossicular status. an intact ossicular system with only a perforation in the tympanic membrane gives the best results. smoking is associated with reduced graft uptake. zoran becvarovski stated that delayed failure of the graft was more commonly seen in smokers(60%) than non-smokers(20%). the patients without tympanic membrane perforation had better graft uptake in the absence of other significant middle ear pathology. with many studies it was concluded that the rate of graft uptake is lesser with anterior perforations than posterior perforations. this is due to lesser blood supply to anterior part of the drumhead and lesser surgical access to the anterior part. cholesteatoma is associated with reduced rate of graft uptake and hearing benefit. generally canal wall down procedure is done for extensive cholesteatoma. the higher rate of recurrence was found to be in cholesteotoma. recurrent cholesteatoma is more than 40% 60% males females 13 15 10 1 4 7 mild moderate severen o . o f p a t ie n t s taken up rejected rameshbabu kalyanasundaram et al. correlation between middle ear risk index and tympanoplasty panacea journal of medical sciences, may-august,2017;7(2): 65-67 67 twice common in children than adults according to stankovic m.(6) debora bunzen, alexandre campos, fabiana sperandio, silvio caldas neto analysed factors which influence the results of the tympanoplasty. they concluded that presence of ear discharge preoperatively did not change the final surgical result. smaller perforations yield better results than subtotal and total perforations. in patients with healthy middle ear mucosa there was 80% success rate.(7) pinar e et al stated that low meri scores, smaller perforation, healthy opposite ear, absence of myringosclerosis and more than 3 months dryness were good prognostic factors.(8) sevim aslan felek studied the prognostic value of meri in ossiculoplasty and compared the outcome of different ossicular prostheses. he stated that meri is a valuable tool to make good patient selection.(9) the role of meri score on the outcome of tympanoplasty was studied by rakesh saboo et al. they concluded that patients with mild meri had maximum graft uptake while those with severe meri had greater failure rates.(10) viktor chrobok et al stated that cholesteatoma, tympanic membrane perforation, status of the ossicular chain and history of previous surgery were highly significant negative prognostic factors influencing the outcome of tympanoplasty.(11) granulation in middle ear predisposes to ossicular necrosis. da costa and paparella found out that ossicle changes developed in 96% of granulation tissue.(12) conclusion the study group comprised 50 patients, of which 19 were males and 31 were females. most of them belong to the lower middle class, with malnutrition and poor literacy. hence meri score was found to be a useful and mandatory tool to predict the extent of disease as well as outcome of the surgery such as tympanoplasty in our area compared to other studies conducted in developed countries. higher the meri lower the graft result. based on the study, meri score was found to be a prognostic indicator on the outcome of tympanoplasty. hence surgical success and hearing benefit can be explained to the patient pre-operatively with consent. references 1. black b. ossiculoplasty prognosis: the spite method of assessment. am j otol. 1992 nov;13(6):544–551. 2. kartush j.m. ossicular chain reconstruction. otolaryngo clinic of north america. 1994;27:689–715. 3. becvarovski z, kartush jm. implications for prognosis and the meri. laryngoscope 2001;111:1806-11. 4. manpreet kaur, baldev singh, b.s. verma, gurpreet kaur, gaurav kataria, savijot singh, parul kansal, bhavna bhatia. comparative evaluation between tympanoplasty alone and tympanoplasty combined with simple mastoidectomy in non-cholesteatomatous csom (mucosal type) in patients with sclerotic bone. iosr jdms jun. 2014;13(6):40-45. 5. veysel yurttafl, ahmet ural, ahmet kutluhan, kazim bozdemir. factors that may affect graft success in tympanoplasty with mastoidectomy. ent updates 2015;5(1):9–12. 6. stankovic m. follow-up of cholesteatoma surgery: open versus closed tympanoplasty. orl 2007;69:299– 305. 7. debora bunzen, alexandre campos, fbiana sperandio, silvio caldas neto. intraoperative findings influence in myringoplasty anatomical result. 2006. 10(4):391-5. 8. pinar e, sadullahoglu k, calli c, oncel s. evaluation of prognostic factors and middle ear risk index in tympanoplasty. otolaryngol head neck surg. 2008 sep;139(3):386-90. 9. sevim aslan felek, hatice celik, ahmet islam, atilla h. elhan, munir demirci, erdal samim. type 2 ossiculoplasty: prognostic determination of hearing results by middle ear risk index. american journal of otolaryngology head and neck medicine and surgery. 2010;3(5):325-331. 10. rakesh saboo, amit modwal, priyanjal gautam. tubotympanic csom: clinical profile of perforation, eustachian tube function and meri score as parameter for outcome of tympanoplasty. transworld medical journal. 2(2):154159. 11. viktor chrobok, arnost pellant, milan meloun, karel pokorny, eva simáková, petra mandysová. prognostic factors for hearing preservation in surgery of chronic otitis media. int. adv. otol. 2009; 5:(3) 310-317. 12. da costa ss, paparella mm, schachern pa, yoon th, kimberley bp. temporal bone histopathology in chronically infected ears with intact and perforated tympanic membranes. laryngoscope 1992; 102: 1229-36. http://www.ncbi.nlm.nih.gov/pubmed/?term=pinar%20e%5bauthor%5d&cauthor=true&cauthor_uid=18722218 http://www.ncbi.nlm.nih.gov/pubmed/?term=sadullahoglu%20k%5bauthor%5d&cauthor=true&cauthor_uid=18722218 http://www.ncbi.nlm.nih.gov/pubmed/?term=calli%20c%5bauthor%5d&cauthor=true&cauthor_uid=18722218 http://www.ncbi.nlm.nih.gov/pubmed/?term=oncel%20s%5bauthor%5d&cauthor=true&cauthor_uid=18722218 http://www.ncbi.nlm.nih.gov/pubmed/18722218 javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); javascript:void(0); original research article http://doi.org/10.18231/j.pjms.2019.026 panacea journal of medical sciences, september-december, 2019;9(3):123-127 123 assessment of autonomic dysfunction between type i and type ii diabetes mellitus kailash s mottera 1 , shiva kumar 2* 1,2consultant physician, dept. of internal medicine, 1lotus hospitals, hsr layout, bangalore, karnataka, 2suryodaya healthcare, malur, karnataka, india *corresponding author: shiva kumar email: drshivkr@gmail.com abstract introduction: the diabetes is the most common disease in the present world and india is country with highest incidence of diabetes mellitus in the world. the autonomic nervous dysfunction due to diabetes is the common complication of the diabetes. in this study autonomic dysfunction in pateints with type i and type 2 dm and its correlation with the duration of diseases is studied. materials and methods: the study was conducted on 30 type i diabetic patients and 40 type ii diabetic pateints. all the diabetic patients were questioned about the presence of symptoms reported to be related to autonomic neuropathy. the conventional autonomic fun ction tests were performed on all the subjects inclusive of sympathetic and parasympathetic tests. the scoring of positive and negative for autonmomic dysfuntion was done. results: the duration of disease in type 1 diabetes, was 6 to 15 years and in type 2 diabetes it was 8 to 18 years with mean duration of 8.5 and 14 years respectively. the mean hba1c in type 1 dm was 6.21±2.09 and it was 7.50±2.45 in type 2 dm. comparison of autonomic function tests in the form of heart rate and bp response in subjects with type 1 and type 2 showed that there no significant statistical difference between the groups. conclusion: it can be concluded the presence of autonomic dysfunction in type 1 and type 2 diabetes mellitus might be due to nerve damage. the duration of diabetes is directly related to such autonomic dysfunction. keywords: diabetes mellitus type 1, diabetes mellitus type 2, autonomic functions tests. introduction the word "diabetes" came from a greek word meaning, "to run through". thomas willis observed that urine of diabetes was "wonderfully sweet" and dobson (1775) demonstrated that the sweetness was due to sugar. in 1869, langerhans discovered the islets of pancreas, which was later given his name. in 1889 a great landmark was reached when von mering and minowski produced diabetes in dogs by total pancreatomy. the diabetes is the most common disease in the present world and india is country with highest incidence of diabetes mellitus in the world.1 prevalence of diabetes in adults in india was found to be 2.4% in rural and 4-11.6% in urban dwellers. high frequencies of impaired glucose tolerance, shown by those studies, ranging from 3.6-9.1% indicate the potential for further rise of prevalence of diabetes in the coming decades.2 the types of diabetes mellitus are type 1 diabetes: which occurs because of the beta cell destruction, usually leading to absolute insulin deficiency, it can be immune mediated or idiopathic. type 2 diabetes: may range from predominantly insulin resistance, with relative insulin deficiency, to a predominantly secretory defect with insulin resistance. other specific diabetes includes gestational diabetes mellitus, genetic defects, and diseases of pancreas, drug induced and diabetes occuring in syndromes.3 there are several complications of diabetes mellitus and it involves several organs of the body. the autonomic nervous dysfunction due to diabetes is the common complication of the diabetes. diabetic autonomic neuropathy can be classified on the basis of presence or absence of symptoms or the nerve or organ involved. overt symptomatic and/or subclinical elicited by detailed diagnostic tests, parasympathetic/sympathetic/ sdrenomedullary.4 it can also be classified on the basis of organs involved cardiovascular system, ocular system, gastrointestinal system, sudomotor and endocrine. autonomic nervous system consists of the sympathetic and parasympathetic systems. there are 2 main efferent limbs of the autonomic nervous system. post-ganglionic parasympathetic fibers from the vagus innervate cardiac, pulmonary and upper gastrointestinal organs, while the pelvic organs are innervated by the sacral parasympathetic outflow. a sympathetic innervation is derived from the preganglionic fibers whose cell bodies are in the interomediolateral column of the spinal cord at the level of the thoracic and upper lumbar roots. these nerve synapses in the bilateral chain of the sympathetic ganglia with postganglionic neurons which widely innervate the vascular smooth muscles, heart kidney, gut and other organs. it is observed that the autonomic dysfunction in diabetes has significanctly contribute to 50% of 5-year mortality, sudden death common (consider electrophysiological studies), greater complications after elective surgery, increased danger with general anaesthesia, the significant increase in major microvascular complications makes it important to screen diabetes at a younger age of 45 years.5,6 the frequency of diabetic autonomic neuropathy is difficult to ascertain reliably. between 17 & 40% of conservative or randomly selected adult diabetics have abnormal cardiovascular function tests according to most large series. 31% of a group of teenage diabetics and 15% of a group of younger diabetic children had abnormal cardiovascular reflexes symptoms usually occur after a prolonged duration. pathogenesis is similar to that of kailash s mottera et al. assessment of autonomic dysfunction between type i and type ii diabetes mellitus panacea journal of medical sciences, september-december, 2019;9(3):123-127 124 somatic neuropathy and is suggested by a generalized correlation between the two.7,8 autonomic neuropathy was only generally recognized as part of the spectrum of nerve damage in diabetes. by the time symptoms have developed, autonomic nerve damage is probably irreversible and carries a poor prognosis. as some autonomic damage occurs in many diabetics, however, prevention of the late stages is clearly desirable.9,10 in this study autonomic dysfunction in pateints with type i and type 2 dm and its correlation with the duration of diseases is studied. materials and methods the study was conducted in adichunchinagiri institute of medical sciences in the department of medicine. the study was conducted on 30 type i diabetic patients and 40 type ii diabetic pateints. inclusion criteria criteria for diagnosis of diabetes type 2 symptoms of diabetes (polyuria, polydipsia, polyphagia, increased fatigue, weight loss, blurred vision, growth impairment) with random blood glucose (venous blood) concentration of 200 mg/dl or more or fasting (of more than 8 hours) blood glucose levels of 126 mg/dl or more or twohour post-prandial blood glucose levels of 200 mg/dl or more. criteria for diagnosis of diabetes type 1: subjects with age less than 30 years, and history of symptoms of diabetes were included in study. the following tests were performed to assess the autonomic functions in the above patients. the tests reflecting parasympathetic function are heart rate variation during deep breathing, heart rate response to valsalva maneuver, immediate heart rate response to standing. the tests reflecting sympathetic functions were blood pressure response to standing and blood pressure response to sustained handgrip. the test procedure was conducted as per the standard protocol as described by d j ewing et al.12 intepretation of the tests is done by calculating the scores according to ewing’s criteria.11,12 ewing’s, the scores are calculating as normal, borderline and abnormal values. results the average age of the particpants included in the study is 34.18±12.56 years for type 2 diabetes and 45.36±15.07 years for type 1 diabetes. the range was from 18 to 48 years and 24 to 54 years in subjects with type 1 and type 2 diabetes respectively. maxiumum number of pateints was seen between 25 to 30 years among type 1 diabetes group and between 40-45 years in type 2 diabetic group. the duration of disease in type 1 diabetes, was 6 to 15 years and in type 2 diabetes it was 8 to 18 years with mean duration of 8.5 and 14 years respectively. significant proportion patients were in 6-10 years duration. the comparison of fbs and ppbs between type 1 and type 2 diabetes patients are presented in the table 1. the comparison of hba1c between type 1 and type 2 diabetes patients are presented in the table 1 and fig. 1. table 1: comparison of fbs, ppbs and hba1c between type 1 and type 2 patients type 1 type 2 p value fbs (mg/dl) 131.90±35.74 123.93±35.92 0.360 ppbs (mg/dl) 226.50±57.58 207.70±57.93 0.182 hba1c 6.21±2.09 7.50±2.45 0.023* *p < 0.05 is considered statistical significant fig. 1: comparison hba1c between type 1 and type 2 patients in cases ewing’s autonomic test scoring system is used to evaluate if a patient had autonomic dysfuntion. this system is described in the methods. it has maximum total score of 10 to a minimum of 0, a score of more than 5, i.e. 6 or more was considered as positive autonomic scores. the distribution of autonomic dysfunction score was positive in 19 patients with type 1 and 25 patients with type 2 had positive autonomic scores (table 2). chi square test was applied between the two groups and there is statistical significance between the type 1 and type 2 diabetes mellitus. table 2: distribution of autonomic scores among the type 1 and type 2 dm autonomic score type i dm type ii dm p value n percentage n percentage negative (<=5.0) 11 36.6 15 37.5 0.939 positive (>5.0 ) 19 64.4 25 62.5 0.871 0 2 4 6 8 10 12 type 1 type 2 h b a 1 c kailash s mottera et al. assessment of autonomic dysfunction between type i and type ii diabetes mellitus panacea journal of medical sciences, september-december, 2019;9(3):123-127 125 table 3: comparison of heart rate and bp response in two groups of patients type 1 dm type 2 dm p value heart rate response to deep breathing 12.26±4.95 14.04±5.26 0.189 heart rate response to valsalva maneuver 1.07±0.27 1.18±0.19 0.051 immediate heart rate response to standing 1.01±0.15 1.07±0.19 0.158 b.p response to standing 14.88±7.51 10.96±9.31 0.063 b.p response to handgrip 14.40±5.57 12.24±3.95 0.061 comparison of heart rate and bp response in subjects with type 1 and type 2 is presented in the table 3. there is no significant statistical difference in the values between the groups (student t test). the comparison of autonomic scores and study variables was done using the unpaired t test. significant difference between participants with positive autonomic scores and negative autonomic scores in the study participants. (table 4). table 4: comparison of study variables in autonomic score positive and negative score among the study participants. variables in diabetics cases autonomic score p value negative positive age in years 42.91±12.59 54.43±15.12 0.001** duration of diabetics in years 5.39±3.06 10.96±6.95 0.001** heart rate variation in deep breathing 16.41±3.11 9.00±3.45 <0.001** heart rate variation in valsalva 1.27±0.13 0.91±0.25 <0.001** heart rate variation in standing 1.11±0.06 0.93±0.16 <0.001** b.p. variation on standing 12.18±4.69 17.00±8.63 0.023* b.p. variation on handgrip 17.09±4.44 12.29±5.52 0.002* glycosylated haemoglobin 5.98±1.41 8.24±2.59 0.001** *p < 0.05 is considered statistical significant, **p < 0.001 is considered high statistical significant, table 5: common presenting symptoms common in type 1 and type 2 dm symptoms type 1 ( out of 30) type 2 (out of 40) impotence 10 17 postural hypotension 4 11 constipation 6 10 diarrhea 2 6 bladder disturbances 8 14 ulcers on foot 6 12 the presenting complaints were in the form of symptoms like impotence (most common), postural hypotension, constipation, diarrhea, bladder disturbances, ulcers on the foot. other complaints were visual distubances, urinary tract infections. discussion the incidence of autonomic dysfunctions increased with the increasing duration of diabetes.maxiumum number of pateints was seen between 25 to 30 years among type 1 diabetes group and between 40-45 years in type 2 diabetic groups. dyrberg et al13 reported an incidence of 15% autonomic neuropathy in diabetics of duration up to 10 years and 62% in diabetics of more than 10 years. m.lakhotia, s.s. jain, et al., 199714 showed a great incidence of dysautonomia with increasing duration (up to 80% in those with duration of more than 5 years). the duration of disease in type 1 diabetes, was 6 to 15 years and in type 2 diabetes it was 8 to 18 years with mean duration of 8.5 and 14 years respectively. this indicates that there is correlation between the duration of diabetes and the autonomic dysfunction as seen in both type 1 and type 2 diabetes mellitus. autonomic dysfunctions are also associated with poor glycemic control as seen by the mean hba1c values in type 1 and type 2 diabetes mellitus. the mean value of glycosylated haemoglobin was 6.21±2.09% among type 1 patients. it was 7.50±2.45 among type 2 diabetic patients. the target hba1c in normal individuals is 7.0% in a study by r.c. gupta, et al.,15 after 6 months of strict metabolic control they found that 22% patients showed significant symptomatic improvement. it is seen that the there are several mechanisms by which the autonomic dysfunction occurs in both type 1 and type 2 diabetes mellitus. one of the mechanisms is vasular presence of arterial stiffness because of vascular denervation which causes structural and functional changes in arterial smooth muscle leading to calcification and ossification. endoneural capillaries of patients with diabetic neuropathy exhibit an increased endothelial cell proliferation and capillary closure that correlates with the seventy of the neuropathy. segmental loss of myelinated fibers, seen in both peripheral and splanchnic nerves, may represent areas kailash s mottera et al. assessment of autonomic dysfunction between type i and type ii diabetes mellitus panacea journal of medical sciences, september-december, 2019;9(3):123-127 126 of regional ischemia caused by closure of provider capillaries, fiber loss increases from proximal to distal nerve, reflecting recurrent areas of proximal ischemia resulting in profound distal nerve dysfunction. endoneural blood flow is one third of that in healthy state. endoneural oxygen tension is decreased.16,17 in diabetes mellitus, the vascular endothelium often produces and releases abnormally low amounts of plasminogen activator, leading to an impaired fibrinolytic system, which might be of importance for the development of angiopathy. the desaturation reactions and especially the 6 desaturation pathway are impaired and there is deficient conversion of linoleic acid to gamma linoleic acid, despite normal dietary intake of essential fatty acids. these leads to abnormal cell membrane, membrane bound enzymes and receptors and myelin turnover, resulting in decreased nerve conduction velocities. further more, the endoneural hypoxia suppresses atpase activity, promoting paranodal demyelination as well as diminished axonal transport (axonopathy).18 disturbances in delta-6-desaturase in the n-6 pathway of essential fatty acids lead to reduced formation of gamma linoleic acid, di-homo gamma linoleic acid and arachidonic acid (precursors of prostaglandin). deficiency of prostacyclin with increase in formation of thromboxane a2 impairs the microcirculation of the vasa vasorum, leading to endoneural hypoxia and a vicious cycle of more capillary damage and further hypoxia. the release of oxygen free radicals further damages endothelial cell functions; axonopathy and myelinopathy dislocate axonal transport by direct impairment of neural atpase activity. this is reflected by impaired nerve conduction velocity.19 the metabolic abnormalites that is noted are myoinositol deficiency 20 myoinositol is a normal dietary cyclic hexose, structurally similar to glucose, concentrated about hundred times more in the nerves than in plasma. when membrane receptor is stimulated, myoinositol liberates second messengers, inositol triphosphate and diacylglycerate, which act to release intra cellular calcium and activate protein kinase. this mediates atp utilisation through sodium potassium atpase activity. hyperglycemia results in competitive inhibition of sodium myoinositol uptake system causing a low myoinositol level and hence poor sodium atpase. this decreases nerve cell membrane potential. hence the conduction velocity decreases, and also lowers further the myoinositol uptake, setting up a vicious cycle. sorbitol accumulation high glucose concentration stimulates aldose reductase and promotes polyol pathways, thus, more and more glucose is converted to sorbitol, which in turn is metabolized to fructose. rising sorbitol levels play an unclear role in the pathogenesis of diabetic neuropathy. aldose reductase inhibitors have beneficial effects in treating as well as preventing autonomic neuropathy. non enzymatic glycosylation similar to that seen in a rbc, hemoglobin results in aggregation of tubulin and microtubulin affecting cellular transport profoundly. this might represent the pathophysiologic mechanism of nerve damage.21-23 it can be concluded the presence of autonomic dysfunction in type 1 and type 2 diabetes mellitus might be due to nerve damage. the duration of diabetes is directly related to such autonomic dysfunction. strict glycemic control might reduce the autonomic dysfunction in diabetes. it also suggested that pateints should be encouraged to undergo autonomic functions tests for any early detection of such symptoms. source of funding none. conflict of interest none. references 1. michael brownlee, lloyd. p. aiello, mark.e.cooper, william’s textbook of endocrinology, 11th edition, chapter 32, 1418-1490 2. k. park. “diabetes mellitus”, park’s textbook of preventive and social medicine, 20th edition, pgs 341-343 3. gabir mm, hanson rl, dabela d. the 1997 american diabetic association and 1999 world health organization criteria for hyperglycemia in the diagnosis and prediction of diabetes. diabetes care 2000;23:1108-12. 4. noronha jl, bhandarkar sd, shenoy pn, retnam vj. autonomic neuropathy in diabetes mellitus. j postgrad med 1981;27:1-6. 5. raelene e. maser and m. james lenhard. review: cardiovascular autonomic neuropathy due to diabetes mellitus: clinical manifestations, consequences, and treatment. j clin endocrinol metab 90(10):5896–5903. 6. carolina m. casellini, aaron i. vinik. clinical manifestations and current treatment options for diabetic neuropathies. endocr pract 2007;13(5):550-66. 7. watkins pj. progression of diabetic autonomic neuropathy. diabetic med 1993;(10):775-875. 8. d j ewing, b f clarke. diagnosis and management of diabetic autonomic neuropathy. br med j 1982;285:916-8. 9. sainani g.s. current concepts in diabetes mellitus, 1st edition. pgs 48-65, 1993. 10. johnson p.c. pathogenesis of diabetic neuropathy. ann neurol 1986;19:450-7. 11. d j ewing, b f clarke. diagnosis and management of diabetic autonomic neuropathy. br med j 1982;285:916-8. 12. d j. the value of cardiovascular autonomic function tests, 10 years experience in diabetes. diabetes care 8:441-98. 13. dyrberg t. prevalence of diabetic autonomic neuropathy measured by simple bedside tests. diabetologia 20 1981;1904. 14. m lakhotia, pkd shah, r vyas, s s jain, a yadav, m k parihar. clinical dysautonomia in diabetes mellitusa study with seven autonomic reflex function tests. japi 1997;45(4). 15. r c gupta, md chittora, a jain. a study of autonomic neuropathy in diabetes mellitus in relation to its metabolic control. japi 1995:43 (7). 16. low p a. recent advances in the pathogenesis of diabetic neuropathy. muscle nerve 1987;121-8. 17. mackay t. autonomic neuropathy. diabetologia 1980;18:4718. 18. ramachandran a. epidemiology of vascular complications in type ii diabetes in indians" novo nordisk update 1999;101. kailash s mottera et al. assessment of autonomic dysfunction between type i and type ii diabetes mellitus panacea journal of medical sciences, september-december, 2019;9(3):123-127 127 19. fagerberg se. diabetic neuropathy, a clinical and histological study in the significance of vascular affections. acta med scand 164;1-80. 20. tomlinson dr. polyols and myoinositol in diabetic neuropathy”, mayo clinic proceeding 1989;64:1030. 21. greene d a. complications; neuropathy, pathogenic considerations. diabetes care 1992;15:1902-25. 22. gupta r c. a study of autonomic neuropathy in diabetes mellitus in relation to its metabolic control. japi 1995;(43):464-6. 23. hilsted j. pathophysiology in diabetic autonomic neuropathy, cardiovascular, hormonal and metabolic studies". diabetes 1982;(31):730-6. original research article http://doi.org/10.18231/j.pjms.2019.003 panacea journal of medical sciences, january-april, 2019;9(1):7-10 7 job satisfaction and burnout among professionals in corporate sectors prashant srivastava1, swarnlata kumari2, manisha kiran3, suprakash chaudhury4*, chetan diwan5 1m. phil scholar, 2ph. d. scholar, 3,5assistant professor, 4professor, 1,2dept. of psychiatric social work, 4dept. of psychiatry, 1,2,3rinpas, kanke, ranchi, jharkhand, 4dr d y patil medical college, pimpri, pune, maharashtra, 5karve institute of social service, pune, maharashtra, india *corresponding author: suprakash chaudhury email: suprakashch@gmail.com abstract job satisfaction and burnout has become a persistent and pervading feature of various corporate sectors. in present scenario, workers are found to be burnt-out and exhausted very soon and the reason for being exhausted is that they are over burdened and highly competitive. the aim of the present study was to compare the level of job satisfaction and burnout in various corporate sector professionals. this cross sectional, analytical study was carried out at lucknow. by purposive sampling technique 120 subjects were included from various corporate sectors that met the inclusion and exclusion criteria and gave consent for the study. they were evaluated on general health questionnaire 12, job satisfaction index and copenhagen burnout inventory. analysis of assessment tool results showed there was no significant difference in the level of job satisfaction and the degree of burnout, but trend was found in the area of work burnout by multiple comparisons of all groups with post hoc test by bonferroni method. the findings of the present study suggest that the level of job satisfaction and the degree of burnout were almost similar in various corporate sectors. however, findings suggest a trend towards higher work burnout in professionals in multinational corporation in comparison to the professionals in public sector corporation. keywords: job satisfaction, burnout, public sector, private sector, multinational corporation. introduction work has a central role in people’s life since it occupies a lot of their time and also provides the financial basis of their lifestyles. therefore it is important the employees’ job environment should be appealing to them and improves their satisfaction with the job. satisfaction at work influences various aspects of work such as efficiency, productivity, absenteeism, turnovers rates, intention to quit, and also the employees’ well-being.1-2 job satisfaction can be viewed as the degree of an employee’s affective orientation toward the work role occupied in the organization.3 it is the extent to which people like (satisfaction) or dislike (dissatisfaction) their jobs.4 in this age of liberalization and globalization all industries and organizations are trying to be competitive. every effort is made to improve output and reduce input, so that profitability increases. there is constant pressure to achieve higher and higher targets. as a result employees have to spend more time in job related activities to the detriment of time spent with family or friends. this is probably the point when employees feel excessive job stress leading to irritability, dysphoria, and dissatisfaction with work, reduced work output and unhappiness of working in the organization. persisting stress may lead to development of chronic negative emotions such as anger, anxiety or depression, which can eventually lead to psychological burnout. once considered as an uncommon condition, burnout is now recognized as very common in some jobs which are very stressful. job burnout is a prolonged response to chronic emotional and interpersonal stressors on the job.5 more specifically, it involves the chronic strain that results from an incongruence, or misfit, between the worker and the job. in the multidimensional model of the burnout phenomenon there are three key dimensions. these include exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment. burnout differs from occupational stress in that it is specific to work that requires intense involvement.6 burnout is a state of physical, emotional fatigue, and it is caused by a long-term commitment to demanding situations. it has been described as a sense of helplessness and hopelessness, low energy levels, chronic tiredness, fatigue, and a feeling of being trapped. there are also evident negative feelings for self, work and life.7 job satisfaction and burnout has become a permanent and pervading feature of corporate sectors. in the present scenario, workers are found to be burnt-out and exhausted very soon and the reason for being exhausted is that they are over burdened and highly competitive.burnout has been most prevalent among workers in the helping professions. studies have shown that these individuals suffer from high stress levels and low job satisfaction.8-9 administrators also experience high stress and low job satisfaction. studies report that 70% of the life stress of administrators was due to their jobs.10 the financial sector in india has undergone tremendous changes in past two decades with increased competition, increased levels of deregulation, which has opened up the indian financial banking system and has placed enormous pressure and has created stress in the bank employees. the age of globalisation has resulted in downsizing and restructuring practices affecting both the private and public sectors. consequently job cuts and layoffs are becoming common even in the public sector. this great change in job security is expected to impact job satisfaction and burnout. there is a paucity of indian studies in this area. in view of the foregoing the present study was undertaken to assess and compare the level of job satisfaction and burnout among the professionals of various corporate sectors. prashant srivastava et al. job satisfaction and burnout among professionals in corporate sectors panacea journal of medical sciences, january-april, 2019;9(1):7-10 8 materials and methods sample for the present study a total of 120 professionals working in various non-banking financial institutions (30 from indian multinational corporation, 30 from indian family owned multinational corporation, 30 from private sector corporation and 30 from public sector corporation) were included and the sample was drawn using purposive sampling technique. design the present study was a cross-sectional organization based one. venue the study was carried out on the population from various corporate sector organizations located in lucknow city. a: indian multinational corporation b. indian family owned multinational corporation c. private sector corporation d. public sector corporation inclusion criteria those professionals who are in these corporate sectors, subjects who gave consent to participate, subjects who scored below the cut-off point of ghq 12, the age range between 20-50 years, subjects whose nature of job is permanent. exclusion criteria not willing to participate, subjects whose nature of job is temporary, absence from his \ her duty for at least one month. tools used general health questionnaire -12(ghq 12): goldberg and william developed the general health questionnaire-12 in 1978. the 12 items questionnaire is used to see the general health as well as it is used to screen for psychiatric morbidity in healthy persons. the scale is extremely popular and used all over the world and translations are available in 38 languages. reliability coefficients of the questionnaire have ranged from 0.78 to 0.95 in various studies.11-12 job satisfaction index job satisfaction index provides an overall index of job satisfaction rather than measuring specific aspects. it consists of 18 items with five alternative responses i.e., strongly agree, agree, undecided, disagree and strongly disagree which are scored 1 to 5. the scale comprises of nine positive and nine negative items. the higher score on the scale implies higher job satisfaction while lower scores indicate lower job satisfaction. the scale has a high index of reliability and high coefficient of correlation of 0.87 and 0.97 respectively.13 it has been widely used in western countries as also in india to measure job satisfaction.1 copenhagen burnout inventory it was used to assess the degree of burnout. it consists of three sub scales: personal burnout, which has 6 items, work related burnout, consists of 7 items, client related burn out consists of 6 items. clients can be patients, students, children, inmates or the kind of recipients. the inventory has very satisfactory reliability and validity. the cbi has been used in a number of countries and has been translated into eight languages.14 analysis of data the data obtained was analyzed using the statistical package for social sciences version 20.0(spss-20.0). to find out the group differences of the clinical variables having categorical data the chi-square test was used. to compare the scores of the rating scales multiple comparisons of all groups with post hoc test by bonferroni method was performed. results the socio-demographic characteristics and work related characteristics of the corporate sector professionals included in the study are given in table 1. there were no significant differences in these characteristics. the results of the psychological assessment are given in table 2. discussion the present study aims to assess and compare the level of job satisfaction degree of burnout (personal, work and client) among the professionals of various corporate sectors. so far very few studies have tried to assess and finally compare the level of job satisfaction and degree of burnout among the professionals of various corporate sectors. the significance of this study also emerge from the fact that this is likely to lead to planning of an effective strategies, to enable these professionals to lead a better and an overall healthier life. one may expect that the knowledge gained will help in building an understanding sufficient to alleviate and ultimately prevent burnout. in the present study there was no significant difference in the level of job satisfaction in the four groups. however, job satisfaction was somewhat higher in indian family owned multinational and public sector firms as compared to private sector and indian multinational firms. this finding is in agreement with an earlier study which found that employees of public sector banks higher levels of stress and lower levels of job satisfaction when compared to employees of new generation private sector banks.15-17 the result of present study reveals that there was trend found in work burnout by the multiple comparisons of all groups with post hoc test by bonferroni method and there was no significant difference was found in the degree of burnout in other areas. the result supported findings are in agreement with the study in which the job descriptive index was completed by 36 private sector employees and by 68 public sector employees and no significant difference was found in the level of job satisfaction between public and private sector employees.18-19 limitation the sample size of the study was small and hence the findings may not be generalized. govt. sector personnel's should have also been included for comparison. due to paucity of time the study was carried out at only a single location. prashant srivastava et al. job satisfaction and burnout among professionals in corporate sectors panacea journal of medical sciences, january-april, 2019;9(1):7-10 9 table 1: socio demographic and work characteristics of various corporate sector professionals variables groups x2 df p indian multinational corporation n(%) indian family owned multinational n(%) private sector corporation n(%) public sector corporation n(%) age 20-30 yrs 14 (46.7%) 22 (73.3%) 15 (50.0%) 22 (73.3%) 8.57 6 0.199 31-40 yrs 15 (50%) 7 (23.3%) 13 (43.3%) 7 (23.3%) 41-50 yrs 1 (3.3%) 1 (3.3%) 2(6.7%) 1 (3.3%) sex male 27 (90%) 26 (86.7%) 26 (86.7%) 24 (80%) 1.30 3 0.729 female 3 (10%) 4 (13.3%) 4 (13.3%) 6 (20%) marital status single 10 (33.3%) 14 (46.7%) 9 (30.0%) 13 (43.3%) 2.39 3 0 .494 married 20 (66.7%) 16 (53.3%) 21 (70.0%) 17 (56.7%) socioeconomic status high 10 (33.3%) 6 (20%) 13(43.3%) 3 (10%) 12.19 6 0.058 middle 20 (66.7%) 23 (76.7%) 15 (50.0%) 25 (83.3%) low 0 (0%) 1 (3.3%) 2 (6.7%) 2 (6.7%) domicile rural 10 (33.3%) 4 (13.3%) 9(30.0%) 4 (13.3%) 5.88 3 0.118 urban 20 (66.7%) 26 (86.7%) 21(70.0%) 26 (86.7%) religion hindu 29 (96.7%) 29 (96.7%) 25(83.3%) 25 (83.3%) 5.93 3 0.115 muslim 1 (3.3%) 1 (3.3%) 5 (16.7%) 5 (16.7%) education up to class x 0 (0%) 0 (0%) 1 (3.3%) 1 (3.3%) 11.92 6 0.064 class xigraduation 16 (53.3%) 9 (30%) 6 (20%) 6 (20%) >graduation 14 (46.7%) 21 (70%) 23 (76.7%) 23 (76.7%) family type joint 10 (33.3%) 9 (30%) 16 (53.3%) 8 (26.7%) 7.56 6 0.272 nuclear 16 (53.3%) 19 (63.3%) 10 (33.3%) 18 (60%) single 4 (13.3%) 2 (6.7%) 4 (13.3%) 4 (13.3%) monthly income 5000-15000 13 (43.3%) 20 (66.7%) 13 (43.3%) 14(46.7%) 6.01 6 0.423 15000-45000 15 (50.0%) 09 (30.0%) 13 (43.3%) 14 (46.7%) above 45000 2(6.7%) 1 (3.3%) 4 (13.3%) 2 (6.7%) length of service < 2 yrs 9 (30% 8 (26.7%) 8(26.7%) 3 (10%) 6.14 6 0.407 2 5 yrs 12 (90%) 17 (56.7%) 15 (50%) 17 (56.7%) > 5 yrs 9 (30%) 5 (16.7%) 7 (23.3%) 10 (33.3%) working hours < 8 hours 9 (30%) 1 (3.3%) 4 (13.3%) 5 (16.7%) 9.45 6 0.150 8 hours 11 (36.7%) 13 (43.3%) 14 (46.7%) 10 (33.3%) > 8 hours 10 (33.3%) 16 (53.3%) 12 (40%) 15 (50%) table 2: between group difference of scores on job satisfaction index and copenhagen burnout inventory variables groups f df p post hoc indian multinational corporation a m±sd indian family owned multinational b m±sd private sector corporation c m±sd public sector corporation d m±sd job satisfaction 57.23± 7.59 60.43± 11.55 59.83± 7.75 60.20± 5.33 0.942 3 0.423 personal burnout 210.00 ±120.27 212.50 ± 113.66 232.50± 124.93 189.16± 86.52 0.747 3 0.526 work burnout 275.23 ± 144.95 229.16 ± 145.04 222.50 ± 160.59 185.00 ± 99.48 2.116 3 0.102 a > d client burnout 218.33 ±193.64 240.83 ± 159.26 250.83 ± 175.36 157.50 ± 126.65 1.917 3 0.131 total burnout 703.56± 385.95 682.50 ± 349.88 705.83± 401.00 531.66 ± 239.33 1.709 3 0.169 conclusion the findings of the present study suggest that the level of job satisfaction the degree of burnout were almost similar in all groups. however, findings suggest a trend towards higher work burnout in professionals in multinational in comparison to the professionals in public sector corporation. conflict of interest: none. references 1. chaudhury s, banerjee a. correlates of job satisfaction in medical officers. mjafi 2004;60:329-32. 2. chaudhury s. job satisfaction of hospital staff: an emerging challenge. med j dy patil univ 2015;8:129-30. 3. lease s. annual review, 1993-1997: work attitudes and outcomes. j vocational behav 1998;53(2):154-83. 4. spector pe. job satisfaction: application, assessment, causes, and consequences. london: sage. 1997. 5. maslach c. job burnout: new directions in research and intervention. curr directions psychol sci 2003;12:189-92. prashant srivastava et al. job satisfaction and burnout among professionals in corporate sectors panacea journal of medical sciences, january-april, 2019;9(1):7-10 10 6. maslach c, jackson s, leiter m. maslach burnout inventory manual. 3rd ed. palo alto (ca): consulting psychologist press. 1996. 7. sorgaard kw, ryan p, hill r, dawson i. sources of stress and burnout in acute psychiatric care: inpatient vs. community staff. soc psychiatry psychiatr epidemiol 2007;42:794-802. 8. freudenberger hj. staff burnout. j soc issues 1974;30(l):15965. 9. freudenberger hj. the staff burnout syndrome in alternative institutions. psychother theory res pract 1975;12(1):73-82. 10. cooper cl, marshall j. white-collar and professional stress. new york: john wiley sons. 1980. 11. goldberg dp, gater r, sartorius n, ustun tb, piccinelli m, gureje o, et al. the validity of two versions of the ghq in the who study of mental illness in general health care. psychol med 1997;27(1):191-7. 12. jackson c. the general health questionnaire. occup med 2007;57:79. 13. brayfield ah, rothe hf. an index of job satisfaction. j appl psychol 1951;35:307–11. 14. kristensen ts, borritz m, villadsen e, christensen kb. the copenhagen burnout inventory: a new tool for the assessment of burnout. work stress 2005;19(3):192-207. 15. george e, zakkariya ka. job related stress and job satisfaction: a comparative study among bank employees. j manag dev 2015;34(3):316-29. 16. mehta p, mehta b. perceived stress among employees of public sector banks and private sector banks: a comparative study. iahrw int j soc sci rev 2015; 3(1): 1-3. http://www.myresearchjournals.com/index.php/iijssr/article/ view/150 17. bano b, jha rk. organizational role stress among public and private sector employees: a comparative study. lahore j business 2012;1:23–36. 18. smith pc, kendall lm, hulin cl. the measurement of satisfaction in work and retirement. chicago: rand mcnally. 1969. 19. schneider sd, vaught rcc. a comparison of job satisfaction between public and private sector manager. public administration q 1993;17(1):68–83. https://www.researchgate.net/journal/0033-3204_psychotherapy_theory_research_practice http://www.emeraldinsight.com/author/george%2c+elizabeth http://www.emeraldinsight.com/author/ka%2c+zakkariya http://www.myresearchjournals.com/index.php/iijssr/article/view/150 http://www.myresearchjournals.com/index.php/iijssr/article/view/150 http://www.myresearchjournals.com/index.php/iijssr/article/view/150 http://www.myresearchjournals.com/index.php/iijssr/article/view/150 http://www.myresearchjournals.com/index.php/iijssr/article/view/150 panacea journal of medical sciences 2022;12(2):380–386 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a study of clinical profile and outcome of malaria in adults at government general hospital, nizamabad d prashanth1, d sharath kumar1, m harikrishna reddy1, ch subhash kumar1,* 1dept. of general medicine, government medical college, nizamabad, telanagana, india a r t i c l e i n f o article history: received 28-07-2021 accepted 03-09-2021 available online 17-08-2022 keywords: complicated falciparum malaria uncomplicated malaria mortality a b s t r a c t introduction: what has to be stressed is the need to be cautious with such individuals and to broaden our differentials to include p. vivax as a possible cause of severe malaria. patients who are aggressively handled and treated can have a better outcome. aims: to study the clinical profile and outcome of malaria in adults at government general hospital in our local area. materials and methods: a cross-sectional, observational study done in department of general medicine in fifty smear positive malaria patients admitted to the medical wards and intensive care units are included in the study. study done for a period of 1 year . patients of either gender, above 18 years of age and below 60 years of age, diagnosed with malaria on peripheral smear were included in study. results: a total number of 50 smear positive malaria patients were included in the study. majority of the patients belongs to the age group of 18-30 years [36%] cns findings: altered sensorium was seen in 20% patients and convulsions were seen in 20% patients. complicated malaria was present in 76% patients and uncomplicated malaria was present in 24% patients. complicated falciparum malaria was present in 30% patients and complicated vivax malaria was present in 46% patients. uncomplicated falciparum malaria was present in 4% patients and uncomplicated vivax malaria was present in 20% patients. mortality was seen in 6% patients. mortality was seen in the age group of 4150 years [66.7%] and 31-40 years [33.3%]. conclusion: malaria complications can be reduced by studying the clinical profile of the disease and using proper antimalarial medication treatment. this aids in the reduction of malaria morbidity and death, as well as the country’s long-term economic prosperity. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction malaria is a parasitic disease of humans and is caused by protozoa of the genus plasmodium. according to who, in 2018, an estimated 228 million cases of malaria occurred worldwide. nineteen countries in sub-saharan africa1 and india carried almost 85% of the global malaria burden. an estimated 405,000 deaths occurred from malaria globally and nearly 85% of deaths were concentrated in 20 countries in the who african region and india. * corresponding author. e-mail address: chsubhashkumar@gmail.com (c. s. kumar). there were an estimated 6,737,000 malaria cases and 9,620 deaths in india in 2018. malaria infections may cause vital organ damage and death. severe malaria is defined by clinical or laboratory evidence of vital organ damage. the manifestations of severe malaria include: cerebral malaria, unarousable coma, jaundice, renal failure, acidosis, severe anaemia, pulmonary oedema/adult respiratory distress syndrome, hypoglycaemia, hypotension/shock, bleeding/disseminated intravascular coagulation, convulsions, haemoglobinuria, hyperparasitaemia. 1 delay in diagnosis and treatment leads to increase in the presentation of severe malaria cases which in turn https://doi.org/10.18231/j.pjms.2022.072 2249-8176/© 2022 innovative publication, all rights reserved. 380 prashanth et al. / panacea journal of medical sciences 2022;12(2):380–386 381 leads to increase in morbidity and mortality. the current study was conducted to study clinical profile, complications and outcome of malaria. exact clinical and laboratory profile is important for the early diagnosis and successful management, which is crucial for saving lives and malaria being endemic in india lack of data from this geographic area on the clinical profile, complications of malaria has prompted us to undertake this study. 2. materials and methods a cross-sectional, observational study done in department of general medicine, government general hospital, nizamabad in fifty smear positive malaria patients admitted to the medical wards and intensive care units are included in the study. study done for a period of 1 year (1st december 2019 to 30th november 2020) 2.1. sample size formula: n = zα2 * pq / d2 where, n is the required sample size. z α is the standard normal deviate, which is equal to 1.96 at 95% confidence interval. p is the prevalence in that study = 68.53 (nadkar my et al.) 2 q = 100-p d = allowable error p = 68.53 (nadkar my et al.) 2 q = 31.47 d = allowable error taken as 20% n = number of samples is to be studied n = zα2 * pq / d2 = (1.96)2* 68.53* 31.47 / (13.706)2 = 8284.94/187.85 =44.10= 44.10 + 4.41 = 48.51 = rounded to 50 2.2. inclusion criteria patients of either gender, above 18 years of age and below 60 years of age, diagnosed with malaria on peripheral smear. 2.3. exclusion criteria patients below the age of 18 years and above the age of 60 years, patients diagnosed with chronic liver, kidney/cns disease. 2.4. methodology after obtaining written informed consent, a detailed history and clinical examination was done to note complications and outcome. the following laboratory investigations for hematological parameters were done: hemoglobin estimation, total and differential leucocyte count, total platelet count. in severe cases coagulation parameters like bleeding time, whole blood clotting time, prothrombin time were done. thick and thin blood smear with giemsa staining were done for confirmation of malaria. biochemical investigations like blood sugar, serum bilirubin, aspartate and alanine aminotransferase, blood urea, serum creatinine and electrolytes were carried out. in patients with respiratory distress and renal failure, x-ray chest and arterial blood gas analysis were done. hbsag, widal test, dengue serology and leptospiral antibodies test were done. all patients were treated with intravenous/oral artemisinin-based combination therapy. other supportive measures in the form of antibiotics, anticonvulsants, antiemetics, blood transfusion inotropic support and fluids, dialysis and ventilator support as and when required. 2.5. statistical analysis data entry was done using m.s. excel and statistically analyzed using statistical package for social sciences (spss version 21) for m.s windows. descriptive statistical analysis was carried out to explore the distribution of several categorical and quantitative variables. categorical variables were summarized with n (%). all results are presented in tabular form and are also shown graphically using bar diagram or pie diagram as appropriate. 2.6. inferential statistics the difference in the two groups was tested for statistical significance and categorical variables tested by chi square test. p-value less than 0.05 considered to be statistically significant. 3. results table 1: distribution of patients based on the age group age group (years) frequency percent 18-30 18 36.0% 31-40 16 32.0% 41-50 16 32.0% total 50 100.0% gender male 31 62.0% female 19 38.0% total 50 100.0% in this study, majority of the patients belongs to the age group of 31-40 years [36%] followed by 41-50 years [32%] and 18-30 years [32%], males constitute 62% and females constitute 38%.table 1 in this study, fever was present in all[100%] the patients, chills & rigor was present in 90% patients, headache was present in 72% patients, nausea &vomiting was present 382 prashanth et al. / panacea journal of medical sciences 2022;12(2):380–386 table 2: distribution of patients based on the clinical presentation clinical presentation frequency percent fever 50 100% chills & rigor 45 90% headache 36 72% nausea &vomiting 23 46% myalgia 19 38% jaundice 13 26% altered sensorium 10 20% convulsions 10 20% decreased urine 8 16% abdominal pain 7 14% breathlessness 5 10% diarrhea 4 8% cough 4 8% bleeding 3 6% in 46% patients, myalgia was present in 38% patients, jaundice was present in 26% patients, altered sensorium was present in 20% patients, convulsions was present in 20% patients, decreased urinary output was present in 16% patients, abdominal pain was present in 14% patients, breathlessness was present in 10% patients, diarrhea was present in 8% patients, cough was present in 8% patients and bleeding was present in 6% patients.table 2 table 3: distribution of patients based on general physical examination physical examination frequency percent pallor 18 36% icterus 13 26% respiratory system examination crepitations 5 10% per abdomen hepatomegaly 9 18% splenomegaly 36 72% cns examination altered sensorium 10 20% convulsion 10 20% in this study, pallor was present in 36% patients; icterus was present in 26% patients. respiratory system examination showed crepitations in 5% patients. in this study, hepatomegaly was present in 18% patients; splenomegaly was present in 72% patients. cns findings: altered sensorium was seen in 20% patients and convulsions were seen in 20% patients.table 3 the hemoglobin level was ranging from 3.2 to 13.4gm/dl. mean hemoglobin was 9.284gm/dl. the association between the groups was found to be statistically not significant. the platelet count was ranging from 0.36 to 2.6 lakh/cumm. mean platelet count was 1.368lakh/cumm. the association between the groups was found to be statistically significant. the total bilirubin level was ranging from 0.8 to 6.6mg/dl. mean total bilirubin was 2.174mg/dl. the association between the groups was found to be statistically not significant. the serum creatinine level was ranging from 0.8 to 5.6mg/dl. mean serum creatinine was 2.16mg/dl. the association between the groups was found to be statistically not significant.table 4 in this study, thrombocytopenia was present in 60% patients, anemia was present in 36% patients, arf was present in 30% patients, jaundice was present in 26% patients, cerebral malaria was present in 20% patients, ards was present in 10% patients, hypotension/shock was present in 10% patients, hypoglycemia was present in 6% patients, bleeding was present in 6% patients.table 5 in this study, p falciparum was present in 34% patients, p vivax was present in 66% patients. among the p falciparum patients, 88.2% are complicated malaria patients. among the p vivax patients, 69.7% are complicated malaria patients. complicated malaria was present in 76% patients and uncomplicated malaria was present in 24% patients. complicated falciparum malaria was present in 30% patients and complicated vivax malaria was present in 46% patients. uncomplicated falciparum malaria was present in 4% patients and uncomplicated vivax malaria was present in 20% patients. fig. 1: distribution of patients based on the outcome in this study, mortality was seen in 6% patients. in this study, mortality was seen in the age group of 41-50 years [66.7%] and 31-40 years [33.3%]. the association between the groups was found to be statistically not significant.table 7 discussion this study was conducted in the department of general medicine, government general hospital, nizamabad. a prashanth et al. / panacea journal of medical sciences 2022;12(2):380–386 383 table 4: distribution of patients based on diagnosis and hemoglobin levels hemoglobin (gm /dl) diagnosis total falciparum malaria vivax malaria n % n % n % <8.0 15 88.2% 3 9.1% 18 36.0% >8.0 2 11.8% 30 90.9% 32 64.0% platelet count (lakhs/cumm) <1.5 15 88.2% 15 45.5% 30 60.0% >1.5 2 11.8% 18 54.5% 20 40.0% total bilirubin (mg/dl) <3.0 5 29.4% 32 96.9% 37 74% >3.0 12 70.6% 1 3.1% 13 26% serum creatinine (mg/dl <3.0 4 23.5% 31 93.9% 35 70.0% >3.0 13 76.5% 02 6.1% 15 30.0% table 5: distribution of patients based on the complications complications frequency percent thrombocytopenia 30 60% anemia 18 36% arf 15 30% jaundice 13 26% cerebral malaria 10 20% ards 5 10% hypotension 5 10% hypoglycemia 3 6% bleeding 3 6% table 6: distribution of patients based on the diagnosis of malaria diagnosis frequency percent falciparum malaria complicated malaria 15 30% uncomplicated malaria 2 4% vivax malaria complicated malaria 23 46% uncomplicated malaria 10 20% total 50 100% table 7: distribution of patients based on the age group and outcome age group (years) outcome total death discharge against medical advice recovery n % n % n % n % 18-30 0 0.0% 0 0.0% 18 40.9% 18 36.0% 31-40 1 33.3% 1 33.3% 14 31.8% 16 32.0% 41-50 2 66.7% 2 66.7% 12 27.3% 16 32.0% total 3 100.0% 3 100.0% 44 100.0% 50 100.0% total number of 50 smear positive malaria patients were included in the study. the study was done over a period of 12 months from 1st december 2019 to 30th november 2020. in this study, majority of the patients belongs to the age group of 18-30 years [36%] followed by 41-50 years [32%] and 31-40 years [32%]. it is coinciding with other authros with age groups as aundhakar s et al. 9 38% (18-30 years), chouhan as et al., 10 48% (21-30 years), shah sj et al., 4 51% (15-30 years), jelia s et al., 11 38% (21-30 years), dabadghao vs et al., 3 33% (21-30 years), devineni sb et al., 12 30% 21-30 years) and madhu m et al., 7 70% (2130 years). our study was comparable to all studies except suryawanshi a et al., 13 and it can be observed that majority of subjects were in age group ranging between 21-30 years. in this study, males constitute 62% and females constitute 38%. 384 prashanth et al. / panacea journal of medical sciences 2022;12(2):380–386 table 8: other complications in present study study year anaemia arf jaundice cerebral malaria ards present study 36% 30% 26% 20% 10% dabadghao vs et al. 3 2016 10% 48% 32% 11% shah sj et al., 4 2016 82.75% kashinkunti md et al. 5 2013 46% 42% 16% 4% nadkar my et al. 2 2011 31.9% 19.46% 8.19% 1.63% chowta mn et al. 6 2007 37.03% 20% madhu m et al. 7 2006 14.73% kochar dk et al. 8 2003 30% our study was comparable to other studies and it can be observed that majority of subjects were male. our study is comparable with studies done by kulkarni vk et al., 14 (m65.67% ,females-34.44%) , shah sj et al., 4 (males-57%, females-43%), jelia s et al., 11 (males -78%, females-22%) , dabadghao vs et al., 3 (males -67%, females-33%), nadkar my et al., 15 (males -71.9%, females-28.1%), chowta mn et al., 6 (males-72%, females-28%). the high infectivity in males might be explained on the basis of the fact that males are more mobile and involved in outdoor activities and they also readily seek medical aid. further, females in india are usually better clothed than males, and hence they are less exposed. in this study, fever was present in all[100%] the patients, chills & rigor was present in 90% patients, headache was present in 72% patients, nausea &vomiting was present in 46% patients, myalgia was present in 38% patients, jaundice was present in 26% patients, altered sensorium was present in 20% patients, convulsions was present in 20% patients, decreased urinary output was present in 16% patients, abdominal pain was present in 14% patients, breathlessness was present in 10% patients, diarrhea was present in 8% patients, cough was present in 8% patients and bleeding was present in 6% patients. pallor was present in 36% patients: icterus was present in 26% patients. respiratory system examination showed crepitations in 5% patients. hepatomegaly was present in 18% patients: splenomegaly was present in 72% patients. cns findings: altered sensorium was seen in 20% patients and convulsions were seen in 20% patients. in this study, the most common symptom was fever (100%), fever is the most common symptom.percentage of patients with fever symptom is similar in other studies as aundhakar s et al., 9 kulkarni vk et al., 14 chouhan as et al., 10 dabadghao vs et al., 3 jelia s et al., 11 shah sj et al., 4 devineni sb et al., 12 except patil dr et al., 16 o’brien at et al., 17 apte s et al., 18 kashinkunti md et al., 5 echeverri m et al., 19 murthy gl et al., 20 gopinathan vp et al., 21 in this study, chills & rigors was present in 90% patients. it is similar to studies done by patil dr et al., 16 o’brien at et al., 17 apte s et al., 18 echeverri m et al., 19 murthy gl et al. 20 headache was present in 72% patients. it is similar to gopinathan vp et al. 21 nausea & vomiting was present in 46% patients. it is similar to gopinathan vp et al., 21 aundhakar s et al., 9 jelia s et al. 11 myalgia was present in 38% patients. it is similar to chouhan as et al., 10 nand n et al. 2 in this study, altered sensorium was present in 20% patients. it is similar to kulkarni vk et al. 14 jaundice was present in 26% patients. it is similar to dabadghao vs et al., 3 jelia s et al., 11 murthy gl et al. 20 decreased urine was present in 16% patients. it is similar to dabadghao vs et al. 3 abdominal pain was present in 20% patients. it is similar to aundhakar s et al. 9 in this study, convulsions was present in 20% patients. it is similar to kulkarni vk et al. 14 breathlessness was present in 10% patients. it is similar to kulkarni vk et al. 14 diarrhea was present in 8% patients. it is similar to shah sj et al., 4 nand n et al. 15 cough was present in 8% patients. it is similar to aundhakar s et al. 2 bleeding was present in 6% patients. it is similar to dabadghao vs et al. 3 in this study, pallor was seen in 36% patients. it is similar to chitharagi vb et al. 22 icterus was seen in 26% patients. it is similar to chitharagi vb et al., 22 chouhan as et al. 10 in this study, splenomegaly was seen in 72% patients. it is similar to chouhan as et al., 10 jelia s et al. 11 hepatomegaly was seen in 18% patients. it is similar to chitharagi vb et al. 22 in this study, thrombocytopenia was present in 60% patients, anemia was present in 36% patients, arf was present in 30% patients, jaundice was present in 26% patients, cerebral malaria was present in 20% patients, hypotension/shock was present in 10% patients, ards was present in 10% patients, hypoglycemia was present in 6% patients, bleeding/dic was present in 6% patients. in this study, thrombocytopenia is the most common complication. it is similar to chitharagi vb et al., 22 dabadghao vs et al., 3 shah sj et al., 4 kashinkunti md et al., 5 and nadkar my et al., 2 studies except shah sj et al., 4 muddaiah m et al. 23 in a study by shah sj et al. 4 most common complication is anemia (82.75%). in a study by muddaiah m et al., 23 most common complication is hepatopathy. prashanth et al. / panacea journal of medical sciences 2022;12(2):380–386 385 in this study, thrombocytopenia was present in 60% patients. it is similar to chitharagi vb et al., 22 (95.2%), chouhan as et al., 10 (88.7%) dabadghao vs et al., 3 (78%), shah sj et al., 4 (62.5%), patil dr et al. 16 (89.2%) and kashinkunti md et al., 5 (48%) nadkar my et al., 2 (89.13%). the platelet count was ranging from 0.36 to 2.6 lakh/cumm. mean platelet count was 1.368lakh/cumm. in this study, considering hb<8gr/dl as anemia, anemia was present in 36% patients. it is similar to chowta mn et al. 6 the hemoglobin level was ranging from 3.2 to 13.4gm/dl. mean hemoglobin was 9.284gm/dl. in this study, considering serum creatinine>3mg/dl as severe renal failure, arf was present in 30% patients. it is similar to nadkar my et al. 2 the serum creatinine level was ranging from 0.8 to 5.6mg/dl. mean serum creatinine was 2.16mg/dl. in this study, considering total bilirubin>3mg/dl as jaundice, jaundice was present in 26% patients. it is similar to dabadghao vs et al. 3 the total bilirubin level was ranging from 0.8 to 6.6mg/dl. mean total bilirubin was 2.174mg/dl. in this study, cerebral malaria was present in 20% patients. it is similar to kashinkunti md et al. 5 in this study, ards was present in 10% patients. it is similar to dabadghao vs et al. 3 in this study, p falciparum was present in 34% patients, p vivax was present in 66% patients. among the p falciparum patients, 88.2% are complicated malaria patients. among the p vivax patients, 69.7% are complicated malaria patients. complicated malaria was present in 76% patients and uncomplicated malaria was present in 24% patients. complicated falciparum malaria was present in 30% patients and complicated vivax malaria was present in 46% patients. uncomplicated falciparum malaria was present in 4% patients and uncomplicated vivax malaria was present in 20% patients. in this study, p falciparum was present in 34% patients. it is similar to dabadghao vs et al., 3 jelia s et al., 11 chowta mn et al., 6 madhu m et al. 7 p vivax was present in 66% patients. it is similar to jelia s et al. 11 in this study, complicated malaria was present in 76% patients and uncomplicated malaria was present in 24% patients. our study matches with dabadghao vs et al., 3 (complicated malaria 53%, uncomplicated malaria -47% rao bs et al., 24 complicated malaria 18.89%, uncomplicated malaria 81.11%. in this study, mortality was seen in 6% patients. our study coincides with study done by chitharagi vb et al., 22 (0.8%), chouhan as et al., 10 (4%), dabadghao vs et al., 3 (10%), kashinkunti md et al., 5 (12%), nadkar my et al., 2 (11.25%) and chowta mn et al., 6 (0%)in this study, mortality was seen in 6% patients. mortality was seen in the age group of 41-50 years [66.7%] and 31-40 years [33.3%]. 4. conclusion malaria is still at rampant in india with debilitating morbidity and mortality. studying the clinical profile of malaria with proper antimalarial drug treatment helps to curb down the complications of malaria. every healthcare facility should follow national and international guidelines and form its in-hospital guidelines regarding proper antibiotic and antimalarial selection. this helps to reduce morbidity and mortality of malaria and helps in the sustained economic growth of the nation. malaria is a completely curable disease. 5. conflicts of interest no potential conflict of interest relevant to this article was reported. 6. source of funding none. references 1. agarwal a, malaria cs. api textbook of medicine. 9th edn. publishers: association of physicians of india; 2012. p. 1177–84. 2. nadkar my, huchche am, singh r, pazare ar. clinical profile of severe plasmodium vivax malaria in a tertiary care centre in mumbai from june 2010-january 2011. j assoc physicians india. 2010;60:11– 3. 3. dabadghao vs, singh vb, sharma d, meena bl. a study of the clinical profile of malaria and its complications. int j cur res rev. 2016;8(1):25–30. 4. shah sj, prajapati v, shah pp. study of clinical profile of hospitalized patients diagnosed with malaria. gcsmc. 2016;5(1):30–6. 5. kashinkunti md, gundikeri s, dhananjaya m. clinical profile of severe plasmodium vivax malaria in a tertiary care centre of north karnataka. ijsrp. 2013;3(7):1–3. 6. chowta mn, chowta kn. study of clinical profile of malaria at kmc hospital, attavar. j clin diagn res. 2007;3:110–5. 7. madhu m, prakash ps. a study of clinical profile of malaria in a tertiary referral centre in south canara. j vect borne dis. 2006;43(1):29–33. 8. kochar dk, agarwal p, kochar sk. hepatocyte dysfunction and hepatic encephalopathy in plasmodium falciparum malaria. qjm. 2003;96(7):505–12. doi:10.1093/qjmed/hcg091. 9. aundhakar s, prajapati p, prajapati s, aundhakar a, kothia d, john d, et al. study of clinical and hematological profile of plasmodium vivax malaria in a tertiary care hospital in western maharashtra. int j sci stud. 2017;5(3):257–60. 10. chouhan as, desai h, kejriwal a, ghanekar j, pereira e. to study clinical profile and complications of plasmodium vivax malaria. jmscr. 2017;5(6):23487–91. 11. jelia s, meena s, meena sr, arif md, jain p, ajmera d, et al. a study of clinical profile and complication of malaria in a tertiary care centre in south-eastern region of rajasthan, india. int j adv med. 2016;3(3):614–20. doi:10.18203/2349-3933.ijam20162505. 12. devineni sb, suneetha o, harshavardhan n. study of platelet count in malaria patients and the correlation between the presence and severity of platelet count with type of malaria. j evol med dent sci. 2015;4(67):11734–6. 13. suryawanshi a, tungikar s. a clinical profile of malaria. int j recent trends sci technol. 2015;14(2):432–5. 14. kulkarni vk, agrawal k. a study of clinical profile of malaria with special reference to complications and outcome. int j adv med. 2017;4(2):317–22. 15. nand n, aggarwal h, sharma m, singh m. systemic manifestations of malaria. j indian acad clin med. 2001;2(3):189–94. http://dx.doi.org/10.1093/qjmed/hcg091 http://dx.doi.org/10.18203/2349-3933.ijam20162505 386 prashanth et al. / panacea journal of medical sciences 2022;12(2):380–386 16. patil dr, nikumbh sd, parulekar a, roplekar k. multiorgan dysfunction in plasmodium vivax malaria: a prospective study. int j sci stud. 2015;3(5):155–62. 17. o’brien at, ramírez jf, martínez sp. a descriptive study of 16 severe plasmodium vivax cases from three municipalities of colombia between 2009 and 2013. malar j. 2009;13:404. doi:10.1186/14752875-13-404. 18. apte s, jain j, parmara, apte a, sinha u, chanchlani r, et al. a study of clinical profile in patients with p. vivax malaria. j evol med dent sci. 2014;3(3):575–81. 19. echeverri m, echeverri m, tobon a, alvarez g, carmona j, blair s, et al. clinical and laboratory findings of plasmodium vivax malaria in colombia. rev inst med trop sao paulo. 2003;45(1):29–34. doi:10.1590/s0036-46652003000100006. 20. murthy gl, sahay rk, srinivasan vr, udapdhaya ac, shantaram v, gayatri k, et al. clinical profile of falciparum malaria in a tertiary care hospital. j indian med assoc. 2000;98(8):160–9. 21. gopinathan vp, ratla pk, bhopte ag. falciparum malaria in north eastern sector. japi. 1981;29(12):1027–35. 22. chitharagi vb, kulkarni rd, anegundi r, ajantha gs, chandra p, r k, et al. clinical profile of malaria in and around hubballi-dharwad: a region of north karnataka. national j lab med. 2017;6(4):1–6. doi:10.7860/njlm/2017/28360:2250. 23. muddaiah m, prakash ps. a study of clinical profile of malaria in a tertiary referral centre in south canara. j vector borne dis. 2006;43(1):29–33. 24. rao bs, vani ms, latha g, lavanya d. incidence, severity, prognostic significance of thrombocytopenia in malaria. int j res med sci. 2015;3(1):116–21. doi:10.5455/2320-6012.ijrms20150120. author biography d prashanth, assistant professor d sharath kumar, assistant professor m harikrishna reddy, assistant professor ch subhash kumar, assistant professor cite this article: prashanth d, kumar ds, reddy mh, kumar cs. a study of clinical profile and outcome of malaria in adults at government general hospital, nizamabad. panacea j med sci 2022;12(2):380-386. http://dx.doi.org/10.1186/1475-2875-13-404 http://dx.doi.org/10.1186/1475-2875-13-404 http://dx.doi.org/10.1590/s0036-46652003000100006 http://dx.doi.org/10.7860/njlm/2017/28360:2250 http://dx.doi.org/10.5455/2320-6012.ijrms20150120 original research article doi: 10.18231/2348-7682.2017.0010 panacea journal of medical sciences, january-april,2017;7(1): 35-39 35 epidemiological study of factors influencing incidence of chronic suppurative otitis media in paediatric age group of rural population vivek harkare1, kanchan dhote2,*, kunal shrimal3, nitin deosthale4, priti dhoke5, sonali khadakkar6 1professor & hod, 2,6senior resident, 3 mbbs student, 4professor, 5associate professor, dept. of ent, nkp salve institute of medical sciences & research centre & lata mangeshkar hospital, nagpur, maharashtra *corresponding author: email: kanchandhote@rediffmail.com abstract chronic suppurative otitis media (csom) is one of the most common illnesses encountered in early childhood as well as in adult life hampering the quality of life. the incidence of csom has increased in recent years. the present study was carried out with the aim of studying the epidemiological factors contributing to causation of chronic suppurative otitis media in paediatric age group and also to suggest corrective measures for the same. a cross-sectional study was carried out in the department of ent in a tertiary care hospital in rural area. total 200 patients suffering from csom visiting ent, paediatrics and medicine outpatient departments were selected. high incidence of csom in children in rural population was observed in the families having more number of children, illiteracy of the parents, low socioeconomic status, prone to various kinds of allergies. we concluded that the incidence can be controlled or prevented by implementing special measures like health education, awareness and providing proper medical aid at primary level. keywords: chronic suppurative otitis media, rural population, socioeconomic status, paediatric age group. introduction otitis media is a continuum of conditions that includes acute otitis media, otitis media with residual or persistent effusion, unresponsive otitis media, recurrent otitis media, otitis media with complications and chronic suppurative otitis media. otitis media may be involved in the development of bacterial meningitis and other central nervous system infections and it often constitute the basis for undertaking one or more of the most frequently performed operations of infancy and childhood, namely myringotomy with or without tympanostomy tube insertion, adenoidectomy and tonsillectomy.(1) when a perforation of the tympanic membrane is present, either spontaneously or due to a tympanostomy tube, the middle ear “gas cushion” is lost, resulting in reflux of nasopharyngeal secretions through the eustachian tube and consequent contamination of the middle ear with potential respiratory pathogens.(2-4) infants and young children are especially at risk for such reflux because their eustachian tubes are short, horizontal, and ‘‘floppy’’.(34) similarly, down syndrome and craniofacial anomalies such as cleft palate affect both the anatomy and function of the eustachian tube and so predispose to chronic suppurative otitis media.(5) chronic suppurative otitis media remain one of the most common childhood chronic infectious diseases worldwide. the worldwide prevalence of csom is 65330 million people and 39-200 million (60%) suffer from clinically significant hearing impairment.(6) it is typically a persistent disease, insidious in onset, often capable of causing severe destruction and irreversible sequel and clinically manifests with deafness and discharge.(7) it is a disease condition characterized by perforation of tympanic membrane with recurrent or persistent muco-purulent otorrhea.(8) soiling of the middle ear from swimming or bathing also leads to intermittent and unpleasant discharges. typical findings may also include thickened granular middle ear mucosa, mucosal polyps, and cholesteatoma within the middle ear. csom is highly prevalent in those of low socioeconomic status in developing countries where overcrowding, poor hygiene, lack of breast feeding, passive smoking, high rates of nasopharyngeal colonization with potentially pathogenic bacteria and inadequate or unavailable health care, frequent upper respiratory tract infections, inadequate nutrition, contaminated water and underresourced or expensive healthcare are important predictors.(9-14) these risk factors weaken the immunological defenses, increasing the inoculums and encouraging early infection.(15) the incidence of chronic suppurative otitis media has increased in recent years despite improvement in living conditions, awareness, socio-economic status, education and better health services. the literature available(5,7,9-13) on aetiopathogenesis of csom mainly concentrates on microbiological aspects and does not take other contributory and epidemiological factors into consideration. this study is carried out to provide local data on the incidence of the disease with its associated epidemiological factors. material and method this cross-sectional study was conducted in the tertiary health care centre, lata mangeshkar hospital, nagpur of rural area for duration of two months from april 2014 to may 2014 after obtaining vivek harkare et al. epidemiological study of factors influencing incidence of chronic suppurative…. panacea journal of medical sciences, january-april,2017;7(1): 35-39 36 approval from institutional ethics committee. modified prasad’s scale(14) was used to assess the socioeconomic status of the family. total 200 patients suffering from csom visiting ent, paediatrics or medicine opds were selected. the written informed consent was obtained from the patients. a proforma was prepared in which detailed history of the patient and clinical findings were recorded. the factors like socio-economic status, educational level, habits of use of tobacco, smoking, alcoholism, familial incidence of similar disease, feeding methods, other habits such as digital sucking etc. were taken into consideration. a detailed clinical assessment was done to confirm the diagnosis. after the completion of study period, all the data was compiled in the master chart for observation. inclusion criteria:  all patients of paediatric age group (up to 18yrs) hailing from rural area visiting the opd and diagnosed to be having csom. exclusion criteria:  various congenital disorders like cleft palate, cleft lip and autosomal disorders leading to csom.  csom secondary to trauma. result the present study was conducted in 200 patients suffering from csom. out of which, 57% subjects were males and 43% of the children were female giving male to female ratio of 1.32:1 (fig. 1). fig. 1: sex distribution table 1: distribution of cases according to age age (years) no. (%) ≤ 1 10(5) 2 – 5 49 (24.5) 6 – 9 59 (29.5) 10 – 13 47 (23.5) > 14 35 (17.5) total 200 (100) it was observed that 29.5% of the children were belonging to the age group of 6-9 years followed by 24.5% of children who belonged to the age group of 2-5 year old and 23.5% belonged to 1013 year old age group. children belonging to the age group of more than 14 were found to constitute 17.5%, where as 5% belonged to less than 1 year old age group in this study (table 1). fig. 2: socioeconomic status it was observed that 73 (36.5%) participants were situated in class vi (upper lower class), 63 (31.5%) in class iii (lower middle class), 29 (14.5%) in class v (lower class), 24 (12%) in class ii (upper middle class) and 11(5.5%) in class v (upper class) (fig. 2). hence, it was observed that most of the children belonging to class i and class ii who were considered to be belonging to higher and upper middle class were less that class iii, class vi and class v assume to be belonging to lower middle class, upper lower class, lower class respectively. in the present study, we observed that out of 200 participants 147 (73.5%) children had parents who were non matriculate, 44(22%) were matriculate and 9% were graduates. table 2: distribution of cases according to allergy allergy no. (%) yes 88 (44) no 112 (56) total 200 (100) it was observed that 44% of the children with csom had symptoms of allergy (table 2). vivek harkare et al. epidemiological study of factors influencing incidence of chronic suppurative…. panacea journal of medical sciences, january-april,2017;7(1): 35-39 37 fig. 3: distribution of cases according to parental smoking it was seen that out of 200 participants 74 children were exposed to passive smoking (fig. 3). it was found that 10 patients had a history of csom in family. in the present study, 51.5% of mothers were multiparous, 41.5% of children were having a mother with two children, and 7%, were found to be the single child of the mother. table 3: distribution of cases according to breast feeding and bottle feeding age (<= 1 year) no. (%) breast feeding bottle feeding yes 8 (80%) 2 (20%) no 2 (20%) 8 (80%) total 10 10 out of the 10 children who were under age group of 1 year, 8 were breastfed while two were fed with a bottle (table 3). out of the sample pool 31 participants had the history of pond bathing, while 169 did not have such a history. fig. 4: medical aid fig. 4 shows that 54(27%) children did not have medical aid in the vicinity of their residence; whereas 146(73%) were residing in a place where they had medical aid in their surroundings. discussion csom is an infection commonly associated with poor socio-economic status or poverty-related conditions such as malnutrition, over-crowding, substandard hygiene, frequent upper respiratory tract infections and under-resourced health care. in the present study of 200 participants, total number of children male and female was 114 and 86; the male female ratio is 1.32:1. in other study based on csom showed that male-female ratio is 1.12:1(16) and the study done by adhikari p et al(17) found that male female ratio is 1.77:1. most of the studies conducted in various parts of the world revealed male dominance. in this study, 29.3% of children suffering from csom belonged to 6 to 9 years of age and 24.2 % of subjects were belonging to 2 to 5 years of age group. csom typically occurs in the young children, especially the under-fives.(8,18) a cross-sectional survey was conducted among 914 children from four primary schools and 12 nurseries found that the disease was equally prevalent in preschool children (5.7%) and primary school children (6.2%) (p = 0.94), and their median age at presentation was 5.9 years.(16) in a study by n kamal et al(19) 53.3% children were in 2-5 years age group. socioeconomic status was assessed by using modified b. g. prasad’s scale which indicated that most of the patients in this study belonged to class iii and class vi (lower middle and upper lower class). presuming the fact that the (lower class section) class v might not be having enough awareness about the disease, class vi (upper lower class) dominated in the study. the children belonging to class i and class ii (upper class and upper middle class section) might have visited private / corporate hospital setups for treatment. in this study it was observed that as high as 36.5% of subjects belonged to class vi (upper lower class), 31.5% belonged to class iii (lower middle class), whereas 14.5% belonged to class v (lower class), 12% belonged to class ii (upper middle class) and as less as 5.5% belonged to class i (higher class). some of the studies mentioned below, which were conducted in various parts of the world including the subcontinent yielded similar results. poverty and poor medical seeking behavior may have contributed to the dominance of this socioeconomic group in the epidemiology of csom in this locality. paradoxically, fewer subjects (two subjects only) fell into the social class v which is the lowest class. the reason may be due to extreme poverty and lack of education which characterizes this group thereby hindering them from seeking and utilizing orthodox care in hospitals. other vivek harkare et al. epidemiological study of factors influencing incidence of chronic suppurative…. panacea journal of medical sciences, january-april,2017;7(1): 35-39 38 studies also reveal the significance of csom with socioeconomic status. the study which was conducted in bangladesh observed that about 63.6% of students with csom were from this less income group(14) and low socioeconomic class in 153 (81%).(20) in the first cross sectional examination out of 4104 students 123 (3%) students were having csom out of which 96 be-longed to low income group, 23 to middle income group and 4 to high income group. when compared this difference was statistically significant (p<0.001). it was observed that the majority of the children who visited the opd with csom were belonging to the parents who were non matriculate i.e. 73.5%, supporting the fact that the educational status and literacy were factors influencing the prevalence. in this study allergy due to various factors was seen in 44% of children with csom. although in some studies as mentioned below, allergy was observed to be one of the main contributing factors ranging from 24% to 89%.(21) it is assumed that it depends upon the type of study and the number of subjects involved. in a meta-analysis of contributing factors for chronic and recurrent otitis media, it was concluded that allergy significantly influences the incidence. a survey of children with csom, 28% was allergic.(20) passive smoking has been considered to be one of the factors influencing the incidence of csom. hence, it was assessed if the parent was a smoker or not. it was observed that 37% of the children had had a smoker in their residence. in a study conducted by lassisi ao et al,(20) clinical and demographic risk factors associated with csom, it was observed that 18% people had a smoking father at home. the study which was conducted in nigeria the result is different. by assessing the presence of csom in family as a factor influencing the prevalence, mother, father and siblings were taken into consideration whether any of them had csom. it was found that 10% of the children had at least one member of family with history of csom. multiparity of mother would indirectly lead to overcrowding in the living place of the child. in this study it was observed that 51.5% of mothers were multiparous, i.e. 103 children were a part of family where their mother had more than two children where as 41.5% of children, i.e. 83 children were having a mother with two children and 7%, i.e. 14 children were found to be the single child of the mother. breast-feeding is believed to provide antimicrobial, anti-inflammatory, and immunomodulatory agents that contribute to an optimal immune system.(21-22) the relative contribution of breast-feeding to preventing middle ear infection otitis media risk has been reported in numerous studies.(23-25) it is reported that breastfeeding, even for only 3 months, could decrease the risk for acute otitis media in children.(26) in this study the children belonging to the age group of less than one year were included to assess whether the baby is breast fed or bottle fed. it was observed that 80% of the children below one year were breastfed and the rest of 20% were bottle fed. in another study, bottle feeding was 61%.(20) considering the fact that in the rural areas some children take bath in ponds where there is no availability of municipal tap water, pond bathing was considered as a factor contributing to the prevalence of csom. it was observed that 15.5% of the children had the history of pond bathing. in a few studies done in other developing countries other than india, it was seen that in rural pediatric population of indonesia in bali and budang regions a significantly high prevalence of csom than rest of the indonesia.(27) the burden of csom in the children studied indicates a high level of dhi in these communities within yemen. a history of ear discharge, swimming in local pools, recurrent respiratory infections, and overcrowded housing were the strongest predictors for csom. there is a need for better ear care and screening programs for early detection and management of this disease.(28) the study was conducted in a tertiary centre including rural population, so it was assessed whether the children presenting with csom had any health care centre in the vicinity of their residence. it was observed that 27% of the children were hailing from a place where they had no medical facility available. chronic suppurative otitis media like any chronic disease, can limit an employability and quality of life. they are particularly disadvantaged because of scarcity of work, poor living conditions and limited health care.(15) as per as health care delivery fails to target high-risk groups in developing countries, infections like csom will persist. therefore, improving equal access to good health needs is a critical factor to ultimately ridding the world of the disease. conclusion higher incidence of csom in children of rural population can be controlled by implementing the following specific measures which are health education, making the parents aware about various contributing factors and their prevention, antismoking/ alcoholism campaigns, improving health care system in rural areas. training the medical and paramedical staff to provide health education and basic medical will aid to the rural population. acknowledgement this research was supported by ent department, nkp salve institute of medical science and research center, nagpur. i thank this institute who provided insight and expertise that greatly assisted the research. i would also like to show my gratitude to dr sudheer reddy, junior resident, ent department and department of medicine nkpsims nagpur. vivek harkare et al. epidemiological study of factors influencing incidence of chronic suppurative…. panacea journal of medical sciences, january-april,2017;7(1): 35-39 39 references 1. paradise jl. otitis media in infants and children. pediatrics 1980;65(5):917-943. 2. roland ps. chronic suppurative otitis media: a clinical overview. ear nose throat j 2002;8(1):8-10. 3. bluestone cd. epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. int j pediatr otorhinolaryngol 1998;42(3):20723. 4. bluestone cd. pathogenesis of otitis media: role of eustachian tube. pediatr infect dis j 1996:15(4):281-91. 5. nelson jd. chronic suppurative otitis media. pediatric infect dis j 1988;7(6):446-48. 6. who. chronic suppurative otitis media. burden of illness and management options 2004. 7. shenoi pm. management of chronic suppurative otitis media. in: booth jb, editor. scott browns otolaryngology. london: butterworths; 1987. pp. 215– 237. 8. ologe fe, nwawolo cc. prevalence of chronic suppurative otitis media among school children in a rural community in nigeria. nig postgrad med j 2002;9:63-6. 9. acuin jm. chronic suppurative otitis media: a disease waiting for solutions. comm ear hearing 2007;4:17–9. 10. lasisi ao, sulaiman oa, afolabi oa. socio-economic status and hearing loss in chronic suppurative otitis media in nigeria. ann trop paediatr 2007;27:291–6. 11. adoga a, nimkur t, silas o. chronic suppurative otitis media: socio-economic implications in a tertiary hospital in northern nigeria. pan afr med j 2010;4:3. 12. taipale a, pelkonen t, taipale m, bernardino l, peltola h, pitkäranta a. chronic suppurative otitis media in children of luanda, angola. acta paediatrica 2011;100:e84–e88. 13. who/ciba foundation workshop report. prevention of hearing impairment from chronic otitis media. nov 1996 uk 19–21. 14. md. mazharul shaheen, ahmed raquib, shaikh muniruddin ahmad. chronic suppurative otitis media and its association with socio-econonic factors among rural primary school children of bangladesh. indian j otolaryngol head neck surg mar 2012;64(1):36–41. 15. acuin j. chronic suppurative otitis media. burden of illness and management options. world health organization. geneva: who, 2004. 16. rupa v, jacob a, joseph a. chronic suppurative otitis media: prevalence and practices among rural south indian children. int j pediatr otorhinolaryngol 1999;48:217. 17. adhikari p, kharel db, ma j, baral dr, pandey t, rijal r, et al. pattern of ontological diseases in school going children of kathmandu valley. int arch. otorhinolaryngol 2008:12(4):502–505. 18. verhoeff m, van der veen el, rovers mm. chronic suppurative otitis media: a review. intj pediatr otorhinolaryngol 2006;70:1. 19. kamal n, joarder ah, chowdhury aa, khan aw. prevalence of chronic suppurative otitis media among the children living in two selected slums of dhaka city. bangladesh med res counc bull 2004;30:95. 20. lasisi ao, olaniyan fa, muibi sa. clinical and demographic risk factors associated with chronic suppurative otitis media. int j pediatr otorhinolaryngol 2007;71:1549. 21. lack g, caulfield h, penagos m. the link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids. pediatr allergy immunol 2011;22:258–266. 22. labbok mh, clark d, goldman as. breastfeeding: maintaining an irreplaceable immunological resource. nat rev immunol 2004;4:565–572. 23. sabirov a, casey jr, murphy tf, pichichero me. breast-feeding is associated with a reduced frequency of acute otitis media and high serum antibody levels against nthi and outer membrane protein vaccine antigen candidate p6. pediatr res 2009;66:565–570. 24. mew jr, meredith gw. middle ear effusion: an orthodontic perspective. j laryngol otol 1992;106:7–13. 25. mcniel me, labbok mh, abrahams sw. what are the risks associated with formula feeding? a re-analysis and review. breastfeed rev 2010;18:25–32. 26. uhari m, mantysaari k, niemela m. a meta-analytic review of the risk factors for acute otitis media. clin infect dis 1996;22:1079–1083. 27. anggraeni r, hartanto ww, djelantik b, ghanie a, utama ds. otitis media in indonesian urban and rural school children. pediatr infect dis j. 2014oct;33(10):1010-5. 28. salem muftah, ian mackenzie, brian faragher. prevalence of chronic suppurative otitis media (csom) and associated hearing impairment among school-aged children in yemen. oman med j.2015 sep;30(5):358365. http://www.ncbi.nlm.nih.gov/pubmed/?term=raquib%20a%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=ahmad%20sm%5bauth%5d http://www.ncbi.nlm.nih.gov/pubmed/?term=ahmad%20sm%5bauth%5d http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/4 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/4 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/4 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/4 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/1 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/1 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/1 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/8 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/8 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/8 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/8 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/9 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/9 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/9 http://www.uptodate.com/contents/chronic-suppurative-otitis-media-csom-pathogenesis-clinical-manifestations-and-diagnosis/abstract/9 original research article http://doi.org/10.18231/j.pjms.2020.002 panacea journal of medical sciences, january-april, 2020;10(1):3-9 3 total laparoscopic hysterectomy with newly designed uterine manipulator (halder’s): safety, efficacy and perforation prevention abhijit halder 1 , indranil dutta 2* 1assistant professor, 2associate professor, dept. of obstetrics & gynaecology, 1college of medicine and jnm hospital, kalyani, west bengal, 2iq city medical college, west bengal, india *corresponding author: indranil dutta email: drindranildutta@gmail.com abstract objective: the objective of the study is to evaluate the safety and efficacy of the new uterine manipulator (halder’s) in performing total laparoscopic hysterectomy (tlh) and to determine whether it prevents perforation of uterus due to forward pushing force. introduction: hysterectomy is one of the most common gynaecological operation performed worldwide of which laparoscopic approach is now a days preferred alternative route compared to open abdominal hysterectomy. according to u.s. surgical data, there is a d ecrease of trend of abdominal hysterectomy from 65% to 54% in favour of laparoscopic route in between 1998 to 2010. it is because laparoscopic approach is associated with shortened hospitalization and postoperative recovery times and low morbidities. but it requires specialized training and skill to perform successfully. manipulation of uterus during tlh is a vital step to avoid inadvertent injuries of vital organs like ureter, bladder and gut. hence the newly designed uterine manipulator (halder’s) is developed to simplify tlh with its inhere nt quality of ease of use and simplicity. special feature of this manipulator is the cervical guard with rotational forward and backward movement which distinguishes it from the all available manipulators in the market. material and methods: from march 2018 to may 2019, 246 cases were done laparoscopically following a standard and simple technique using halder’s uterine manipulator in different centres in west-bengal of which 200 cases were shortlisted as they fulfilled the inclusion criteria’s of halder’s manipulator. after introduction of halder’s uterine manipulator through cervix, the operation was performed using bipolar or ultrasound energy for coagulation and cutting the vascular pedicles and ligaments. the entire procedure was done laparoscopically and the uterus was removed vaginally. the vaginal cuff was closed by continuous suture in single layer with polyglactin material. results: most common indication was abnormal uterine bleeding due to leiomyoma(aub-l), the average weight of uterus was 220±95gms. mean operation time was 64.6±15.5 minutes. estimated blood loss was 80ml±20 ml. there was no bowel injury but one ureteric injury, one bladder injury and one uterine perforation were found. great ranges of movement found during manipulation. conclusion: the easy, smart and simple halder’s uterine manipulator could be the option to do tlh, in reducing the complications and having more favourable operative outcomes. this manipulator can be used by inexperienced persons at vaginal end. keywords: total laparoscopic hysterectomy, quality assessment questionnaire sheet, halder’s uterine manipulator, cervical guard, uterocervical insert, colpotomy tube, colpotomy tube fixation screw. introduction hysterectomy is one of the most common gynaecological operation performed worldwide of which laparoscopic approach is now a days preferred alternative route compared to open abdominal hysterectomy. according to u.s. surgical data, there is a decrease of trend of abdominal hysterectomy from 65% to 54% in favour of laparoscopic route in between 1998 to 2010.1 it is because laparoscopic approach is associated with shortened hospitalization and postoperative recovery times and low morbidities. but it requires specialized training and skill to perform successfully. till today hysterectomy is being performed abdominally because of its easier learning curve compared to laparoscopic approach.2 laparoscopic approach requires specialized trainings which is usually not available in most of the medical colleges. laparoscopic approach is associated with better outcome in respect to post-operative morbidity and faster recovery and reduced long-term complications like incisional hernia, adhesion formation.3 for laparoscopic gynaecologist, one of the most important step is proper uterine mobilisation to reduce complications.4 there is a high incidence of serious complications with tlh such as ureteric injury, bladder injury, haemorrhage etc due to less experience of surgeons.5 proper manipulation of uterus is the primary necessary step for smooth performance of total laparoscopic hysterectomy. the debate stays between myoma screw and uterine manipulator as best method for uterine manipulation, because no method is perfect for performing tlh till date. uterine manipulator or myoma screw both has promising role in successful and uncomplicated tlh operation. myoma screw acts by pulling principle and uterine manipulators depend on push method. pushing method sometimes end up in perforation of uterus in the midst of operation. myoma screw blocks one assistant port which is considered to be the main drawback. several types of uterine manipulators have been developed to improve the tlh operation till date such as clemont-ferrand’s, hohl, rumi with kohs, hourcabie, endopath, vcare, dr mangeshikar etc.6,7 amongst them the clemont-ferrand, rumi, dr mangeshikar are of first line choices by surgeons. there is no single manipulator which can fulfil all the criteria to be the best manipulator.7,8 clemont-ferrand, rumi with koh are very expensive, and is a complex to assemble. moreover rumi with koh has restricted elevation movement and also not applicable in narrow vagina. v care single use system which adds to the cost and not applicable for large uterus. multiple reports showed abhijit halder et al. total laparoscopic hysterectomy with newly designed uterine manipulator… panacea journal of medical sciences, january-april, 2020;10(1):3-9 4 disintegration of instrument and parts to be left behind with rumi i, v care, clearview.8 dr mangeshikar manipulator manufactured by karl storz, germany is the most popular manipulator now a days because of its less difficult assembly mechanism, unique levo and dextro rotation movement, good ante and retroversion movement, lateral movement with well pneumo-occluder function.9 pneumoperitoneum maintainance is very essential criteria for tlh operation which is lacking in endopath, hourcabie. unusual complication like iatrogenic uterine rupture which also caused bowel perforation is reported by hohl.10 uterine perforation by clearview, v care has also been reported in maude database and literature.6,9 the intrauterine tip of v care perforated the uterus whereas perforation during cervical dilation before installation has been reported with clearview.7 balloon perforation has been reported with rumi due to intrauterine balloon hyper insufflation.11 uterine perforation during forceful manipulation makes the operation difficult and prolonged, which is underreported but often faced by the surgeons. surgeons can manage to complete tlh with difficulty or by using myoma screw from above. but it is definite that the operation becomes hazardous due to unnecessary bleeding from the perforation site and recurrent perforation by assistant through the same site in the midst of operation. operation time is also prolonged which makes the surgeon irritated and impatient. the halder’s uterine manipulator was developed to alleviate most of available uterine manipulators’ drawbacks most importantly for avoiding perforation complication. this instrument has no chance of disarticulation and can maintain pneumoperitoneum well along with good manipulation and movement ranges. as it is a very low cost device and reusable, it is better suited in developing country health care environment. this instrument was designed by a gynaecologist of west bengal, india who had difficulty during tlh due to perforation caused by his vaginal assistant regularly in his initial time of laparoscopic surgery. this instrument is solely based on a rod with a nut like rotating device. the concept of cervical guard on the shaft of the instrument made changes and the assistant couldn’t perforate even with greatest force in which he was practiced to. following this, the device with modification made from factory distributed to his local colleagues for use and they also got excellent results. now this modified simple instrument is being used in west bengal and some other centres outside west bengal in india with the same benefits. aims and objectives primary objective to evaluate the efficacy and safety of the newly designed uterine manipulator ‘halder’s uterine manipulator’ in performing tlh. secondary objective 1. to determine the chance of uterine perforation by forward pushing force during manipulation. 2. to determine the ranges of movement of the manipulator and satisfaction level by laparoscopic surgeons. inclusion and cxclusion criteria patients who had benign gynaecologic diseases like adenomyosis, fibroid, endometrial hyperplasia, grade i, ii endometriosis requiring hysterectomy were included. patients with gynaecological cancers and cases with severe (grade iii, iv) endometriosis were excluded from the study. materials and methods study period march 2018 to may 2019. study areas this prospective descriptive study was conducted at different centres in west-bengal, like joymala memorial hospital, kalyani, care and cure private hospital, barasat, iq city medical college, durgapur, eden hospital, north 24 parganas, apollo gleneagles hospital, kolkata, ruby general hospital, kolkata by different laparoscopic surgeons after obtaining due consent from them to participate in the study. the surgeons of those hospitals were provided with quality assessment questionnaire for feedback. the instrument was provided to them for trial in their cases and method of use was taught by youtube video demonstration.12 study materials 246 cases were done laparoscopically following a standard and simple technique using halder’s uterine manipulator in different centres in west-bengal of which 200 cases were shortlisted as they fulfilled the inclusion criteria’s of halder’s manipulator. age, weight and bmi of each patient were asked to be recorded by the surgeons. the information of total number of tlh with their indication, previous operation history, average time taken for each operation, estimated blood loss in ml were asked to be recorded by the surgeons in each operation. surgeons were provided with the quality assessment questionnaire sheet to be filled up in due time. the data collected and analysed. instrument description the halder’s uterine manipulator (fig. 1) is based on a simple stainless-steel shaft (b) of 45cm length. it is specially designed in a thread like fashion which has the capability of a rotating a screw nut like device which is named as cervical guard in this device. the accessories and parts of halder’s manipulator (marked by alphabet as below in fig. 2, fig. 5) https://www.sciencedirect.com/topics/medicine-and-dentistry/uterine-rupture abhijit halder et al. total laparoscopic hysterectomy with newly designed uterine manipulator… panacea journal of medical sciences, january-april, 2020;10(1):3-9 5 1. 3 cervical inserts (4cm, 6cm, 8cm) 2. shaft or rod 3. cervical guard with a hole (3 cm outer diameter) 4. threads at rod tip (5.5 cm length) 5. 2 cervical cups (35 & 40 mm in diameter) with ceramic margin 6. colpotomy tube 7. colpotomy tube fixation screw 8. rod handle – detachable the distal end of the shaft has handle (h) which is detachable by screwing movement (fig. 1). the metallic cervical guard (c) is 3 cm in outer diameter and of 2 cm thickness with a hole of 2.8 cm diameter. it can be screwed over the threads (d) on the shaft (b). it can move forward and backward with clockwise and anticlockwise movement respectively. it helps to achieve more length in the utero-cervical canal while elevation movement and doesn't allow the rod to be advanced more in the uterine cavity during forceful manipulation during tlh. even single cervical insert fitted at the shaft tip can perform various surgery of different uterocervical length because length can be changeable with rotational movement of the cervical guard forward and backward. the uterocervical inserts (a) were 0.5cm breadth and come in 3 different length (4cm, 6cm, 8cm) for different size uterus (fig. 2, 5). each has an upward 15 degrees angle for anteverted and retroverted uterus and can be connected to the shaft tip. after measuring the utero-cervical length, appropriate insert can be fit at the tip of the instrument. the tubular cervical cups (e) were made of ceramic material (20 mm) at proximal edge. each was 6 cm in height and came in 2 different diameters of 35 and 40 mm respectively. the colpotomy tube (f) can be attached with different sizes of colpotomy cup (e). it has a fixation screw (g) which is used to fix the colpotomy tube with cup to be fixed anywhere over the shaft of the instrument. the handle (h) is also detachable by clockwise rotational movement from the shaft. this feature helps the vaginal assistant to introduce the colpotomy cup any time in the middle of operation without exteriorising the whole instrument. the diagram of halder’s manipulator as in patent application showing all parameters is given in fig. 5. the patent application is published by government of india (fig. 6). fig. 1 fig. 2 fig. 3 fig. 4 fig. 5 f c abhijit halder et al. total laparoscopic hysterectomy with newly designed uterine manipulator… panacea journal of medical sciences, january-april, 2020;10(1):3-9 6 fig. 6: patent document installation technique of halder’s manipulator after putting patient on general anaesthesia and positioning her in lithotomy position with the buttocks at the edge of the operation table, uterine mobility, size and position were assessed by vaginal examination. it will help to get idea about appropriate cup size to be taken. all halder’s uterine manipulator components were sterilized prior to each operation. the patient’s bladder was then emptied and the catheter retained. after the cervical canal was dilated with the hegar’s dilator, upto 5 mm. the appropriate length insert (a) is selected by measuring the uterocervical canal by uterine sound or by the hegar’s dilator keeping them side by side. even if proper length not ascertained it may be directly put into the canal and the cervical guard is rotated forward or backward to get proper position so that it does not perforate during elevation of uterus forcefully. the speciality of this instrument is rotating movement of the cervical guard on the rod which makes it unique. following this the tlh operation is performed with or without b/l salpingo-oophorectomy. the operation technique may differ surgeon to surgeon. the colpotomy tube with cup may be put inside the vagina from the beginning of operation or may be slid over later and fixed over the rod with the fixation screw. the surgeons who prefer to use the cup only for colpotomy, they may not use the cup with tube from beginning. when the mackenrodt’s ligaments are coagulated and cut they may put the colpotomy tube with cup from behind after detaching the handle from the shaft not exteriorising the instrument from uterine cavity. it alleviates the need of repeated introduction of the instrument through the cervix. the colpotomy cup with tube may be kept already over the rod but outside the vagina (mostly done by the surgeons) until the step of colpotomy. even when there is difficulty to delineate the area upto which bladder needs to be dissected down over the cervix, surgeon may push the colpotomy tube (e) with cup (d) over the rod. as the diameter of the smallest cup is more than the cervical guard (fig. 3), the colptomiser easily goes over it to be placed at the fornices over the cervix. following this, exaggerated forward push by the assistant with the colpotomy tube makes the uv fold prominent, lateralises the ureter and more traction obtained which help in precise dissection, safe coagulation and cutting. the cup can be fixed over the shaft at this stage by fixing it with the fixation screw. it helps the assistant to use only one hand and another to rest if fatigue. colpotomy done by monopolar current. specimen retrival done by holding the cervix by vulsellum under camera guidance. during this step a folded mop is put over the external vaginal orifice, beside the vulsellum to prevent gas leak. intracorporeal vault suturing was done by each surgeon. total operating time was recorded in ot details. all patients were followed up by each surgeon after 6 weeks. results from march 2018 to may 2019, total of 246 cases were done with halder’s uterine manipulator including all the 6 hospitals by 10 different surgeons. an average of 25 surgeries with halder’s manipulator were done by each surgeon in the time period. patients were between the ages of 42 and 64. their average age and bmi were 44.4 years and 23.8 kg/m2. all patients underwent tlh procedure using halder’s uterine manipulator. indications for hysterectomy were aub-l, aub a, grade 1 and 2 endometriosis and endometrial hyperplasia in 85, 74, 24 and 17 patients respectively. previous surgical history on uterus of the study population is depicted in table 1. patient characteristics and the operative outcomes are shown in table 2. the mean operating time was 64 minutes. the mean uterine size was 220 grams ranged from 70-1100 grams. there were 1 case of bladder injury, 1 case of ureteric injury, 1 case of uterine perforation by instrument tip amongst 200 cases recruited in the study. table 1: history of previous surgery in tlh patients operated with halder’s uterine manipulator (n=200) no previous operation on uterus 74 previous h/o 1 caesarean section 38 previous h/o 2 caesarean section 18 previous h/o 3 caesarean section 2 previous h/o myomectomy 4 previous h/o ectopic operation 2 abhijit halder et al. total laparoscopic hysterectomy with newly designed uterine manipulator… panacea journal of medical sciences, january-april, 2020;10(1):3-9 7 table 2: patient characteristics and operative features patient characteristics operative features age (years) 44.4±2.5 body weight (kg) 58.5±6.6 bmi (kg/m2) 23.8±3.5 uterine size (grams) 220±95 operative times (min) 64 ± 15.5 estimated blood loss (ml) 60 ±20 table 3: intraoperative major complications in tlh with halder’s uterine manipulator assisted operation no of patients bladder injury ureteric injury bowel injury uterine perforation with instrument tip parts retained in uterine cavity vescico-vaginal fistulae 200 1 1 0 1 0 0 table 4: efficacy and safety features found in tlh with halder’s uterine manipulator depending on questionnaire feedback (total score for each criteria-5) c r it e r ia a n te v e r si o n r e tr o v e r si o n m o v e m e n ts l a te r a l m o v e m e n ts e le v a ti o n m o v e m e n ts r e u sa b le p n e u m o p e r it o n e u m in d e p e n d e n t m o v e m e n ts e a si n e ss o f u se a n d a ss e m b li n g c h a n c e o f u te r in e p e r fo r a ti o n p n e u m o p e r r it o n e u m m a in te n a n c e average score obtained from the surgeon’s feedback 4.4 4.8 5 5 4.6 5 5 4.9 4.5 table 5: the advantages and disadvantages of halder’s uterine manipulator (interpreted depending on the feedback provided through the questionnaire by different surgeons) advantages disadvantages
 1. movement ranges + 1300 in anterior plane, 900 in the posterior plane when only the rod with cervical guard used. 2. with colpotomy tube pushed inside over the rod, it is 900 in anterior plane and 450 in posterior plane. 3. reusable instrument. 4. pneumooccluder function is good 5. less costly 6. very less time needed for installation of the manipulator. 7. easily cleaned and sterilised, as less joints. 8. no chance of disintegration of parts to be left behind. 9. effective in large uterus as whole uterocervical canal length can be used for manipulation. 10. inexperienced vaginal assistant can perform easily on verbal commands. 1. specimen retrieval depends on camera and vulsellum. no inherent easy technique for specimen retrieval. 2. in large uterus (more than 12 wks size) specialy where there is posterior fibroid, myoma screw was needed for better visualisation of the posterior peritoneum and adnexal structures. 3. no independent movement at the instrument tip, levo and dextrorotation of utero-cervical insert is not possible. 4. external vaginal orifice is the fulcrum for the leverage system of the manipulator. discussion uterine manipulator is an important tool which can improve outcome of tlh.5 the most dreadful complication faced till today is ureteric injury. uterine manipulator was developed for prevention of injury to adjacent organs and it has shown promising results.7,8 a good manipulator which is user friendly and will help avoid dreadful complications, will make beginners to do more laparoscopic surgery than abdominal open surgery. though there are many manipulators available in market, no single instrument is not without any drawback. some are very good in anteversion/retroversion and lateral movements, some lack that characteristic. few are advantageous from other aspect like pneumoperitoneum maintenance, reusability etc. abhijit halder et al. total laparoscopic hysterectomy with newly designed uterine manipulator… panacea journal of medical sciences, january-april, 2020;10(1):3-9 8 in case of clermont ferrand and rumi system, the mechanism of assembly itself is quite difficult.8 the halder’s uterine manipulator is designed to overcome most of drawbacks and difficulties of available uterine manipulators specially in the scenario of a developing country health care facility. if only the rod with cervical guard is used with the vaginal orifice as fulcrum, ranges of movement excellent as because of its inherent quality to avoid accidental perforation of uterus. but if colpotomy tube is put inside, the range of motion decreases little bit. the vaginal fornices can be easily identified when the colpotomy tube with cup is pushed inside over the rod. ureter can be more lateralized from the field of surgery when the instrument is pushed forward and colpotomy tube is fixed over the rod with fixation screw. the colpotomy cup with tube act as very good pneumo-occluder. no leak of gas has been demonstrated in the study. the drawback of this instrument is that removal of the specimen is to be done by vulsellum under camera guidance. but most of the surgeons are familiar with specimen retrieval technique through vagina. during vulsellum introduction for holding the cervix there is chance of loss of pneumo-peritoneum but this is not a problem if a folded mop is wrapped over the external vaginal orifice. only number 5 hegar’s dilatation is necessary for halder’s manipulator as the tip insert is of only 5mm breadth. only one assistant is enough to install the instrument. less expertise personnel can do application and manipulation easily. in this study it was found that we had one case of bladder injury, one ureteric injury and another case of uterine perforation amongst the 200 cases (table 3). the patient who had bladder rent was a patient with previous 2 caesarean section. bladder was densely adherent to the anterior uterine wall and anterior abdominal wall. there was no role of manipulator in causation of bladder injury. the ureteric injury was during cutting the ovarian pedicle. the ovary was grossly adhered to posterolateral wall of uterus and ovarian fossa. maybe, the surgeon was unaware of the chance of ureter to be drawn up. in that particular case where uterine perforation happened was due to exaggerated dilatation of internal os due to chronic use of norethisterone for more 3 months to control bleeding. the uterus was very soft and os dilated more than needed due to preoperative 2 tablets of misoprostol application. as a result the cervical guard which was 3 cm in diameter went through the os. it is to be mentioned that the diameter of the cervical guard has been increased to 3.5 cm to relatively avoid such occurrence. the surgeons have to be aware of the consistency and dilatability of the os before operation. they shouldn’t use norethisterone for long term before operation. during search for perforation with uterine manipulator studies are scarce. few case reports on perforation by uterine manipulators were found. one case happened by rumi manipulator in 2005, one case with rumi with koh in 2007, 2 cases by kronner’s manipulator in 2007 and 2015.10,11 most of the perforation reported in non tlh gynaecological cases. it may be due to the reason that in tlh, as the uterus anyway is to be removed, no uterine perforation was important to be reported. no study focussed on the difficulty of operation if there was perforation by the tip of the instrument in the middle of the operation. though underreported it is quite common during tlh and often faced by the surgeon, especially if the design of the tip of the manipulator is like hegar’s dilator. even though the instrument tip is withdrawn from the perforation site, and directed to other area of fundus away from perforation, the instrument tip again comes out through the same perforation site during forward pushing. as a result, the assistant becomes attentive not to push forcefully to restrain from perforation. halder’s manipulator is devoid of this problem. surgeon as well as the assistant are satisfied to each other during surgery with halder’s manipulator. conclusion halder’s uterine manipulator is a modification of previously available popular manipulators with the advantage of avoiding perforation complication of the uterus. it has very less articulation and joints. it only depends upon screwing rotational movements of the cervical guard, colpotomy cup and the handle. so only one type of movement has to be remembered by the vaginal assistant. it makes the instrument user friendly. pneumoperitoneum is well maintained by this device. the device will allow beginners and less experienced surgeons to perform a successful tlh with more confidence and better outcomes. if endometriotic colon adhesions or gut adhesion over the uterus due to pid found during tlh, this instrument can be used without the fear of having iatrogenic gut or bladder injury due the presence of cervical guard which will guard the assistant from accidental uterine perforation even if forceful manipulation done. as learning curve is very steep it will become user friendly also. these qualities may help the halder’s uterine manipulator to be the instrument of choice. this instrument is cheap, smart, easy to use and effective in performing most of the cases in the field of gynaecological surgery. these results need to be evaluated and confirmed in a larger numbers of patients. conflict of interest none. source of funding self only for initial manufacturing of the manipulator which was reasonable and supplied to others. references 1. choosing the route of hysterectomy for benign disease. acog in collaboration with committee members, kristen a. matteson, samantha f. butts, msce committee opinion number 701, november 2017. 2. millar wj. hysterectomy, 1981/82 to 1996/97. statistics canada. health reports2001;12:9–22. abhijit halder et al. total laparoscopic hysterectomy with newly designed uterine manipulator… panacea journal of medical sciences, january-april, 2020;10(1):3-9 9 3. aarts jw, nieboer te, johnson n. surgical approach to hysterectomy for benign gynaecologicaldisease. cochrane database syst rev. 2015;(8):cd003677. 4. albright bb, witte t, tofte an. robotic versus laparoscopic hysterectomy for benign disease: a systematic review and meta-analysis ofrandomized trials. j minim invasive gynecol. 2016;23:18-27. 5. wattiez a, soriano d, cohen sb, nervo p, canis m, botchorishvili r, et al. the learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. j am assoc gynecol laparosc. 2002;9:339-45. 6. koh ch. a new technique and system for simplifying total laparoscopic hysterectomy. j am assoc gynecol laparosc. 1998;5:187-92. 7. van den haak. l, alleblas. c. efficacy and safety of uterine manipulators in laparoscopic surgery: a review. arch gynecol obstet. 2015;015-3727-9. 8. mettler l, nikam ya. a comparative survey of variousuterine manipulators used in operative laparoscopy. gynecol surg. 2006;3:239-43 9. hedge cv. mangeshikar uterine manipulator. j obstet gynaecol india. 2016;66(2):134-6. 10. akdemir a, cirpan t. iatrogenic uterine perforation and bowel penetration using a hohl manipulator: a case report. int j surg case rep. 2014;5:271-3. 11. nwanodi ob, novac s, khulpateea n. iatrogenic uterine perforation with kronner uterine manipulator. gyneacol obstet case rep. 2015;1(1:2):1-4. 12. the patency application of halder’s uterine manipulator has been published by government of india on 20/05/2019 (application number-201931019950). 13. youtube video demonstration. (https://youtu.be/im7luhqlrhu). how to cite: halder a, dutta i. total laparoscopic hysterectomy with newly designed uterine manipulator (halder’s): safety, efficacy and perforation prevention. panacea j med sci. 2020;10(1):3-9. original research article http://doi.org/10.18231/j.pjms.2020.007 panacea journal of medical sciences, january-april, 2020;10(1):26-28 26 to assess the prevalence of undernutrition among male and female children of age group of 0-5 years in a rural area of vidarbha region amrapali gajbhiye 1* , gajanan vellhal 2 , mary mathews 3 1ph.d. scholar, 2professor and head, 3principal, 2dept. of community medicine, 1mgm institute of health sciences, navi mumbai maharashtra, 2seth j.s. medical college, kem hospital, mumbai, maharashtra, 3mgm college of nursing, mumbai, maharashtra, india *corresponding author: amrapali gajbhiye email: wankhede.amrapali@gmail.com abstract the malnutrition is one of the major problems among under-five children that can be used to find out the need for nutritional surveillance, nutritional care, or appropriate nutritional intervention programmes in a community. the aim of the study to assess the prevalence of undernutrition in the age group of 0 to 5 years. a community based study was conducted to assess the prevalence of stunting, wasting, &underweight among under-five children in the field practice area of katol. data was collected by predesigned, pre-tested questionnaires from 1/12/15 to 31/12/15.details like history, sex & weight were recorded and length/height was measured using standard technique. the length /height and weight were plotted agai nst who centiles curves & after this malnutrition were graded according to who classification. data analysis was done by using who anthro and staa software. study subjects were belonging to the age group of 0-5 yrs. samples were selected by randomization. as per who classification of protein energy malnutrition the study reveals that, there was significantly higher number of children 86.48% (32/37) were showed malnutrition by applying anthropometric parameter (χ2-value0.6614 p=0.416) subsequently, high percentage of malnutrition was found in under-five children in male children. keywords: undernutrition, malnutrition. introduction malnutrition among under–five children is a major and crucial public health problems in india. undernourished children have significantly higher risk of mortality and morbidity.1 in spite of exceed economic progress made in the last two to three decades, malnutrition among children in both urban and rural india still claims many lives. however, arise cases of malnutrition has caught the public eye and so healthcare providers as well as the government are taking the essential steps to improve the existing status of nutrition for children in india.2 malnutrition is a silent emergency. it is frequently part of a vicious cycle and chain of circumstances that includes poverty and disease. these three factors are interlinked sin such a way that each contributes to the presence and persistent to the others. socioeconomic and political changes that improve health and nutrition can break the cycle. in maharashtra rates of malnutrition.3 stunting (low height for age), 40%, underweight (low weight for age), 50%, wasting (low weight for height), 21%,4 in nagpur, currently, in nagpur, the protein-energy malnutrition (iap classification) is 52.23% and vitamin b deficiency is 46.53%.5 in spite of all these attempts, the problem still exists and has not been determined to the desired level. on this ground it has now become necessary to investigate the depth of the problem, by understanding the situation inside the house. aims and objectives to assess prevalence of undernutrition in children of age group 0 to 5 years in vidarbha region. materials and methods the present study adopts a descriptive approach study design. study was conducted in rural field practice area under nkp salve medical college, katol block, nagpur, among all under-five children randomly selected phc (yenva). data was collected by predesigned, pre-tested questionnaires from 1/12/15 to 31/12/15. details like history, sex &weight were recorded and length/height was measured using standard technique. the length /height and weight were plotted against who centiles curves & after this malnutrition was graded according to who classification.6 data analysis was done by using who anthro and staa software. study subjects were belonging to the age group of 0-5 yrs. samples were selected by randomization. as per who classification of protein energy malnutrition sample size 37 under-five children. the present study proposes to adopt the descriptive study approach of the children age group of 0-5 years. the tool was valided by experts from tool validity committee of mgm university. valuable suggestions were given & necessary correction was made after the consultation with the guide. permission was obtained from the medical officer of phc (yenva). before assessment self -instruction was done by the investigator & the purpose of the study mentioned. consent of the samples was taken. demographic information was completed by using interview method. the protein energy malnutrition assessment of the samples was done by physical assessment& who grading was mailto:wankhede.amrapali@gmail.com amrapali gajbhiye et al. to assess the prevalence of undernutrition among male and female panacea journal of medical sciences, january-april, 2020;10(1):26-28 27 distributed as underweight (low weight for age), wasting (low weight for height and stunting (low height for age). the collected data was coded, tabulated &analysed by using descriptive statics (mean, standard deviation, percentage) correlation coefficient was used to find out the association between the demographic variables & assessment of nutritional status. all the information was appropriate tabulated & illustrated. the data regarding underweight of under-five children was analysed statistically by using chi square test it was found to be not significant at 0.05 level of significance. observations and results in 37 sample5 (13.51%) underfive were normal and 32(86.49%) were undernourished (fig. 1) fig. 1: prevalence of malnutrition in under five children (n=37) table 1: percentage of underweight, stunting and wasting among under five children (who classification) (n=37) gender m(21) f(16) total(37) normal 02(9.52%) 03(18.75%) 05(13.51%) underweight 14(66.67%) 09(56.25%) 23(62.16%) wasting 03(14.28%) 02(12.5%) 05(13.51%) stunting 02(9.52%) 02(12.5%) 04(10.81%) total 21(100%) 16(100%) 37(100%) χ2-value0.6614 p= 0.416 prevalence of malnutrition was higher in male (90.48%) than female (81.25%) however the difference was not found statistically significant (p=0.416). table 2: comparison of prevalence of undernutrition in male and female under-five children (n=37) who criteria n=19 male n=13 female chi-square pvalue under weight 66.67% 56.25% 0.4189 0.517 wasting 14.29% 12.50% 0.0248 0.875 stunting 9.52% 12.50% 0.0834 0.773 fig. 2: comparison of prevalence of under nutrtion in male and female under-five children amrapali gajbhiye et al. to assess the prevalence of undernutrition among male and female panacea journal of medical sciences, january-april, 2020;10(1):26-28 28 in observation & result total sample size was 37 out of which19 were male & 13 were females. as per who criteria, underweight, wasting & stunting was assessed and evaluated (table 2) more percentage for underweight was found in males i.e. 66.67% in comparison with females i.e. 56.25% same thing was noticed for wasting. whereas for stunting more females were there that is 12.50%and in males were 9.52%. after analysis the data was found to be nonsignificant since the sample was less. discussion protein energy malnutrition is a wide spread nutritional disease in developing countries. a huge proportion of males were suffering7 from malnutrition as compared to females. in study group out of 32 undernourished children 19 were males and 13 were females. in present study the percentage of undernutrition was significantly higher in 0-5 year age group of children. similar results was found by gupta et al improper weaning; recurrent infections make this age group more vulnerable.8 in our study prevalence of underweight, wasting and stunting was 66.68%, 14.28% and 9.52% in males as well as 56.25%, 12.50%, 12.50% respectively in females total prevalence is 86.49% finding of the study was compared with sengupta (74% stunted, 42% wasted and 29.5% underweight)9 and rao vg underweight (61.6%), stunting(51.6%) and wasting (32.9%)].10 here higher prevalence of malnutrition in our study may be because of rural area. recommendation reducing the child malnutrition in 0-5 age group can be distributed by availability of supplementary feed. health care providers to focus on health education among parents, especially the mothers to fulfil the nutritional needs in terms of quality and quantity of the child at certain age groups. conclusion in present study, majority of under five children were in undernutrition i.e (86.48%) and it was found more in males than females in vidarbh region. source of funding none. conflict of interest none. references 1. basal rd, mehra m. malnutrition: a silent emergency. india j public health 1991;43(1):1-2. 2. bloss e, wainaina f, bailey rc. prevalence and predictors of underweight, stunting, and wasting among children aged 5 and under in western kenya. j trop pediatr 2004;50(5):260-70. 3. agarwal v. integrated management of neonatal and childhood illness: continuing medical education module public health department. 2005:6-8. 4. progress for children a report card on nutrition unicef: times of india, may 2006. 5. software for assessing growth and development of the world’s children geneva who, 2010. 6. sahu sk, kumar sg, bhat bv, premarajan kc, sarkar s, roy g, et al. malnutrition among under-five children in india and strategies for control. j nat sci biol med 2015;6(1):18-23. 7. gupta anil. effect of geophagia on the nutritional status of children underfive years 0f age. indian streams res j 2015;(12)1-8. 8. kumar p. social classification need for constant upgrading. indian j community med. 1993:18(2):60-1. 9. srivastava rk, anwar f, sen gupta mk, prabha c. malnutrition among rural indian children: an assessment using web of indices. int j public health epidemiol 2013;2(4):78-84. 10. sahu sk, kumar sg, bhat bv, premarajan kc, sarkar s, roy g, et al. malnutrition among under-five children in india and strategies for control. j nat sci biol med 2015;6(1):18-23. how to cite: gajbhiye a, vellhal g, mathews m. to assess the prevalence of undernutrition among male and female children of age group of 0-5 years in a rural area of vidarbha region. panacea j med sci. 2020;10(1):26-8. panacea journal of medical sciences 2020;10(2):83–89 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article correlation of obesity indices with qtc interval and ankle brachial index in young adult population astha1, bindu krishnan2,*, n b kulkarni2 1rural medical college, loni, maharashtra, india 2dept. of physiology, rural medical college, loni, maharashtra, india a r t i c l e i n f o article history: received 02-04-2020 accepted 13-05-2020 available online 26-08-2020 keywords: obesity ankle brachial index conicity index qtc interval waist circumference bmi a b s t r a c t background: in recent times, obesity has acquired an epidemic status world over and in india. the association of obesity with vulnerability to cardiovascular ailments and peripheral vascular disease are well defined. the present study was designed to correlate between chosen obesity indices with electrocardiographic variables, ankle brachial index(abi) and systolic and diastolic blood pressure in asymptomatic young adults. materials and methods: a cross-sectional study performed on 100 subjects, with equal number of male and female participants. blood pressure, electrocardiogram, pulse rate were recorded in the participants after resting for ten minutes. waist circumference, hip circumference, height and weight were measured using standard protocols defined by who. student’s t test, anova test and pearsons correlation test were used to find the significance. results: among the randomly selected 100 subjects, 46% of male and female subjects were in the obese category (body mass index >25.0). almost 38% of male and 60% of female subjects had a waist circumference more than the cut-off value. 28% of male and 88% of female subjects were found to have a conicity index (ci) more than the cut-off value. leftward shift of the mean qrs axis correlated significantly with increasing obesity indices in both sexes. a persistent increase in systolic and diastolic blood pressure was observed among obese individuals. results in male subject show that ci correlated with qtc interval (r=0.71; p=0.001) and diastolic blood pressure (r=0.32; p=0.02). results among female subjects show that bmi correlated significantly with systolic(r=0.34; p=0.01) and diastolic blood pressure (r=0.35;p=0.01), wc positively correlated with systolic blood pressure(r=0.32; p=0.02) and there was a significant negative correlation between wc and abi (r= -0.42; p=0.002) and ci correlated negatively with abi (r= -0.36; p=0.01). conclusion: abdominal obesity is increasingly prevalent among young adults. the measurement of anklebrachial index by using oscillometric blood pressure instrument can be used in primary health centers and relatively unequipped clinics for provisional diagnosis of peripheral arterial disorder and related disorders. © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction in recent times, obesity has acquired an epidemic status world over and in india. world health organisation (who) defines overweight and obesity as abnormal or excessive fat accumulation that presents a risk to health. national family health survey 4 (nfhs-4) 2015-2016 reports that 19% and 21% of men and women in the age group of * corresponding author. e-mail address: drbindukrishnan@gmail.com (b. krishnan). 15-49 years are obese. 1 an icmr-indiab study states the prevalence rate of obesity and central obesity in the range of 11.8% to 31.3% and 16.9% to 36.3%. 2 this does not bode well for us, considering the high risk of lifestyle diseases it renders one susceptible to. while, at its core, it is a disease of calorific imbalance, the intricacies of its pathogenesis are debatable. from hormonal and neural mechanisms to gut microbiota, several culprits have been implicated. genetics and epigenetics have been https://doi.org/10.18231/j.pjms.2020.021 2249-8176/© 2020 innovative publication, all rights reserved. 83 https://doi.org/10.18231/j.pjms.2020.021 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto:drbindukrishnan@gmail.com https://doi.org/10.18231/j.pjms.2020.021 84 astha, krishnan and kulkarni / panacea journal of medical sciences 2020;10(2):83–89 assuming prominence in the etiology of obesity in recent times. 3 obesity is associated with diabetes, atherosclerosis, hypertension, metabolic syndromes and with vulnerability to cardiovascular ailments and peripheral vascular disease. 4 among the various risk factors associated with coronary mortality in the framingham study, obesity is an important independent risk factor. 5 various anthropometric measures like body mass index (bmi), waist hip ratio, waist circumference (wc) and conicity index (ci) are used in measuring total body fat and abdominal adiposity. asian indians phenotype with a greater abdominal obesity in spite of having a lower body mass index have been found to be more prone to diabetes, coronary artery disease than caucasians. 6 data from studies suggest that the cut-offs for defining overweight and obesity need to be different for asian indians, as they tend to develop obesity related co-morbidities at lower levels of bmi. 7 bmi is the most researched measure of generalised obesity and we have used the cut-off values as defined for asian indian population. 8 a higher bmi has shown correlation with the biochemical measures of obesity, such as raised blood cholesterol and triglycerides. abdominal obesity is associated with various metabolic risk factors and studies have shown this association is stronger than generalised obesity for both cardiac factors as well as peripheral vascular diseases. who guidelines mention that wc, whr are found to be superior to bmi in reflecting abdominal obesity. 9 a meta regression analysis of studies on wc and whr as predictors for cardiovascular events, proved that both wc and whr are associated with cardiovascular disease. 10 an indian study found the prevalence of abdominal obesity by using wc were 46% in men and 64% in women. 11 they had used the cut off points recommended by who expert on obesity in asian and pacific population that is 90cm for men and 80 cm for women. conicity index (ci) is another important measure of abdominal adiposity. it has a builtin adjustment of waist circumference for height and weight and has been found equivalent to other indices in predicting metabolic and cardiovascular anomalies. 12 conicity index assigns a value that suggests where the shape of a body lies, ranging from a cylinder to a cone. a given conicity index serves as the multiplier to the circumference of a cylinder with the height and weight of the individual, to give the actual waist circumference of the person, which renders them "conical". 13 almeida in his study has reported a cut-off point for ci as 1.25 as indicator for increased incidence of cardiovascular risk factors and ci had the highest sensitivity and specificity for the same. the cutoff points for conicity index as a high coronary risk among brazilian adult men and women were 1.25 (73.91% sensitivity, 74.92% specificity) and 1.18 (73.39% sensitivity, 61.15% specificity) respectively. 14 obesity is known to cause various changes in the heart like left atrial and left ventricular enlargement, diastolic dysfunctions along with atrial and ventricular repolarization abnormalities. electrocardiographic changes have been correlated with obesity, even in asymptomatic young adults in many studies. this correlation points to some degree of causation being established, since reduction in obesity has been seen to reverse the ecg changes, although reversal is more marked for shift in axes than durations. even in nonobese persons, it has been observed that an increasing bmi influences these changes. 15 qrs duration, qt interval, and qtc are the most widely studied ecg parameters with regard to obesity. ventricular arrhythmia and sudden cardiac arrest are known to occur with prolonged qt interval. the qt and qtc are found to be prolonged in obese subjects due to an autonomic dysfunction with a sympathovagal imbalance. qtc prolongation has been correlated with cardiac risk even in young, healthy adults. 16 very few studies establishing the same have been conducted on women. abdominal obesity has been correlated with a longer qrs duration as well as a shift in qrs axis, independent of age, sex, and ethnicity. general obesity also shows a linear correlation with these attributes. 17 p wave indices, especially prolonged pr interval has been widely accepted as a marker of atrial fibrillation, which may have fatal complications. 18 peripheral artery disease(pad), an important component of the cardiovascular triad has been linked with obesity as one of its risk factors. ankle brachial index(abi) is an indicator of atherosclerosis and can serve as prognostic marker for cardiovascular events. in fact, it has been shown to predict angiographically observable pad with 95% accuracy. 19 the normal cut-off values for abi are between 0.9 and 1.4. gold standard for measuring abi is doppler, but many studies have shown that using an automated oscillometric blood pressure device can be a simple, accurate method to estimate the abi with minimal training. 20 the high leptin concentration in obese individuals has particularly been held accountable for the vascular anomalies indicated by abi. 21 while this index has been a remarkably good indicator for the middle aged and elderly, there aren’t significant studies proving the same in young adults. in our study, we have tried to correlate chosen obesity indices(bmi, wc, ci) with easily measured cardiovascular risk parametersqtc interval and other ecg variables, ankle brachial index and blood pressure and their effectiveness as indicators of these risks in young, asymptomatic adults. 2. materials and methods this cross-sectional analytical study was conducted for a period of two months in the department of physiology, rural medical college, loni. institutional ethical clearance astha, krishnan and kulkarni / panacea journal of medical sciences 2020;10(2):83–89 85 was obtained before the start of the study. (rmc/ug-pg /2019/04) after informing the subjects on the objectives of the study, and obtaining a written consent, the study was performed on 100 young adults of both sexes (50 each). young adults in age group 18-26 years and willing to participate were included in the study. subjects who were symptomatic/on medication for any of the following systemic illnesses like hypertension, diabetes, cardiac diseases, bronchial asthma, allergic disorders were excluded. subjects indulging in any form of substance abuse and taking medication for any psychiatric illness were also excluded from the study.various electrocardiographic variables, systolic and diastolic blood pressure and ankle brachial index were compared with obesity indices like bmi, wc and ci in all the subjects. 2.1. anthropometric measurements bmi was calculated as body weight in kilograms divided by body height in meter square. standing height was measured using a wall mounted stature meter with the shoes removed and recorded to the nearest 0.1 cm. weight was recorded using a digital weighing machine with the subject wearing light clothes and shoes off. waist circumference (wc) was measured in standing posture using a stretch resistant tape at the midpoint between the lower margin of least palpable rib and top of the iliac crest at the end of normal expiration. ci was calculated using valdez equation which uses weight (kg), height (m), wc(m) as follows: waist circum f erence (m) √0.109 x √weight(kg)/height(m) 2.2. operational definitions according to bmi, subjects were divided into 3 groups: group i (18.0 -22.9 kg/m2), group ii (23.0-24.9 kg/m2) group iii (>25 kg/m2). the cut-off for wc was ≥ 90 cm in case of males and ≥ 80 cm in case of females to define abdominal obesity. the cut-off used for conicity index was ≥ 1.25 in case of males and ≥ 1.18 for females. 2.3. blood pressure recording and ankle brachial index all participants were rested for ten minutes before blood pressure measurement. blood pressure was measured in all the four limbs starting from the right arm, right leg, left leg and left arm using a standard automated blood pressure cuff system. (omron automatic blood pressure monitor) by using appropriate cuff size, blood pressure was repeated in all four limbs, whenever there was an error or difference of more than 10mm while recording. the abi for each lower limb was calculated as the ankle systolic blood pressure divided by the highest of the two brachial systolic blood pressures. 2.4. electrocardiography the subjects rested for five minutes in supine position. twelve lead electrocardiogram was performed with the paper speed of 25 mm/sec and amplitude of 10mm/mv. heart rate, qrs duration and amplitude, pr interval, qt interval, qrs axis was measured. corrected qt interval was calculated using bazett’s formula: qtc = qt/± rr. 2.5. statistical analysis results were expressed as mean and sd. student’s t test was used for analyzing parametric variables. for comparison of variables among more than two groups, anova test was done. pearson’s correlation coefficient test was used to analyze correlation of parametric data. a p value of<0.05 was considered as significant. the data was analyzed using the spss software version 22. 3. results data of 100 young adults (50 male and 50 female subjects) were completed and included in the final analysis of the study. the mean age of female and male subjects was 20.4years and 21.02 years respectively. the mean bmi, wc, ci were 24.08 ± 3.70, 86.09 ± 10.61, 1.25± 0.088 among the participants. figure 1 shows the distribution of obese (bmi>25.0), waist circumference, conicity index among subjects(n) above the cut off point. table 1 shows that there was a significant difference in the body mass index, waist circumference, and conicity index between the groups. table 2 shows there was a statistically significant difference in qrs axis among male subjects (p <0.05). systolic and diastolic blood pressure showed statistically significant increase in group iii when compared to group i with respect to bmi. with respect to wc and ci there is an increase in systolic and diastolic blood pressure among subjects who have a higher cut off value (tables 3 and 4 ). in table 5, results among males show that bmi correlated positively with abi (r=0.38; p=0.01), ci correlated with qtc interval (r=0.71; p=0.001)and diastolic blood pressure (r=0.32; p=0.02). results among female subjects (table 6) show that bmi correlated significantly with systolic(r=0.34; p=0.01) and diastolic blood pressure (r=0.35;p=0.01), wc positively correlated with systolic blood pressure(r=0.32; p=0.02) and there was a significant negative correlation between wc and abi (r= -0.42; p=0.002) and ci correlated negatively with abi (r= -0.36; p=0.01). 4. discussion the relationship between various adiposity parameters with electrocardiographic variables, blood pressure and ankle brachial index were attempted in asymptomatic 100 young adults. among the randomly selected 100 subjects, 46% 86 astha, krishnan and kulkarni / panacea journal of medical sciences 2020;10(2):83–89 table 1: anthropometric measurements of the subject and comparison of adiposity indices between groups variable group i (mean± sd) bmi 18.0 -22.9 kg/m2 group ii (mean ±sd) bmi 23.0-24.9 kg/m2 group iii (mean ±sd) bmi >25 kg/m2 p value m-16 f-24 m-11 f-12 m-23 f-14 height(cm) 1.74±0.06 1.59±0.07 1.74±0.08 1.59±0.08 1.73±0.07 1.63±0.06 <0.0001∗ weight(kg) 62.56±6.52 52.16±6.48 73.81±7.96 60.39±6.67 82.04±7.10 77.46±9.95 <0.0001* bmi (kg/m2) 20.53±1.59 20.53±1.58 24.15±0.64 23.82±0.58 27.39±2.02 28.89±2.53 <0.0001* wc (cm) 76.36±6.50 77.03±6.78 86.32±7.43 87.43±3.80 93.64±6.31 98.96±7.54 <0.0001* ci 1.17±0.07 1.23±0.08 1.22±0.09 1.30±0.05 1.24±0.06 1.32±0.06 <0.0001* *significant, bmi: body mass index, wc: waist circumference, ci: conicity index, sbp:systolic blood pressure, dbp: diastolic blood pressure, abi: ankle brachialindex. table 2: comparison of electrocardiographic variables, blood pressure and ankle brachial index among the three groups based on bmi parameter group i group ii group iii p value m -16 f -24 m -11 f -12 m -23 f-14 m f rr interval 0.78±0.11 0.76±0.10 0.77±0.12 0.84±0.23 0.73±0.12 0.79±0.11 0.06 0.81 pr interval (sec) 125.38±34.19 128.33±31.03 133±21.93 136.17±19.07 145.26±39.60 131.92±30.43 0.212 0.735 qrs duration (sec) 101.81±25.08 94.17±13.09 94.01±13.13 90.92±15.66 98.35±13.82 93.29±10.97 0.97 0.678 qtc(sec) 377.78±32.36 396.93±30.31 365.89±24.7 390.63±43.86 371.60±41.66 394.34±22.27 0.642 0.857 qrs axis 61±16.62 46.29±16.99 40.09±14.78 35±33.82 39.65±18.88 43.36±24.00 0.001* 0.412 sbp (mm hg) 116.81±6.74 103.08±9.05 122±13.12 110.58±11.09 120.52±9.17 114.43±14.83 0.329 0.01* dbp (mm hg) 74.06±7.46 68.38±7.31 75.45±8.25 71.92±11.10 74±9.08 78.14±10.19 0.88 0.01* abi 1±0.06 1.05 1.01±0.05 1.03±0.07 1.04±0.06 1.02±0.056 0.09 0.98 *significant, bmi: body mass index, sbp: systolic blood pressure, dbp: diastolic blood pressure, abi: ankle brachial index table 3: comparison of electrocardiographic variables, blood pressure and ankle brachial index among the two groups based on wc parameters wc <90 (in males) wc <80cm (in females) wc >90cm (in males) wc >80cm (in females) p value m 10 mean ± sd f20 m -40 f-30 m f rr interval 0.791±0.119 0.754±0.10 0.876±0.136 0.787±0.11 0.027 0.285 pr interval(sec) 139.19±40.08 129.30±26.64 139.194±40.08 132.20±39.41 0.347 0.559 qrs duration(sec) 102.4±15.90 95.0±13.49 99.48±13.73 93.14±7.86 0.714 0.978 qtc(sec) 378.88±38.26 402.14±27.12 346.79±80.46 389.72±33.47 0.067 0.266 qrs axis 47.87±39.56 45.75±35.28 44.47±24.06 40.76±35.01 0.070 0.428 sbp (mm hg) 118.48±9.26 102.00±9.16 121.57±9.92 111.70±12.79 0.280 0.004* dbp (mm hg) 74.61±7.88 68.85±6.26 73.89±9.06 74.03±11.31 0.802 0.056 abi 1.00±0.06 1.06±0.06 1.04±0.06 1.02±0.06 0.110 0.013* *significant, wc: waist circumference, sbp: systolic blood pressure, dbp: diastolic blood pressure, abi: ankle brachial index of male and female subjects were in the obese category (bmi>25.0). almost 38% of male and 60% of female subjects had a wc more than the cut off value. twenty eight percent of male subjects were found to have a ci of more than 1.25 while 88% of female subjects had ci more than 1.18. a leftward shift of the mean qrs axis occurred with increasing fatness in both men and women participants. this association was confined to the range of normal qrs axis. there was a persistent increase in systolic and diastolic blood pressure as the bmi increased and in subjects having wc, ci more than the cut-off point. results in male subject show that bmi correlated positively with abi, ci correlated with qtc interval and diastolic blood pressure. among female participants bmi correlated significantly with systolic and diastolic blood pressure, wc positively correlated with systolic blood pressure and there was a significant negative correlation between wc and abi and ci correlated negatively with abi. astha, krishnan and kulkarni / panacea journal of medical sciences 2020;10(2):83–89 87 table 4: comparison of electrocardiographic variables, blood pressure and ankle brachial index among the two groups based on ci parameters ci< 1.25 (in males) ci< 1.18 (in females) c i >1.25(in males) c i >1.18(in females) p value m -36 f6 m -14 f-44 m f rr interval(sec) pr interval(sec) 140.06±38.19 145.67±30.74 137.71±23.6 129.05±27.49 0.831 0.176 qrs duration(sec) 50.08±10.16 45.17±9.02 47.79±5.56 47.39±5.56 0.930 0.75 qtc(sec) 373.97±27.24 406.3±28.96 368.08±51.5 393.11±31.70 0.166 0.33 qrs axis 51.72±20.33 44.37±17.27 33.36±20.28 41.77±24.40 0.006* 0.797 sbp (mm hg) 118.75±10.44 99.5±7.81 122±6.43 109.23±12.32 0.283 0.06 dbp (mm hg) 72.86 70±7.45 78.14±72.23 72.23±10.20 0.04* 0.608 abi 1.02 1.07±0.09 1.03±0.049 1.03±0.06 0.62 0.15 *significant, ci: conicity index, sbp: systolic blood pressure, dbp: diastolic blood pressure, abi: ankle brachial index table 5: correlation between adiposity indices and electrocardiographic variables, blood pressure and ankle brachial index in males parameters rr interval pr qrs qtc qrs axis sbp dbp abi bmi r-value 0.26 0.03 -0.05 -0.12 0.16 0.20 0.02 0.38 p-value 0.06 0.81 0.68 0.38 0.24 0.16 0.88 0.01* wc r-value 0.18 0.13 0.006 -0.20 0.22 0.27 0.19 0.27 p-value 0.20 0.36 0.96 0.15 0.108 0.05 0.16 0.05 ci r-value -0.01 0.14 0.07 0.71 0.26 0.23 0.32 0.21 p-value 0.93 0.30 0.60 0.0001∗ 0.068 0.1 0.02* 0.14 *significant, bmi: body mass index, wc: waist circumference, ci: conicity index, sbp: systolic blood pressure, dbp: diastolic blood pressure, abi: ankle brachial index table 6: correlation between adiposity indices and electrocardiographic variables, blood pressure and ankle brachial index in females parameters rr interval pr qrs qtc qrs axis sbp dbp abi bmi r-value 0.03 0.04 -0.005 -0.031 0.018 0.34 0.35 0.03 p-value 0.81 0.74 0.97 0.83 0.89 0.01* 0.01* 0.81 wc r-value 0.04 0.04 0.006 0.001 0.028 0.32 0.25 -0.42 p-value 0.73 0.77 0.96 0.99 0.84 0.02* 0.07 0.002* ci r-value -0.03 0.01 -0.05 0.08 0.030 0.18 0.02 -0.36 p-value 0.79 0.94 0.71 0.57 0.83 0.19 0.84 0.01* *significant, bmi: body mass index, wc: waist circumference, ci: conicity index, sbp: systolic blood pressure dbp: diastolic blood pressure, abi: ankle brachial index nicolau et al. in their study had assessed ci, bmi and wc as predictors along with other coronary artery disease risk factors. 22 bmi is the most widely used index to categories obesity but it is sometimes affected by gender, social and ethnic differences. many metabolic abnormalities including hyperinsulinemia, increased triglyceride levels, increased resistance to insulin, hypertension are known to be associated with abdominal obesity. other mechanisms which are attributed to atherosclerosis and abdominal obesity are endothelial dysfunction, abnormal regulation of endocrine, autonomic and immune function due to cytokines secreted by adipose tissues. 23 a higher bmi has shown correlation with the biochemical measures of obesity, such as raised blood cholesterol and triglycerides. studies involving population from asian indian, united states and europe have suggested that wc alone or along with whr maybe a better anthropometric marker when compared to bmi for they reflect abdominal fatness more specifically. 24 electrocardiographic variables like pr interval, qrs interval, qtc are the most widely studied ecg variables in obesity. qtc interval is the time period spanning from depolarization of the ventricle to the end of repolarization, corrected for heart rate. obesity is one of the known causes for qt interval prolongation. prolonged qt interval is associated with sudden death and ventricular arrhythmia. 25 in our study, there was no effect of weight gain on qtc. in all the groups, qtc was within the normal value of 450ms in males and 470 ms in females. erol et al in their study of uncomplicated obesity on qt interval have shown a positive correlation between qtc and both wc and bmi. 17 girola a et al observed in their study that qtc did not correlate with bmi, wc in uncomplicated 88 astha, krishnan and kulkarni / panacea journal of medical sciences 2020;10(2):83–89 fig. 1: distribution of obese (bmi>25.0), waist circumference, conicity index among subjects(n) obese or overweight individuals. 26 qrs axis deviation is well correlated with increasing fatness. this deviation has been attributed to upward shift of the diaphragm due to abdominal fat, which results in the heart getting pushed to lie in a more horizontal situation. this theory is validated by similar qrs axis shift in pregnant women. obesity is a strong risk factor for abnormal abi and an established risk factor for pad. pad findings are more common in older people. but atherosclerosis begins in childhood and is known to progress into adulthood due to various factors like increased levels of glucose, blood lipids, body weight, hypertension etc. 27 ankle brachial index can be used as an indicator of atherosclerosis and can serve as prognostic marker for cardiovascular events. in our study, abi was within the normal range of 0.9 to 1.3. in a systematic review it was reported that the current available evidence demonstrates that the yield of the abi screening test in asymptomatic individual will depend on the prevalence of other traditional risk factors. 28 high and low abi is known to increase the 10-year cardiovascular risk estimates in these individuals. 29 in our study, the average age being 21.50 years and study subjects having no other contributory risk factors, not many changes were observed in abi reading. 5. limitations the study was conducted among asymptomatic young adults (18-25 years). though studies have advocated that measurement of bp and cholesterol should begin at 20 years and then every 5 years thereafter, 30 except for blood pressure and qrs axis deviation our study did not show any significant changes in qtc and abi.while 100 is a significant sample size for a pilot study which we attempted here, grouping according to sex, left 50 to each group. so, there is need for a study focussing with a larger sample size, particularly in females. 6. conclusion ecg and oscillometric ankle brachial index can be used as quick, cheap, and convenient methods for assessment of cardiovascular risk patients. by using a digital bp apparatus, primary health care / anganwadi workers if trained correctly can make a provisional assessment of peripheral arterial anomalies in high risk patients who can then be referred to the nearest tertiary healthcare for confirmation of peripheral vascular disease, by using doppler. 7. source of funding icmr. 8. conflict of interest none. acknowledgments the study was an icmr sts approved project. we would like to thank icmr for funding the project. references 1. international institute for population sciences (iips) and icf, 2017. national family health survey (nfhs-4), 2015-2016. 2. pradeepa r, anjana rm, shashank r. joshi et al and the icmrindiab collaborative study group. prevalence of generalized & abdominal obesity in urban & rural indiathe icmr indiab study (phase-i). indian j med res. 2015;142(2):139–50. 3. zhang h, dibaise jk, zuccolo a, kudrna d, braidotti m, yu y, et al. human gut microbiota in obesity and after gastric bypass. proc natl acad sci. 2009;106(7):2365–70. 4. lavie cj, milani rv, ventura ho. obesity and cardiovascular disease risk factor, paradox, and impact of weight loss. j am coll cardiol. 2009;53(21). 5. peter wf, wilson. established risk factors and coronary artery disease :the framingham study. am j hypertens. 1994;7(7):7–12. 6. mckeigue p. coronary heart disease in south asians overseas: a review. j clin epidemiol. 1989;42(7):597–609. 7. misra a, khurana l. obesity and the metabolic syndrome in developing countries. j clin endocrinol metab. 2008;93(11):s9–s30. 8. ravikumar v. correlation of adiposity indices with electrocardiographic ventricular variables and vascular stiffness in young adults. j clin diagn res. 2017;11(6):21. 9. waist circumferece and waist -hip ratio: report of a who expert consultation, geneva, 8-11 december 2008. 10. misra a, chowbey p, makkar bm, vikram nk, wasir js, chadha d, et al. consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for asian indians and recommendations for physical activity, medical and surgical management. j assoc physicians india. 2009;57(3):163–70. 11. kurpad s, &amp; tandon s, &amp; himanshu, srinivasan k. waist circumference correlates better with body mass index than waist to hip ratio in asian indians. natl med j india. 2002;16(11):189–92. 12. gowda v, philip k. abdominal volume index and conicity index in predicting metabolic abnormalities in young women of different socioeconomic class. j assoc physicians india. 2016;5(7):1452–6. 13. valdez r. a simple model-based index of abdominal obesity. j clin epidemiol. 1996;44:955–6. 14. almeida rt, alemida mm, araujo tm. abdominal obesity and cardiovascular risk: performance of anthropometric indexes in women. astha, krishnan and kulkarni / panacea journal of medical sciences 2020;10(2):83–89 89 arq bras cardio. 2009;92:345–50. 15. zierle-ghosh a, jan a. body mass index(bmi); 2018. 16. leotta g, maule s, rabbia f, colle sd, tredici m, canadè a, et al. relationship between qt interval and cardiovascular risk factors in healthy young subjects. j hum hypertens. 2005;19(8):623–7. 17. arslan e, yiğiner o, yavaşoğlu i, ozçelik f, kardeşoğlu e, nalbant s. effect of uncomplicated obesity on qt interval in young men. pol arch med wewn. 2010;120(6):209–13. 18. duru m, seyfeli e, kuvandik g, kaya h, yalcin f. effect of weight loss on p wave dispersion in obese subjects. obes. 2006;14(8):1378–82. 19. yao st, hobbs jt, irivne wt. ankle systolic pressure measurements in arterial disease affecting the lower extremities. br j surg. 1969;56(9):676–9. 20. price jf, stewart mcw, douglas af, murray gd, fowkes gfr. frequency of a low ankle brachial index in the general population by age, sex and deprivation: cross-sectional survey of 28980 men and women. eur j cardiovasc prev rehabil. 2008;15(3):370–5. 21. scarpace1 pj, zhang y. elevated leptin: consequence or cause of obesity? front biosci. 2007;12:3531–44. 22. fontela pc, winkelmann er, viecili prn. study of conicity index, body mass index and waist circumference as predictors of coronary artery disease. rev port cardiol. 2017;36(5):357–64. 23. farooqi s, o’rahill s. genetics of obesity in humans. endocrine rev. 2006;7(27):710–8. 24. bajaj hs, pereira ma, anjana rm, deepa r, mohan v, mueller nt, et al. comparison of relative waist circumference between asian indian and us adults. j obes. 2014;doi:10.1155/2014/461956. 25. leotta g, maule s, rabbia f, colle sd, tredici m, canadè a, et al. relationship between qt interval and cardiovascular risk factors in healthy young subjects. j hum hypertens. 2005;19(8):623–7. 26. girola a, enrini r, garbetta f, tufano a, caviezel f. qt dispersion in uncomplicated human obesity. obes res. 2001;9(2):71–7. 27. mcmahan ca, gidding ss, malcom gt, tracy re, strong jp, and hcm. pathobiological determinants of atherosclerosis in youth risk scores are associated with early and advanced atherosclerosis. pediatr. 2006;118(4):1447–55. 28. leng gc, fowkes fgr, lee aj, dunbar j, housley e, ruckley cv. use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. bmj. 1996;313(7070):1440–4. 29. resnick he, lindsay rs, mcdermott mm, devereux rb, jones kl, fabsitz rr, et al. relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality. circ. 2004;109(6):733–9. 30. zhang y, vittinghoff e, pletcher mj, allen nb, hazzouri aza, yaffe k, et al. associations of blood pressure and cholesterol levels during young adulthood with later cardiovascular events. j am coll cardiol. 2019;74(3):330–41. author biography astha mbbs student bindu krishnan associate professor n b kulkarni professor and hod cite this article: astha , krishnan b, kulkarni nb. correlation of obesity indices with qtc interval and ankle brachial index in young adult population. panacea j med sci 2020;10(2):83-89. http://dx.doi.org/10.1155/2014/461956 introduction materials and methods anthropometric measurements operational definitions blood pressure recording and ankle brachial index electrocardiography statistical analysis results discussion limitations conclusion source of funding conflict of interest case report doi: 10.18231/2348-7682.2017.0028 panacea journal of medical sciences, may-august,2017;7(2): 104-106 104 uterine arteriovenous malformation secondary to scar pregnancy smita goenka1,*, madhuri gawande2, sulbha joshi3, chetna ratnaparkhi4 1junior resident, 2assistant professor, 3professor & hod, dept. of obstetrics & gynecology, 4associate professor, dept. of radiodiagnosis, nkp salve institute of medical sciences, nagpur, maharashtra *corresponding author: email: smita.goenka19@gmail.com abstract uterine arteriovenous(av) malformations resulting in abnormal uterine bleeding is relatively rare condition. it can be congenital or acquired. acquired av malformation is usually secondary to trauma, pregnancy or malignancy. the mainstay of management is uterine artery embolization or definitive surgery. we report a case of av malformation in lower uterine segment secondary to previous ruptured scar pregnancy. the condition was diagnosed by doppler ultrasound and confirmed by mr angiography. our subject opted for hysterectomy over uterine artery embolization. the clinical findings were confirmed by histopathological examination by presence chorionic villi. keywords: arteriovenous malformations, scar pregnancy, uterine artery embolization, doppler ultrasound, mr angiography. introduction the incidence of cesarean section is increasing worldwide. hence the incidence of scar pregnancy that is implantation of gestational sac in lower uterine segment at previous scar site is also increasing. scar pregnancy represents 6% of all ectopic pregnancies.(1) the secondary complication of scar pregnancy can be development of uterine arteriovenous malformation at that site. it can result in abnormal uterine bleeding which is usually resistant to medical management.(2) the av malformation in uterus is a rare cause of abnormal uterine bleeding. it can be either congenital or acquired. acquired av malformation is usually after pregnancy or pregnancy related complications.(3) we are reporting a case of av malformation in lower uterine segment secondary to previous ruptured scar pregnancy. we are reporting this case for its rarity. very few cases are reported on literature search. case history a 37-year-old woman one para and previous one ectopic pregnancy reported in outpatient department of our tertiary care hospital with chief complaints suggestive of irregular and heavy menstrual bleeding since 6 months. she had complaints of irregular and episodic bleeding per vaginum not responding to hormonal management. there was no history suggestive of dysmenorrhoea, post-coital bleeding. on obstetric history she had one full term cesarean delivery for fetal distress 4years back. after her detailed history, it was noticed that six months before she had two and half months amenorrhea followed by severe pain in abdomen. through her previous case records we got to know that she had ruptured scar pregnancy at nine weeks of gestation for which laparotomy was performed. the products of conception were removed and scar site was sutured after refreshing the margins. the subject lost for follow up after that. she was asymptomatic for one month after the procedure. after one month she developed intermittent bleeding pervaginum for which she consulted and was treated by physician. it was not responding to medical management. during course of treatment she also received two units of blood transfusions for anemia. on examination her general condition was stable. she was pale. abdomen was soft with no lump palpable. on per speculum and vaginal examination her cervix and vagina was normal. there was fullness in lower uterine segment. her serum beta hcg was done which was within normal limits. on ultrasonography uterus was normal in size, shape and echotexture. endometrium was normal. in lower uterine segment there were hypoechoic areas with echogenic focus within, which on color doppler showed increased vascularity. largest 1.5 cm x1.4cm lesion showed arterial low resistance flow. findings were suggestive of av malformations of lower uterine segment (fig. 1). fig. 1: tuft of tortuous blood vessels on mr angiography post contrast study suggested that a well defined heterogenous lesion noted in lower uterine segment and proximal cervix measuring 3.7 cm x3.6 cm x4cm hypointense with few hyperintesities. on smita goenka et al. uterine arteriovenous malformation secondary to scar pregnancy panacea journal of medical sciences, may-august,2017;7(2): 104-106 105 contrast multiple dilated tortuous vascular channels were noted in bilateral parametrium. a branch of right internal iliac artery was likely feeding the lesion and multiple dilated collaterals were noted with early drainage into right iliac vein (fig. 2). fig. 2: mr angiography shows the dilated tortuous vascular channels in right parametrium, feeding vessel from right internal iliac artery the diagnosis kept was possibility of uterine av malformation involving lower uterine segment. considering her age the option of uterine artery embolization was given. but patient opted for hysterectomy over uterine artery embolization due to financial issues. intraoperatively uterus and ovaries were normal size and shape. a bulge was seen in lower uterine segment more on right side at previous scar site with prominent blood vessels over it. as soon as uterovascical fold was opened, a dead necrotic tissue mass 3 cm x2 cm size could be removed from scar site which was connected to the uterus cavity (fig. 3). fig. 3: bulge in lower uterine sgment more on right side, and retained products of conception at the same site it was not foul smelling. the cervix was normal. total hysterectomy was done. the approximate blood loss was approximately 300 ml. intraoperative and postoperative period was uneventful. the histopathology report was degenerated chorionic villi in necrotic tissue removed from previous scar site was suggestive of previous scar pregnancy. there were dilated vessels more on right side of lower uterine can be suggestive of av malformation in lower uterine segment (fig. 4). fig. 4: dilated vessels and chorionic vill discussion uterine av malformation resulting in abnormal uterine bleeding is relatively rare condition. it can present as life threatening hemorrhage accounting to 1 to 2% of all genital hemorrhages.(4-5) the pathogenesis of uterine av malformation can be either congenital or acquired. congenital av malformation is secondary to abnormal embryonic differentiation.(6) acquired uterine malformation can be the result of trauma, instrumentation, uterine surgery, therapeutic abortion, uterine malignancy and gestational trophoblastic disease.(7) acquired av malformation of the uterus are characterized by single or multiple av fistulas (amfs) which represents the direct connection of an artery and vein. there is no intervening capillary bed. whereas the congenital av malformations have nidus of poorly differentiated blood vessels between artery and vein.(8) the venous system is unable to accommodate the high flow, high pressure state resulting in higher propensity of bleeding.(7) the ultrasonography with doppler studies can diagnose uterine av malformation. the acquired avm is usually secondary to trauma or previous intervention. in our case it was secondary to previous scar pregnancy. the incidence scar pregnancy is rising due to increase in cesarean section rate. in 1978 the first cesarean scar implantation was reported. cesarean scar pregnancy can be diagnosed by visualization of a gestational sac which is low and anterior in relation to the endometrial stripe complex with attenuated overlying myometrium. the overlying myometrium measures five mm or less in thickness.(9) the proposed mechanism for av malformation secondary to scar ectopic pregnancy can be from failed obliteration of placental blood vessels after removal of retained products of conception. or if the chorionic villi are retained, it will lead to collateral vessels formation and pseudo-aneurysmin vessels.(3) on literature search rygh et al(1) reported first case of av malformation of uterus as a consequence of previous scar ectopic pregnancy in 2009. uterine av malformation can be very well diagnosed by doppler ultrasound in a case of smita goenka et al. uterine arteriovenous malformation secondary to scar pregnancy panacea journal of medical sciences, may-august,2017;7(2): 104-106 106 abnormal uterine bleeding. ultrasound findings include heterogeneous, ill-defined mass, with multiple, hypoechoic cystic or tubuli form structures varying in size and focal or asymmetrical endometrial and myometrial thickening. doppler ultrasound demonstrates arteriovenous shunt with high-velocity and low resistance flow.(10) mr arteriography can distinguish between an avm and avf by demonstrating presence and absence of nidus respectively. as hysteroscopy is routinely done in cases of aub, hysteroscopy can diagnose avm and can differentiate between polyp or retained products of conception.(1) the differential diagnoses with similar sonographic findings include gestational trophoblastic disease, retained conception products and abnormal placentation. the management of uterine av malformation is occlusion of nidus, whereas av fistulas require occlusion of the fistulus communication or its feeding vessels.(7) the feeding vessels can be occluded by uterine artery embolization only when distal territory of av malformation can withstand ischemia. the technical and clinical success rate of uae for traumatic avms are reported 100 and 93% respectively.(11) for those who deny for uae or when embolization fails, surgical removal of uterus is mainstay of management. because collateral vessels formation is more as in our case non surgical management would have been limited and non successful.(3) janelle et al reported a case of av malformation secondary to cesarean scar pregnancy which had failed embolization and was extending in the parametrium. to reduce intraoperative bleeding prior internal iliac artery ligation might be required.(7) acquired av malformation is mostly after pregnancy or pregnancy related complications and may coexist with retained products of conception, gestational trophoblastic disease. the treatment of retained products of conception is curettage. but with av malformation this procedure can evoke torrential bleeding.(1) hence, before subjecting these patients for definitive surgery prior ultrasound with doppler should be kept in mind. conclusion uterine av malformation is uncommon cause of abnormal uterine bleeding and can lead to life threatening hemorrhage. when aub not responding to medical management without any uterine pathology av malformations should be kept in mind. though uncommon, uterine av malformation can be secondary to scar ectopic pregnancy. the mainstay of diagnosis is by doppler ultrasound and mr angiography. transcatheter embolisation of feeding vessels is a minimally invasive treatment for such lesions. those who deny or when embolization is unsuccessful the only option left is definitive surgery. references 1. rygh ab, greve oj, fjetland l, berland jm, eggebo tm. arteriovenous malformation as a consequence of a scar pregnancy. acta obstet gynecol scand 2008;88(7):853-5. 2. ash a, smith a, maxwell d. caesarean scar pregnancy. bjog 2007;114(3):253–63. 3. chittawar p, patel k, agrawal p, bhandari s. hysteroscopic diagnosis and successful management of an acquired arteriovenous malformation by percutaneous embolotherapy. j midlife health 2013 jan-mar;4(1):57– 9. 4. farias ms, santi cc, lima aaaa, teixeira sm, de biase tcg. radiological findings of uterine arteriovenous malformation: a case report of an unusual and life-threatening cause of abnormal vaginal bleeding. radiol bras 2014 mar/abr;47(2):122–4. 5. cura m, martinez n, cura a. av malformation of uterus. acta radiol. 2009; 50: 823-9. 6. kasznica j, nisa vn. congenital vascular malformation of the uterus in a stillborn: a case report. hum pathol. 1995;26:240-1. 7. jennele km, leslie ag, gloria ms, annekathryn g. the role of radical surgery in the management of acquired uterine arteriovenous malformation. case rep oncol. 2013 may-aug;6(2):303–10. 8. senthil kumar aiyappan, upasana r, savitha v. doppler sonography and 3d ct angiography of acquired arteriovenous malformations: report of two cases. j clin diagn res. 2014 feb;8(2):187–9. 9. matthew rheinboldt, dan osborn, zach delproposto. cesarean section scar ectopic pregnancy: a clinical case series. j ultrasound. 2015 jun;18(2):191–5. 10. o'brien p, neyastani a, buckley ar. uterine arteriovenous malformations: from diagnosis to treatment. j ultrasound med. 2006;25:1387–92. 11. ghai s, rajan dk, asch mr. efficacy of embolization in traumatic uterine vascular malformations. j vasc inter radiol. 2003;14:1401-8. 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2020;10(2):56–57 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com editorial microbiology laboratory: a backbone for covid management neena nagdeo1,* 1dept. of microbiology, n. k. p. salve institute of medical sciences & research centre and lata mangeshkar hospital, nagpur, maharashtra, india a r t i c l e i n f o article history: received 19-08-2020 accepted 21-08-2020 available online 26-08-2020 © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction over the past 2 decades, coronaviruses (covs) have been associated with significant disease outbreaks in east asia and the middle east. the severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers) began to emerge in 2002 and 2012, respectively. recently, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), causing coronavirus disease 2019 (covid-19), emerged in late 2019, and it has posed a global health threat, causing an ongoing pandemic in many countries and territories. 1 covs belong to the family coronaviridae (subfamily coronavirinae), the members of which infect a broad range of hosts. sars-cov-2 is considered one of the seven members of the cov family that infect humans, 2 leading to a pandemic. microbiology laboratories play a vital role in diagnosis of infectious diseases particularly viral diagnosis. in covid management there is a vibrant role of a microbiologist which starts with proper collection and transport of sample, followed by establishment of virology laboratory. in the laboratory it is the responsibility of a microbiologist to carry out the tests like pcr, rapid antigen test or antibody tests. rt pcr test requires skill, patience and dedication for which training in molecular technologies is required. rapid antigen testing is made available now which is used for * corresponding author. e-mail address: neenagdeo@yahoo.co.in (n. nagdeo). screening of large population for covid-19 and antibody tests for sero-surveillance of various groups. microbiology labs not only conduct different tests but they are also involved in development and production of new testswith high sensitivity and specificity. along with these, microbiologist has to look after the infection control practices in hospital, proper biomedical waste management, teaching and training of medical staff about covid diagnosis and prevention. microbiology lab becomes an important part or essential part of research related to covid diagnosis, management, prevention or vaccine development. to combat this covid pandemic indian council of medical research is helping all laboratories by formulating guidelines. every functional laboratory is following these guidelines and since the guidance evolves periodically, the latest revised version is followed. testing laboratories also ensure timely reporting to state health officials for rapid initiation of contact tracing and report is also uploaded on the online portal of icmr. funds are provided for research projects that have direct bearing on the applicability of their outcome for the benefit to the public. while dealing with covid-19, microbiology laboratories have to overcome many challenges and at times resource limitations. the labs require trained staff in molecular lab so all microbiologists along with the technicians have to undergo this training to work in virology labs. after setting up a lab there is a mandatory https://doi.org/10.18231/j.pjms.2020.015 2249-8176/© 2020 innovative publication, all rights reserved. 56 https://doi.org/10.18231/j.pjms.2020.015 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto:neenagdeo@yahoo.co.in https://doi.org/10.18231/j.pjms.2020.015 nagdeo / panacea journal of medical sciences 2020;10(2):56–57 57 requirement by icmr to have a nabl accreditation for private medical colleges and private labs to ensure quality and technical competence. this competence is not required from govt set up. the research funds are usually provided to the government labs leading private institutes to lag behind in research due to this discrimination. in spite of these challenges, microbiologists are ready to deal with covid converting every problem into an opportunity and helping the mankind in this pandemic. 2. conflict of interest none. references 1. rodriguez-morales aj, bonilla-aldana dk, balbin-ramon gj, rabaan aa, sah r, paniz-mondolfi a. history is repeating itself: probable zoonotic spillover as the cause of the 2019 novel coronavirus epidemic. infez med. 2020;28:3–5. 2. zhu n, zhang d, wang w, li x, yang b, song j. a novel coronavirus from patients with pneumonia in china. n engl j med. 2019;382:727– 33. author biography neena nagdeo professor cite this article: nagdeo n. microbiology laboratory: a backbone for covid management. panacea j med sci 2020;10(2):56-57. introduction conflict of interest case report http://doi.org/10.18231/j.pjms.2019.020 panacea journal of medical sciences, may-august, 2019;9(2):82-84 82 normal pressure hydrocephalus in a patient with alcohol dependence: a case report prajakta patkar1, ichpreet singh2, s mujawar3*, suprakash chaudhury4, daniel saldanha5 1-3senior resident, 4professor, 5professor and head, dept. of psychiatry, dr. d. y. patil medical college, hospital and research centre, dr d y patil university, pimpri, pune, maharashtra, india *corresponding author: s mujawar email: suprakashch@gmail.com abstract normal-pressure hydrocephalus (nph) is characterized by a classic triad of symptoms namely urinary incontinence, dementia, and gait disturbances. it may present initially with psychiatric symptoms like depression, perceptual disturbances, anxiety, etc. this case report describes a 58-year-old male patient with alcohol dependence who presented with complaints of urinary incontinence, forgetfulness, imbalance while walking and standing, fearfulness, hearing of unreal voices along with sleep appetite impairment since 3-4 months. he was consuming alcohol since the last 20 years. on examination, he was conscious, oriented to time and place. he had mild tremors. vitals were stable. mental status examination revealed patient was shabby, ill kempt, uncooperative, irritable, along with delusion of persecution and auditory hallucinations. insight about his illness was impaired. mmse score was 18. mri suggested a disproportionate dilatation of the ventricular system as compared to the basal cisterns, sylvian fissures and cortical sulci. careful examination of patients presenting with above symptoms is necessary for proper management of patients with nph. keywords: normal pressure hydrocephalus, psychosis, psychiatric symptoms, depression, perceptual disturbances, anxiety. introduction hakim and adams in 1965 first described normal-pressure hydrocephalus (nph).1 it is characterized by a classic triad of symptoms namely urinary incontinence, dementia, and gait disturbances. its incidence increases with advancing age, and most patients are above the age of 60. in patients less than 65 years of age the prevalence is found to be less than 1%, and up to 3% for patients who are 65 or older. no sex predilection was found.2-4 it is thus one of the few causes of reversible dementia, but it is still underdiagnosed.3,5 involvement of different areas of the brain especially prefrontal lobes have been shown by imaging and recently molecular studies, which may result in psychological symptoms like depression, perceptual disturbances, anxiety, etc.6-9 recent research involving nuclear imaging has shown poor perfusion of periventricular, prefrontal regions, and basal ganglia.10-12 in addition, brain functional imaging studies revealed involvement of orbito-frontal and anterior cingulate cortex in idiopathic normal-pressure hydrocephalus (inph).13-14 groenewald e et al reported a case of a 62-year-old man who came with a history of psychiatric symptoms since 2 months. the symptoms were preceded by cognitive dysfunctions, urinary incontinence and an abnormality of the gait. he was diagnosed with nph and improvement was seen in his symptoms after surgery was successfully carried out.15 yoshiyama and colleagues published a study in which they used a questionnaire to examine as to how the patients with inph were evaluated in medical centre for dementia (mcds) in japan. in this study more than 590 patients with inph underwent an mcd examination in a year. they found that 73 out of 87 mcds reported that inph patients should be examined by both dementia specialists and neurosurgeons after shunt surgery.16 the inphcrash study which included one hundred seventy-six nph patients and 368 controls found that the complaint of depression is as such overrepresented in nph patients compared with the general population, in spite of treatment with a shunt and concluded that screening for depression is necessary to evaluate nph patients so as to diagnose and treat any coexisting depression present in such patients.17 here, we present a case of nph who presented with alcohol dependence syndrome with psychiatric symptoms. case history a 58-year-old male, retired professional boxer, reported to psychiatry opd of a tertiary care hospital with his wife. he came with chief complaints of excessive alcohol use since the last 30 years. he also had complaints of urinary incontinence, forgetfulness, imbalance while walking and standing, fearfulness, hearing of unreal voices along with sleep appetite impairment since 3-4 months. patient was apparently alright 3-4 months ago when he started forgetting day to day things about his routine e.g. whether he had a bath, had food or read the newspaper etc. he would repeatedly ask for food and would find it difficult to remember the names of the family members staying at home. there were times when he would forget the way to his own home and had to be picked up or dropped home by someone. patient often would pass urine in his clothes without realizing and would sit in the soiled state until someone changed his clothing. however, there was no fecal incontinence. the family also observed that he had started to lose his balance while standing and walking and would often need support even to do his day to day activities. he constantly complained that he was scared that he would fall down as he could not stand or walk alone without help. of late the patient had started feeling fearful without any apparent reason and would at times even start crying that someone is trying to harm his life but couldn’t mention names and couldn’t be convinced to the contrary. he agreed to be hearing multiple voices of people who scared him prajakta patkar et al. normal pressure hydrocephalus in a patient with alcohol dependence: a case report panacea journal of medical sciences, may-august, 2019;9(2):82-84 83 saying that they will kill him. the voices were vivid and not will dependent, coming from outer objective space. patient was not able to maintain his own hygiene. relatives complained that he wasn’t sleeping very well since last 3-4 months and in fact had not slept at all since 10-12 days. his appetite was also grossly impaired to the extent that he wouldn’t even ask for it and had to be fed by someone. there was history of chronic alcohol use since last 30 years which was dependence pattern and eye opener was also present since last 2 years, although he was completely abstinent for the last month now. there was no history of seizures or major medical illness in the past. on examination, he was conscious, oriented to time and place. he had mild tremors. vitals were stable. cns examination showed no impairment in the sensory or motor systems. all the deep tendon reflexes were normal and both the planters were flexors. cardiovascular, respiratory and per abdominal examinations were normal. mental status examination revealed patient was shabby, ill kept, uncooperative, and in touch with reality. spoke in normal tone and speed, relevantly and coherently. affect was irritable along with delusion of persecution and auditory hallucinations. insight and judgment was impaired. mmse score was 18. mri was done which showed that there was disproportionate dilatation of the ventricular system as compared to the basal cisterns, sylvian fissures and cortical sulci. this suggested normal pressure hydrocephalus (fig. 1 and fig. 2). patient was admitted and started on tablet haloperidol 2.5mg hs. neurology opinion was taken and was transferred under their care. the patient was unfortunately lost to follow up. fig. 1: mri brain showing disproportionate dilatation of the ventricular system as compared to the basal cisterns, sylvian fissures and cortical sulci fig. 2: mri brain showing normal pressure hydrocephalus discussion nph which is a reversible cause of dementia is seen to present with or complicate psychiatric symptoms such as in the case reported above. prompt identification of such neurological disorders in patients presenting with behavioural symptoms plays a major role in key treatment decisions and prognosis of these patients.18 a study of 33 patients reported that the natural course of inph shows progress and deterioration with time leading to worsening in gait, balance and cognitive symptoms which may or may not be reversible. hence, for maximum benefits of shunt treatment, surgery should be performed as soon as possible to prevent further deterioration.19 a european multicentre study found that treatment of nph by diversion of csf to the peritoneal cavity or heart was effective in reversing symptoms in more than 80% of the patients.20 however, nph may be found to initially present with psychiatric symptoms and early surgical intervention for management of psychiatric symptoms is not considered in such cases.21-23 in another case report a patient with a diagnosis of schizophrenia preceding the diagnosis of nph had failed to respond to antipsychotic medication and after the surgical treatment of the nph the improvement of the psychotic symptoms was seen.24 allali g et al in a study of 33 nph patients found apathy is a good predictor of better outcomes of gait disorders in patients with nph after csf tapping was done in these patients.25 another study observed 5 patients who presented with cognitive decline, and gait disturbance, with or without incontinence for 2 years period. there were clinical or ct signs of raised intracranial pressure in 4 of the 5 patients. the underlying pathologies found in them included idiopathic meningeal fibrosis, periaqueductal glioma, meningeal lymphocytic lymphoma, basilar aneurysm and basilar invagination. all of them showed response to the insertion of a shunt. however, one patient with inph who was shunted during the same period, did not improve. they challenged the concept of normal pressure hydrocephalus as a cause of cognitive deterioration.26 hence, further research is needed in cases of prajakta patkar et al. normal pressure hydrocephalus in a patient with alcohol dependence: a case report panacea journal of medical sciences, may-august, 2019;9(2):82-84 84 nph presenting with psychiatric symptoms so that we can diagnose and treat them as early as possible which will lead to better outcomes and a better quality of life in these patients. conflict of interest none. references 1. adams rd, fisher cm, hakim s, ojemann rg, sweet wh. symptomatic occult hydrocephalus with normal cerebrospinalfluid pressure. new engl j med 1965;273(3):117–26. 2. younger ds. adult normal pressure hydrocephalus. in younger ds (ed.). motor disorders .2nd ed. philadelphia, pa: lippincott williams & wilkins. 2005. pp.581–84. 3. brean a, eide pk. prevalence of probable idiopathic normal pressure hydrocephalus in a norwegian population. acta neurol scand 2008;118(1):48–53. 4. tanaka n, yamaguchi s, ishikawa h, ishii h, meguro k. prevalence of possible idiopathic normal-pressure hydrocephalus in japan: the osaki-tajiri project. neuroepidemiol 2009;32(3):171–5. 5. brean a, fredo hl, sollid s, muller t, sundstrom t, eide pk. five-year incidence of surgery for idiopathic normal pressure hydrocephalus in norway. acta neurol scand 2009;120:314– 6. 6. mcmurtray am, chen ak, shapira js. variations in regional spect hypoperfusion and clinical features in frontotemporal dementia. neurol 2006;66:517–22. 7. antonucci as, gansler da, tan s. orbitofrontal correlates of aggression and impulsivity in psychiatric patients. psychiatry res 2006;147:213–20. 8. charney ds, deutch a. a functional neuroanatomy of anxiety and fear: implications for the pathophysiology and treatment of anxiety disorders. crit rev neurobiol 1996;10:419-46. 9. chatziioannidis s, charatsidou i, nikolaidis n. psychotic symptoms in normal pressure hydrocephalus. psychiatriki 2013;24(3):217-24. 10. momjian s, owler bk, czosnyka z. pattern of white matter regional cerebral blood flow and autoregulation in normal pressure hydrocephalus. brain 2004;127:965–72. 11. klinge pm, brooks dj, samii a. correlates of local cerebral blood flow (cbf) in normal pressure hydrocephalus patients before and after shunting –a retrospective analysis of [(15)o]h(2)o pet-cbf studies in 65 patients. clin neurol neurosurg 2008;110:369–75. 12. hains ab, arnsten aft. molecular mechanisms of stressinduced prefrontal cortical impairment: implications for mental illness. learning memory 2008;15:551-64. 13. murakami m, hirata y, kuratsu ji. predictive assessment of shunt effectiveness in patients with idiopathic normal pressure hydrocephalus by determining regional cerebral blood flow on 3d stereotactic surface projections. acta neurochirurgica 1997;149(10):991-7. 14. nakayama t, ouchi y, yoshikawa e. striatal d2 receptor availability after shunting in idiopathic normal pressure hydrocephalus. j nucl med 2007; 48:1981–6. 15. groenewald e, joska ja, rothemeyer s. normal-pressure hydrocephalus presenting with psychiatric symptoms. s afr med j 2016;106(2):62. 16. yoshiyama k, kazui h, takeda m. the current status of medical care for idiopathic normal-pressure hydrocephalus in medical centers for dementia in japan. brain nerve 2015;67(9):1139-45. 17. israelsson h, allard p, eklund a, malm j. symptoms of depression are common in patients with idiopathic normal pressure hydrocephalus: the inph-crash study. neurosurg 2016;78(2):161-8. 18. kahn da. commentary on cognitive and psychiatric symptoms associated with normal pressure hydrocephalus and frontotemporal dementia. j psychiatr pract 2013;19(6):505-7. 19. andrén k, wikkelsø c, tisell m, hellström p. natural course of idiopathic normal pressure hydrocephalus. j neurol neurosurg psychiatry 2014;85(7):806-10. 20. klinge p, hellstrom p, tans j, wikkelso c. one-year outcome in the european multicentre study on inph. acta neurol scand 2012;126:145–53. 21. yusim a, anbarasan d, bernstein c. normal pressure hydrocephalus presenting as othello syndrome: case presentation and review of the literature. am j psychiatry 2008;165:1119–25. 22. kito y, kazui h, kubo y. neuropsychiatric symptoms in patients with idiopathic normal pressure hydrocephalus. behav neurol 2009;21:165–74. 23. lying-tunell u. psychotic symptoms in normal-pressure hydrocephalus. acta psychiatr scand 1979;59(4):415-9. 24. schneider u, malmadier a, dengler r, sollmann wp, emrich hm. mood cycles associated with normal pressure hydrocephalus. am j psychiatry 1996;153(10):1366-7. 25. allali g, laidet m, armand s, saj a, krack p, assal f. apathy in idiopathic normal pressure hydrocephalus: a marker of reversible gait disorders. int j geriatr psychiatry 2018;33(5):735-42. 26. chambers br, hughes aj. dementia, gait disturbance, incontinence and hydrocephalus. clin exp neurol 1988;25:4351. julydecember 2012 pdf for website incidental finding of microfilaria in a case of lymphoma–leukaemia 1 2 2 3 gowardhan vidula , karmarkar pragati , wilkinson anne , maimoon sabiha abstract: filariasis is a common health problem in developing countries like india. microfilariae have been incidentally detected in fnac ((fine needle aspiration cytology) of various lesions in clinically unsuspected cases of filariasis with absence of microfilariae in the peripheral blood. we report a case where patient was asymptomatic for the filarial disease, which was incidentally detected on cytological smears. there are only a few reported cases in cytology literature documenting association of microfilaria with lymphoma. careful screening of fnac smears might be helpful in detecting microfilariae, even in asymptomatic patients, especially in highly endemic areas. introduction: filariasis is a common health problem in developing countries like india. wucheria bancrofti is responsible for 90% cases of filariasis (1). it causes disease by blocking lymphatic vessels. the diagnosis is conventionally made by demonstrating microfilariae in peripheral blood smear. however, microfilariae have been incidentally detected in fnac (fine needle aspiration) of various lesions in clinically unsuspected cases of filariasis with absence of microfilariae in the peripheral blood. microfilaria have been detected by fnac (fine needle aspiration cytology) at different sites like breast, thyroid, lymph node, liver, lungs, bone marrow, body fluids and subcutaneous nodules (2). they have also been reported in association with various benign and malignant tumours although the role in tumerogenesis is controversial. there are only a few reported cases in cytology literature documenting association of microfilaria with lymphoma. case report: a 55-year-old female presented with abdominal lump and body ache. on examination, there was hepatosplenomegaly with axillary (0.5x0.5cm) and inguinal lymphadenopathy (2x2cm). fnac from right inguinal lymph node was done. cytological findings: the cytological findings were suggestive of nonhodgkin's lymphoma. microfilaria was also present. it was identified to be wucheria bancrofti by the presence of a hyaline sheath, granules extending from the head to tail and the tail tip free of nuclei (fig. 1 & 2). figure 1: fnac smear from left inguinal lymph node-microfilaria of wucheria bancrofti (tail tip free of nuclei) in a clear background (papanicolaou stain x1000) figure 2: fnac smear from left inguinal lymph node. a microfilaria surrounded by neoplastic lymphoid cells. (papanicolaou stain x1000) 39 1 2 assistant professor, associate 3 professor, additional professor department of pathology, nkpsims & rc, digdoh hills, hingna road, nagpur -440019. v_gowardhan@rediffmail.com pjmsvolume 2 number 2: julydecember 2012 case report peripheral smear findings: haematological features were suggestive of chronic lymphoid leukaemia. there was no eosinophilia. microfilaria was not seen in peripheral smear. discussion: filariasis presents with a wide spectrum of clinical manifestations, however a significant number of infected individuals in endemic areas remains asymptomatic throughout their life (3). they are an important source of infection in the community. thus the disease and infection do not necessarily accompany each other (4). fnac is valuable in detection of asymptomatic and clinically unsuspected cases of filariasis, though microfilaria in cytological smears is considered as incidental findings (5). in the study done by walter a et al (6), the initial diagnosis was made from the cytological smear in all 35 cases; none had clinical filariasis. microfilariae have been reported in association with neoplastic lesions such as squamous cell carcinoma of maxillary antrum, ewing's sarcoma of bone, transitional cell carcinoma of bladder, non-hodgkin's lymphoma, and meningioma (7). in our case, microfilaria was incidentally found associated with leukemia – lymphoma. the fna smears revealed sheathed microfilaria, wucheria bancrofti was confirmed by both cephalic end and tail tip free of nuclei (8). an association of microfilariae with non-hodgkin's lymphoma is known, as observed in our case. the patient was asymptomatic for the filarial disease, which was incidentally detected on cytological smears. the presence of microfilaria in association with tumors of lymph nodes and lymphatics can be explained as they are the normal habitation for the filarial organism (9). various authors have expressed the opinion that because these parasites circulate in the vascular and lymphatic systems, their appearance in tissue fluids and exfoliated surface material would possibly occur under conditions of obstruction by scars or tumors and damage due to inflammation, trauma or stasis. in tumors, the rich blood supply could possibly encourage the concentration of parasite at that site (10). their presence can also be explained by the fact that larvae may be present in the vasculature and aspiration may lead to the rupture of vessels resulting in hemorrhage and release of microfilariae (7). conclusion: although microfilariae in cytological material are considered incidental findings, this cases illustrate the value of routine fine needle aspiration cytology in the detection of asymptomatic and clinically unsuspected cases of bancroftian filariasis. absence of microfilariae in the peripheral blood does not exclude filarial infection. careful screening of fnac smears might be helpful in detecting microfilariae, even in asymptomatic patients, especially in highly endemic areas. references: 1. varghese r, raghuveer c, pai mr, bansal r. microfilariae in cytologic smears: a report of six cases. acta cytol 1996; 40 (2):299-301. 2. valand ag, pandya bs, patil yv, patel lg. subcutaneous filariasis: an unusual case report. indian j dermatol 2007; 52: 48-9. 3. jha a, shrestha r, ayal g, pant ad, adhikari rc, sayami g. cytological diagnosis of bancroftian filariasis in lesions clinically anticipated as neoplastic. nepal med coll j 2008; 10 (2): 108-114. 4. pahua r, arora vm. microfilaria in cytology smears from upper arm swelling. j cytol 2010; 27(4): 155. 5. sivakumar s. role of fine needle aspiration cytology in detection of microfilariae; report of 2 cases. acta cytol 2007 sept-oct; 51(5): 803-6. 6. walter a, krisnaswami h, cariappa a. microfilariae of wucheria bancrofti in cytologic smears. acta cytol 1983 julaug; 27 (4): 432-6. 7. gupta s, sodhani p, jain s, kumar n. microfilariae in association with neoplastic lesions: report of five cases. cytopathology 2001; 12: 120-126. 8. gutierrez y. filariae of lymphatics. diagnostic pathology of parasitic infections with clinical correlation 1990; 284-285. 9. agrawal pk, shrivastava an, agrawal n. microfilaria in association with neoplasms. a report of six cases. acta cytol 1982; 26: 480-90. 10. sinha bk, prabhakar pc, kumar a, salhotra m. microfilaria in a fine needle aspirate of breast carcinoma: an unusual presentation. j cytol 2008; 25:117-8. 40 pjmsvolume 2 number 2: julydecember 2012 case report page 43 page 44 429 too many requests you have sent too many requests in a given amount of time. title: original research article doi: 10.18231/2348-7682.2017.0023 panacea journal of medical sciences, may-august,2017;7(2): 83-88 83 the attitudes and practices of faculties towards research sanjay mehta1,*, dimple mehta2, kunjan kikani3 1professor & hod, 3professor, dept. of microbiology, 2professor & hod, dept. of pharmacology, c. u. shah medical college and hospital, surendranagar, gujarat. *corresponding author: email: sanjayjm@gmail.com abstract the present study was conducted on faculties from a medical college setup to evaluate their attitudes and practices towards research. the study tries to measure the research utilization and outputs of faculties by analysis of research presentations and publications. a forty point questionnaire was prepared for evaluation and assessment of attitudes and practices towards research amongst the faculties. randomly, 50 members of the faculties were selected for the project study. out of total 50 faculty members 49 (98%) were interested in research, 37 (74%) had conducted research in the past, 21 (42%) had published the research work which they had carried out in the past. at the time of study 18 (36%) faculty members were engaged in research work, out of whom 12 (24%) were engaged in research as a part of their further study while only 6 (12%) were doing the research for the purpose of research. all 50 faculty members felt that research needed improvement. the attitude towards the research is quite healthy as compared to actual practice. there is a lack of utilization of research related infra-structure and facilities. there is less than desirable research output in the form of poster / paper presentation in academic meets and research publications in the journals by medical faculties in teaching institution. keywords: research, attitudes, practices, medical faculties. introduction research in a common parlance refers to “a search for knowledge” and may be defined as “a systematized effort to gain new knowledge.(1) research comprises of creative work undertaken on systematic basis in order to increase the stock of knowledge and use of this knowledge to device new applications. thus health research is the systematic generation of new knowledge in the field of medical, natural, social, economic, and behavioral sciences and its use to improve the health of individual or groups. according to global forum for health research, health research does not end till the people’s health is improved in a measurable way.(2) the clinical researchers have been classified as “endangered species” by many authors (3) who have tried to analyze the trend of decreasing interest towards health research. this trend of waxing and waning interest towards updating knowledge and undertaking clinical research is quite apparent and dangerously true amongst the faculties of medical institutions in india and other asian countries.(4,5) health research is essential for improvement of health care.(2) unfortunately, health research has a low priority in the developing world. in all disciplines of science and technology, india has 137 researchers per million citizens,(6) as compared to 4,663 researchers per million citizens in the united states.(7) the published research output from south asia is small south asian health researchers accounted for only 1.2% of all papers within the ‘institute for scientific information’ database from 1992–2001.(8) developing countries must therefore enhance their research capacity to efficiently address the growing burden of both communicable and non-communicable diseases.(9) the rapidly evolving medical science of today necessitates that the medical students, pg trainees and faculties keep abreast with the latest developments. this requires the understanding and use of scientific principles and methods. research activity of pg trainees and faculties is important as it promises better clinical care, critical reasoning, lifelong learning and future research activity.(10,11) with rising health costs, local literature is important for facilitating evidence based and cost-effective decisions and thereby improving clinical practice. the utilization and production of research along with human and institutional development are two important components of health research.(12) before trying to find remedial measures, it is important to identify the “etiological” factors responsible for this “malice” so that those factors can be analyzed and “preventive and therapeutic” measures can be initiated. the present study was conducted on faculties from a medical college setup to evaluate their attitudes and practices towards research. the study tries to measure the research utilization and outputs of faculties by analysis of research presentations and publications. materials and method the study was conducted at c. u. shah medical college and hospital, surendranagar (india) in september-october, 2007. a forty point questionnaire was prepared for evaluation and assessment of attitudes and practices towards research amongst the faculties. total of 50 teaching staff members participated and answered a voluntary and confidential proforma of the project study. details of the qualitative and quantitative responses were noted down in proforma, analysis of sanjay mehta et al. the attitudes and practices of faculties towards research panacea journal of medical sciences, may-august,2017;7(2): 83-88 84 various parameters by standard statistical methods(1) was done and the results discussed. the possible remedial measures especially from the stand point of the management / authorities are suggested. results the major findings of the study are presented in the following tables 1 to 5. table 1: characteristics of study population sex-wise distribution male female total 33 (66%) 17 (34%) 50 (100%) age-wise distribution 21-40 years 41-60 years > 60 years total 33 (66%) 8 (16%) 9 (18%) 50 (100%) table 2: attitude towards research of study population interest shown in research by the faculties highly interested interested not interested total faculties 23 (46%) 26 (52%) 1 (2%) 50 (100%) qualification-wise distribution mbbs / diploma 4 (8%) 3 (6%) 1 (2%) 8 (16%) md / ms 13 (26%) 13 (26%) 0 (0%) 26 (52%) m.sc. 6 (12%) 10 (20%) 0 (0%) 16 (32%) [x2 = 26.65, degree of freedom = 8, p <0.001. the result is significant](2) designation-wise distribution resident / tutor 6 (12%) 3 (6%) 1 (2%) 10 (20%) asst. professor 11 (22%) 11 (22%) 0 (0%) 22 (44%) asso. professor 5 (10%) 2 (4%) 0 (0%) 7 (14%) professor 1 (2%) 10 (20%) 0 (0%) 11 (22%) [x2 = 13.63, degree of freedom = 6, p <0.05. the result is significant](2) response to question “is research waste of time & money?” no don’t know yes total 50 (100%) 0 (0%) 0 (0%) 50 (100%) response to question “is research beneficial?” yes no total 50 (100%) 0 (0%) 50 (100%) response to question “is there a need to promote the research?” yes no total 50 (100%) 0 (0%) 50 (100%) table 3: preparation for research by study population conferences attended by faculties. [50 participants] state level national international average 293 160 30 9.66 / faculty workshops attended by faculties. [50 participants] state level national international average 134 93 8 4.7 / faculty utilization of library by faculties daily weekly monthly total 13 (26%) 28 (56%) 9 (18%) 50 (100%) main aim of library visits of faculties. [50 participants] knowledge teaching research 44 (88%) 29 (58%) 24 (48%) reading habits of faculties sanjay mehta et al. the attitudes and practices of faculties towards research panacea journal of medical sciences, may-august,2017;7(2): 83-88 85 always sometimes never total research articles 26 (52%) 24 (48%) 0 (0%) 50 (100%) reference book 36 (72%) 14 (28%) 0 (0%) 50 (100%) internet usage for research by faculties regular sometimes never total 20 (40%) 0 (0%) 30 (60%) 50 (100%) table 4: practice of research by study population research conducted in the past by faculties. yes no total 37 (74%) 13 (26%) 50 (100%) presentation of research in conference (poster) by faculties state level national international average 28 46 1 2 / faculty presentation of research in conference (paper) by faculties state level national international average 44 31 4 2.1 / faculty publication of research in journal by faculties published not published total 21 (57%) 16 (43%) 37 (100%) number of publication by faculties state level national international average total 57 65 18 6.6 / faculty last 3 years 20 9 1 1.4 / faculty current research scenario; research work undertaken by faculties engaged not engaged total 18 (36%) 32 (64%) 50 (100%) table 5: obstacles or motives for not doing or doing research reason for not conducting research at present by faculties: total faculties 32 (100%) lack of resources 15 (47%) lack of time 14 (44%) lack of research materials 12 (38%) lack of research facilities 12 (38%) lack of research training 10 (31%) lack of educational materials 3 (9%) other 4 (13%) main aim of involvement in current research by faculties: total faculties 18 (100%) additional qualification & promotion 12 (67%) purely research 6 (33%) obstacles faced during current research work by faculties: total faculties 18 (100%) internet facility 10 (56%) journals 9 (50%) reference materials 8 (44%) resources / funds 8 (44%) laboratory facilities 7 (39%) time 4 (22%) hospital records 2 (11%) procedural delay 2 (11%) departmental co-operation 1 (6%) discussion the dwindling interest in research has been a point of concern especially in the field of health research in academic medical institutions. the characteristics of the study population (table 1) showed variety of features, wherein the dominant age/sex group is males of 31-40 years of age. the major portion of study population is married and majority having children and staying in campus. the qualifications varied from fresh undergraduates to experienced post graduates including veteran faculties. residents to emeritus professors from pre-clinical, para-clinical and clinical departments were included in the study. the features observed may be comparable to those of other teaching medical institutions. the questionnaire was framed to identify the attitude of the faculty members towards the health research, their participation in scientific and academic events and to measure the research utilization and output. an attempt was also made to elicit the reasons for interest/apathy towards research and also to identify the constraints and restraints along with the bottlenecks sanjay mehta et al. the attitudes and practices of faculties towards research panacea journal of medical sciences, may-august,2017;7(2): 83-88 86 and lacunae in the setup. the questionnaire was pretested. all faculty members except one expressed interest in research (table 2). high interest in research was expressed by 23 (46%) faculty members. the degree of interest was associated with different variables like age, sex, marital status, children, residential status, qualifications, designation, specialty, and experience. it was noted that there was significant association of qualification and designation with interest in research. the fresh postgraduate trainees expressed high interest towards research in comparison to senior postgraduates. the reason could be that the attainment of postgraduate degree may have resulted in complacency along with the fact that there were no other incentives provided to sustain the interest in research. higher interest was noted among residents, assistant professors and associate professors in comparison to professors. again, absence of additional benefits after reaching the top level of employment may be responsible for this observation. other variables of study population like age, sex, marital status, children, residential status, specialty and experience did not have any significant impact on the attitude of interest in research amongst the faculty. the study population unanimously agreed that research is not a waste of time and money. the faculty members had attended reasonable amount of scientific meets (table 3). on an average 9.66 conferences and 4.7 workshops were attended by faculty members till then though active participation was relatively less in form of presentations and publications. majority of faculty members (56%) utilized library services on weekly basis, while 9 (18%) visited library monthly, and 13 (26%) visited regularly. the main aim of the library visit was to strengthen knowledge and refer the reference books more in comparison to find research materials. internet usage for academic and research activity was very less, as 30 (60%) faculty members had never used internet services for the research purpose. out of 50 faculty members, 37 (74%) had conducted research in past (table 4). many of them had presented their research in conferences either as paper or poster with an average of 4.1 (2 + 2.1) presentations per faculty. out of 37 faculties who had conducted research in the past, 21 (57%) had published their research work in a journal with an average of 6.6 publications per faculty. the recent publications (<3 years) was low with just 1.4 publication per faculty. out of 37 faculty member 16 (43%) had never published their research works. the principle reason for not conducting the research and publishing the research was lack of information about research and publication, lack of training and time constraints. the common motives for conducting the research were additional qualification, knowledge and self recognition. the current scenario of research left much to be desired as out of 50 faculty members only 18 (36%) were engaged in research while 32 (64%) faculty members did not have any research work on hand. the main reasons cited for not undertaking research were lack of resources, time, research materials, facilities and training. out of 18 faculty members engaged in research, 12 (24%) were doing research as a part of their higher studies for improvement of qualification and only 6 (12%) faculty members were involved in a research for the purpose of a research. the major difficulties researchers faced during the research period were lack / inadequacy / access to internet facility, journals, reference materials, and resources, laboratory facilities, and hospital records. time constraints, procedural delay and departmental co-operation also played an important role (table 5). the current study tends to bring out the wide gap (fig. 1) between the attitude and practices as most 49 (98%) faculty members expressed their interest in research and had a view that the research is beneficial, 37 (74%) faculty members carried out research in the past, 21 (42%) of them had published their research, 18 (36%) faculty members were engaged in research work, out of whom only 6 faculty members (12%) were carrying out research for the purpose of research while everybody unanimously vows that research needs to be promoted in institution. sanjay mehta et al. the attitudes and practices of faculties towards research panacea journal of medical sciences, may-august,2017;7(2): 83-88 87 fig. 1: research attitudes & practices hence the need to bridge this gap to improve the quality and practices of research in medical institutions is obvious and necessary steps like research policy and procedures, incentives, encouragement of active participation in academic meets, providing adequate research facilities, enrichment of library with latest journals and library books as well as access to highspeed internet connectivity must be initiated at institutional level. research training program for m.b.b.s. students and postgraduate students may be very useful as it can increase the research awareness and promote the research activity in institution.(13-15) conclusion the attitude towards the research is quite healthy as compared to actual practice. there is a lack of utilization of research related infra-structure and facilities. there is less than desirable research output in the form of poster/ paper presentation in academic meets and research publications in the journals by medical faculties in teaching institution. research needs to be improved by means of strengthening the research related infrastructure and research training of faculties. research training program for undergraduate and postgraduate students may increase the research awareness and may promote the research activity in institutions. references 1. kothari cr. research methodology: methods and techniques. 1st ed. delhi: wiley eastern limited; 1987. 2. currat lj, francisco a, al-tuwaijri s, ghaffar a, jupp s. the 10/90 report on health research 2003–2004. geneva: global forum for health research. 2004 [cited 2009 october 12]. 3. available from: http://announcementsfiles.cohred.org/gfhr_pub/assoc/s14 789e/s14789e.pdf. 4. phillipson ea. is it the clinical-scientist or clinical research that is the endangered species? clin invest med. 2001;25(1/2):23-5. 5. aslam, f, qayyum, ma, mahmud h, qasim r, haque iu. attitudes and practices of postgraduate medical trainees towards research a snapshot from faisalabad. j pak med assoc. 2004;54(10):534-6. 6. khan h, khwaja mr, waheed a, rauf ma, fatmi z. knowledge and attitudes about health research amongst a group of pakistani medical students. bmc med educ. 2006 [cited 2009 october 12]; 6(54). available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1635552 /pdf/1472-6920-6-54.pdf. 7. united nations educational, scientific and cultural organization institute for statistics. country profile: india. 2005 [cited 2009 october 12]. available from: http://stats.uis.unesco.org/unesco/tableviewer/document. aspx?reportid=124&if_language=eng&br_country=3 560&br_region=40535. 8. united nations educational, scientific and cultural organization institute for statistics. country profile: united states. 2005 [cited 2009 october 12]. available from: http://stats.uis.unesco.org/unesco/tableviewer/document. aspx?reportid=124&if_language=eng&br_country=8 400&br_region=40500. 9. 8tutarel, o. geographic distribution of publications in the field of medical education. bmc medical education. 2003; 2(3). 10. buddha b, lalini cr. cardiovascular and infectious diseases in south asia. the double whammy. bmj. 2004 [cited 2009 october 12]; 328(781). available from: http://pubmedcentralcanada.ca/ptpicrender.fcgi?aid=4245 12&blobtype=html&lang=en-ca 11. aslam f, shakir m, qayyum ma. why medical students are crucial to the future of research in south asia. plos medicine. 2005 [cited 2009 october 12]; 2(11). available from: http://journals.plos.org/plosmedicine/article?id=10.1371/j ournal.pmed.0020322. 12. hebert rs, levine rb, smith cg, wright sm. a systemic review of resident research curricula. aced med. 2003;78(1):61-8. 13. sadana r, d’souza c, hyder aa, mushtaque a, chowdhury r. importance of health research in south asia. bmj. 2004;328:826–30. 14. mokry j, mokra d. opinions of medical students on the pre-graduate scientific activities – how to improve the 0 5 10 15 20 25 30 35 40 45 50 total faculties conducted research currently engaged in research feels research needs to be promoted 50 49 37 21 18 6 50 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22aslam%20f%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22qayyum%20ma%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22mahmud%20h%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22qasim%20r%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22haque%20iu%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22haque%20iu%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22levine%20rb%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22smith%20cg%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22wright%20sm%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus sanjay mehta et al. the attitudes and practices of faculties towards research panacea journal of medical sciences, may-august,2017;7(2): 83-88 88 situation? biomed pap med fac univ palacky olomouc czech repub. 2007;151(1):147-9. 15. segal s, lloyd t, houts ps, stillman pl, jungas rl, greer rb. the association between student’s research involvement in medical school and their postgraduate medical activities. acad med. 1990;65(8):530-3. 16. lloyd t, phillips br, aber rc. factors that influence doctors’ participation in clinical research. medical education. 2004;38:848-51. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22lloyd%20t%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22houts%20ps%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22stillman%20pl%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22jungas%20rl%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22greer%20rb%203rd%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus original research article doi: 10.18231/2348-7682.2018.0008 panacea journal of medical sciences, january-april 2018;8(1):34-39 34 pattern of ocular morbidity amongst patients of elderly age group in central india priti singh1,*, rahul agarwal2 1assistant professor, 2professor and head, dept. of opthalmology, 1gandhi medical college, bhopal, 2ln medical college, bhopal, madhya pradesh, india *corresponding author: email: singh_priti2178@yahoo.com abstract elderly population in india is rapidly on an increase due to increased life expectancy. visual status is one of the most important health quality indicators for the elderly who are highly prone to develop various eye diseases which form a major health problem to them. so we have tried to study the pattern of ocular morbidity in this age group, to understand the risk factors responsible for blindness in the elderly so that we can focus on the preventive measures that we can adopt to avoid this. in our hospital bassed cross sectional study 500 patients above 50 years of age were taken. detailed history based on pre-prepaired questionare was taken followed by complete ocular examination and relevant investigations to diagnose the ocular disease in these elderly people. we found that refractive errors followed by cataract were found to be the most common ocular problems in our sample population. various risk factors like age, gender, residence, educational status, socio-economic status, hypertension, diabetes, cooking fuel used, smoking, alcoholism, and tobacco consumption were tabulated and there significance in causing ocular morbidity and blindness was studied. finally we concluded that there is a high incidence of ocular morbidity in old age individuals most of the causes being either treatable or preventable. therefore the focus should be on providing affordable quality eye care services at both the urban and rural areas so that we can prevent ocular morbity and blindness in these elderly individuals specially those with low educational and socioeconomic status. keywords: cataract, glaucoma, dry eye, retinopathy, refractive errors. introduction by 2025, the population of elderly is expected to be about 840 million in low income countries.1 in india, 10.4% of the total population will be 60 years or older by 2020.2 with rapid increase in elderly population, emphasis should be laid on their better quality of life comprising physical, social and economic well being. the visual status is one of the major factors determining the quality of life.1 in 2010 anestimated 285 million people worldwide were visually disabled, about nearly 90% of them living in developing countries.1 according to a fact about 80% of the blindness is avoidable and about 65% of all people who are visually impaired are aged >50 years.1 these facts and figures signify that in a developing country, like india, little concern is given to the geriatric health problems and limited information is available about the pattern of ocular morbidity in elderly population.3 this provides a rationale to conduct our study as it will provide knowledge about prevalence of different ocular morbidities and its associated risk factors in geriatric population so that a large number of elderly population can be prevented and treated for the prevailing ocular morbidities which is also included under ‘vision 2020: the right to sight’1 programme. the formulation of any effective intervention health programme begins with the knowledge of the magnitude of the problem in a given community. although costly and time consuming the actual assessment of a health problem is far less expensive than the intervention itself and may suggest where and how prevention activities can best be implemented. the study was designed to diagnose elderly patients with ocular diseases by thorough history taking, examination and relevant investigations which was thenanalysed to know about the prevalence of ocular diseases. the study was significant as large and random population of both rural and urban area could be screened for the different ocular morbidites in a cost effective way. the present studyassisted to know the prevalenceof different ocular morbidities and identify their associated risk factors that may help to formulate measures to eliminate avoidable blindness and compare our results with some previous studies;enabling us to tackle it more effectively. aims and objectives 1. to determine the prevalence of the different types of ocular morbidities in elderly. 2. to study about the risk factors associated with ocular morbidity and prevention of blindness in elderly. materials and methods a hospital based cross-sectional study was carried out at ophthalmology opd of a hospital. the sample population included patients of >50 years of age who visited the eye o.p.d in between working hours. the sample size of the population was 500. exclusion criteria: the patients < 50 years of age, the patients who did not give consent, and patients of dementia and mental derangements in whom the history was unreliable were excluded from the study. priti singh et al. pattern of ocular morbidity amongst patients of elderly age group in central india panacea journal of medical sciences, january-april 2018;8(1):34-39 35 inclusion criteria: patients >50 years of age who visited the opd and gave consent were included in the study. an informed consent was obtained from the patient on a consent form before proceeding further. ethical approval regarding the study was obtained from the relevant authority. a thorough history taking procedure to know the chief complaints was carriedout with special emphasis on the associated factors. a predesigned questionnaire was asked to the patient (to know about the associated factors of ocular morbidities); as given in the case record form attached.the questions were asked in a manner that the patient understood. the socio-economic status of the patient was ascertained by kuppuswamy scale1 for urban population and prasad’s scale4 for rural population. the patients for diabetes wereinvestigated by blood sugar estimation and for hypertension, blood pressure was recorded and diagnosed by comparing with standard results.5 after history taking, external ocular examination was done with the help of torch light and loupe.6 the visual acuity with and without pin hole was taken with the help of snellen’s chart for literate andlandolt’sc-chart for illiterate patients.6 retinoscopy6 and/or autorefractometry6 were done to find out the refractive error. a visual acuity of <6/9 was considered as a visual impairment. a detailed examination of conjunctiva, sclera, cornea, iris, pupil, anterior chamber, lens, posterior chamber and posterior segment was carried out to find out any abnormality.6 instruments used-measurement of intra ocular pressure by tonometry, examination of lacrimal apparatus by syringing, schirmer’sstrip and fundus examination by ophthalmoscope and slit lamp was done as required.6 based on the clinical features, examinations and investigations diagnosis was confirmed for the type of ocular morbidity present.6 the data was then organised, examined and analysed to calculate the prevalence of different ocular diseases by the standard formula and methods.1 the correlation of the different factors associated with the prevalent ocular morbidities was determined and test of significance such as chi square test, chi square test with yates’ correction and fisher exact test were applied to find out any statistical significance was present or not. results the prevalence of different ocular morbidities in the 500 patients that we examined is shown in fig. 1. fig. 1: prevalence of different ocular morbidities in >50 year patients apart from the above; less than 5 cases of the following diseases were also observed: blepharitis, colour blindness, exophthalmos, ocular allergy, strabismus and stye. in the present study many patients were having >1 ocular morbidity, either in the same eye or in the opposite eye. all the multiple ocular diseases found in the same patient were taken as separate diseases. maximum patients were found in age group 51-60 years (n= 220), out of which 91(41.36%) had refractive errors. no statistically significant findings seen agewise (p value > 0.05). total 265 males and 235 females were examined. the difference in occurrence of refractive error and cataract between males and females is statistically significant (p value <0.05). in remaining ocular morbidities, no gender wise difference was seen. table 1: distribution of ocular morbidities on the basis of residence ocular morbidty rural patients (n=218) urban patients (n=282) p value refractive errors 83(38.07%) 130(44.5%) 0.0719 cataract 80(36.6%) 107(37.9%) 0.7752 dry eye 30(13.7%) 12(4.1%) 0.0001 retinopathies 8(3.67%) 15(5.32%) 0.3826 glaucoma 8(3.6%) 9(3.08%) 0.7698 pterygium 5(2.29%) 9(3.08%) 0.5462 dacryocystitis 4(1.83%) 6(2.13%) 0.8166* macular diseases 5(2.29%) 5(1.77%) 0.6801 entropion/ectropi on 3(1.38%) 6(2.13%) 0.7736* corneal opacity 4(1.83%) 5(1.77%) 0.9589* priti singh et al. pattern of ocular morbidity amongst patients of elderly age group in central india panacea journal of medical sciences, january-april 2018;8(1):34-39 36 the difference in occurrence of dry eye between urban and rural patients is statistically highly significant (p value<0.01) (table 1). table 2: distribution of ocular morbidities on basis of educational status ocular morbidity illiterate (n=140) primary (n=102) middle (n=110) high (n=63) graduate &> (n=85) p value r.errors 44(31.4%) 44(43.14%) 54(59%) 31(49.2%) 40(47.06%) 0.028 cataract 66(47.1%) 42(41.18%) 40(36.3%) 15(23.8%) 24(28.24%) 0.006 dry eye 26(18.5%) 10(9.8%) 4(3.64%) 1(1.59%) 1(1.18%) <0.001 retinopathyes 3(2.14%) 4(3.92%) 5(4.55%) 7(11.12%) 4(4.71%) 0.1* glaucoma 4(2.86%) 3(2.94%) 2(1.82%) 2(3.17%) 6(7.06%) 0.5674* pterygium 5(3.57%) 3(2.94%) 4(3.6%) _ 2(2.35%) 0.834* dacryocystits 3(2.14%) 2(1.96%) 3(2.73%) 1(1.59%) 1(1.18%) 0.99* macular diseases 1(0.71%) _ 1(0.91%) 4(6.35%) 4(4.71%) 0.037* entopion/ ectropion 2(1.43%) 2(1.96%) 3(2.73%) 2(3.17%) _ 0.975* corneal opacity 3(2.14%) 3(2.94%) 1(0.91%) _ 2(2.35%) 0.945* the difference in occurrence of refractive error and macular diseases between educational statuses of the patient is statistically significant (p value<0.05) (table 2). the difference in occurrence of cataract and dry eyes between educational statuses of the patientis is also statistically significant (p value<0.01). table 3: distribution of ocular morbidities on basis of socioeconomic statuses ocular morbidity upper (n=2) upper middle (n=130) lower middle (n=140) upper lower(95) lower (133) p value r.errors 1(50%) 70(53.85%) 71(50.7%) 26(27.36%) 45(33.83%) <0.0001 cataract _ 47(36.15%) 50(35.7%) 38(40%) 52(39.09%) 0.8520 dry eye _ 1(0.77%) 4(2.8%) 10(10.5%) 27(20.3%) <0.0001# retinopathies 1(50%) 4(3.08%) 10(7.1%) 3(3.1%) 5(3.7%) 0.399* glaucoma _ 2(1.53%) 6(4.2%) 3(3.1%) 6(4.5%) 0.516 pterygium _ 2(1.5%) 6(4.2%) 3(3.1%) 3(2.2%) 0.782* dacryocystits _ 1(0.77%) 1(0.71%) 6(6.32%) 2(1.51%) 0.0442*# macular diseases _ 5(3.85%) 1(0.71%) 3(3.1%) 1(0.75%) 0.446* entopion/ ectropion _ 3(2.31%) 1(0.71%) 4(4.21%) 1(0.75%) 0.444* corneal opacity _ 2(1.5%) _ 4(4.21%) 3(2.2%) 0.985* kuppuswamy scale1 was used for urban population and prasad’s scale8 was used for rural population. the difference in occurrence of dacryocystitis between socioeconomic statuses of the patient is statistically significant. (p value<0.05) the difference in occurrence of refractive errors and dry eyes between socioeconomic statuses of the patient is statistically highly significant. (p value<0.01) (table 3). table 4: distribution of ocular morbidities in hypertensives and diabetics patients ocular morbidity hypertensives (n=135) non-hypertensives (n=365) p value diabetics (n=62) non-diabetics (n=438) p value r.errors 50(37.03%) 163 0.1261 19(30.6%) 194 0.042 cataract 58(42.9%) 129 0.1179 25(40.3%) 162 0.6114 dry eye 6(4.4%) 36 0.0525 8(12.95%) 34 0.1720 retinopathies 12(8.8%) 11 0.0054 9(14.5%) 14 0.0001 glaucoma 8(5.9%) 9 0.0580 4(6.5%) 13 0.2973* pterygium 2(1.5%) 12 0.4629* 2(3.2%) 12 >0.05* dacryocystits _ 10 2(3.2%) 8 >0.05* priti singh et al. pattern of ocular morbidity amongst patients of elderly age group in central india panacea journal of medical sciences, january-april 2018;8(1):34-39 37 macular diseases 3(2.3%) 7 >0.05* 1(1.6%) 9 >0.05* entopion/ectr opion 1(0.7%) 8 >0.05* _ _ _ corneal opacity 1(0.7%) 8 >0.05* 1(1.6%) 8 >0.05* the difference in occurrence of retinopathies between hypertensives and non-hypertensives isstatistically highly significant (p value<0.01). the difference in occurrence of retinopathies between diabetics and non-diabetics is statistically highly significant (p value<0.01). the difference in occurrence of refractive errors between diabetics and non-diabetics is statistically significant (p value<0.05) (table 4). table 5: distribution of ocular morbidities among smokers and non-smokers with tobacco consumption ocular morbidity smokers (n=112) nonsmokers (n=388) p value tobacco consumption (n=160) no tobacco consumption (n=340) p value r.errors 30(26.8%) 183 0.0001 51(31.9%) 162 0.0009 cataract 38(33.9%) 149 0.3887 40(25%) 147 0.0001 dry eye 6(5.3%) 36 0.1875 6(3.75%) 36 0.0101 retinopathies 6(5.3%) 17 0.6641 1(0.62%) 22 0.0073* glaucoma 2(1.8%) 15 0.4624* 5(3.125%) 12 0.8159 pterygium 1(0.9%) 13 >0.05* 2(1.25%) 12 >0.05* dacryocystits 1(0.9%) 9 >0.05* 2(1.25%) 8 >0.05* macular diseases 2(1.8%) 8 >0.05* 2(1.25%) 8 >0.05* entopion/ectropion 1(0.9%) 8 >0.05* _ _ _ corneal opacity 1(0.9%) 8 >0.05* 1(0.625%) 8 >0.05* the difference in occurrence of refractive errors between smokers and non-smokers is statistically highly significant (p value<0.001). the difference in occurrence of cataract between smokers and non-smokers is statistically significant (p value<0.05). the difference in occurrence of refractive errors, cataract, dry eye and retinopathies between tobacco consumers and non-consumers is statistically highly significant (p value<0.01) (table 5). table 6: distribution of ocular morbidities with cooking fuel use ocular morbidity gas cylinder/ stove users (n=455) smoky chulha users (n=45) p value r.errors 201(44.2%) 12(26.7%) 0.0235 cataract 166(36.5%) 21(46.7%) 0.1781 dry eye 38(8.3%) 4(8.8%) 0.9014* retinopathies 19(4.2%) 4(8.8%) 0.2861* glaucoma 13(2.9%) 4(8.8%) 0.0894* pterygium 12(2.6%) 2(4.4%) 0.8202* dacryocystits 9(1.9%) 1(2.2%) 0.9111* macular diseases 10(2.2%) _ 0.6106^ entopion/ ectropion 8(1.7%) 1(2.2%) 0.8233* corneal opacity 7(1.5%) 2(4.4%) 0.4174* the difference in occurrence of refractive errors between lpg users and biomass fuel users is statisticallysignificant (p value<0.05) (table 6). discussion the present study was undertaken in the light of the available literature to determine the prevalence of the different types of ocular morbidities and to study about the risk factors associated with ocular morbidity priti singh et al. pattern of ocular morbidity amongst patients of elderly age group in central india panacea journal of medical sciences, january-april 2018;8(1):34-39 38 and prevention of blindness in 500 patients of > 50 years of age. in the present study, the most prevalent ocular morbidities included refractive errors myopia, hypermetropia, astigmatism, aphakia, pseudophakia, and anisometropia. the prevalence was 42.6% that is lesser than found by agrawal d et al7 in study carried out in an urban population, which might be due to the fact that only patients >50 years were considered in the present study. refractive errors were most prevalent in the study done by shrote vk et al8 in the rural area of central india singh mm et al,3 rizyal a et al,9 ukponmwan cu10 but the prevalence was lower as it was carried out in all the age groups. the prevalence of refractive error was found lesser in the studies done by singh a et al,11 normalina m et al,12 khadse a et al,13 garg pet al,14 inaamul haq et al.15 the second most prevalent ocular morbidity was cataract. its prevalence rate was 37.4%. it is higher than the studies carried out in an urban population by agrawal d et al,7 shrote vk et al,8 rizyal a et al,9 ukponmwan cu,10 khadse a et al,13 inaamul haq et al,15 singh jp et al,16 in the aravind comprehensive eye survey,17 the prevalence of cataract in those aged 50 years and above was found to be 47.5%. the results in the blue mountain eye study18 conducted in nursing home residents also shows a higher prevalence of cataract. in the studies done by singh mm et al,3 normalina m et al,12 garg p et al,14 cataract was found to have a higher prevalence. cataract was found to be most prevalent ocular morbidity (41.89%) in a study done by singh a et al11 which might be due to the fact that it included only rural population. in the present study prevalence of dry eye was found to be 8.4%. a lower prevalence of 4% was found in the study done by rizyal a et al9 which might be due to the fact that only patients >50 yrs. were considered in the present study. howevere a higher prevalence was found by garg p et al14 and sahai a et al.19 in the present study prevalence of retinopathies that included diseases like retinal artery occlusion, retinal vein occlusion, diabetic retinopathy, hypertensive retinopathy; was found to be 4.6% slightly higher than found out by garg p et al.14 a study done by rizyal et al9 showed the prevalence of diabetic retinopathy to be 1% while that of ukponmwan cu,10 normalina m et al,12 and martinez gs et al20 showed 2.5%, 0.7%, 0.5% respectively. in the present study prevalence of glaucoma irrespective of its type was found to be 3.4%, similar to the results obtained in the studies done by garg p et al14 and martinez gs et al20 but is higher than the prevalence found by agrawal d et al,7 normalina m et al,12 khadse a et al13 and inaamul haq et al.15 the prevalence of glaucoma was also found to be higher in the studies done by ukponmwan cu10 and singh a et al.11 in the present study prevalence of pteygium was found to be 2.8% similar to that found by khadse a et al13 and is higher than the prevalence found by agrawal d et al7 in a study conducted in an urban population of meerut. a slight higher prevalence was found by ukponmwan cu.10 a study done by rizyal a et al9 showed the prevalence of both pterygium and pinguecula to be 10.8%. in the studies done by singh mm et al,3 normalina m et al12 and garg p et al14 pteygium was found to have a higher prevalence. in the present study prevalence of dacryocstitis was found to be 2% that is slightly higher than the prevalence found by agrawal d et al7 and hussain a et al21 in a study conducted in an urban population of meerut. the prevalence was lower than that found by garg p et al.14 we found that prevalence of macular diseases, which consisted primarily of age related macular degeneration (armd); cystoid macular edema (cme), traumatic macular edema and macular hole, was found to be 2%. a higher prevalence of maculopathies was found by ukponmwan cu10 with armd’s as 3%. studies done by singh mm et al,3 rizyal a et al,9 garg p et al,14 martinez gs et al20 showed the prevalence of armd to be 2%, 5.25%, 6.4%,6.89%, and 12.2% respectively. in a study done by normalina m et al12 none was found to have age related macular degeneration, however drusen were noted. in the present study prevalence of diseases of the eye lids that included entropion and ectropion was found to be 1.8% that is lower than the results found by, normalina m et al,12 garg p et al14 and some other studies. in the blue mountains eye study18 ectropion was found to be higher than the present study. the present study prevalence of the corneal opacity was found to be 1.8% that is higher than the prevalence found by agrawal d et al7 but lower than the prevalence found in the studies done by normalina m et al,12 garg p et al,14 inaamul haq et al.15 thus, the results of the present study correlates with the results found by many studies but also controvert with the results of other studies which may be due to the difference in the design of the present study as compared to other studies or may be significant. the present study was a hospital based cross sectional study that might have caused a higher prevalence of certain diseases. the smaller duration of the study, the seasonal and geographical impact might also have affected the disease prevalence. many other studies were conducted taking into account the younger as well as older population, while the present study was conducted only in patients of >50yrs; thus was more specific with diseases of elderly and resulted in non-significance of age related increase in prevalence of certain diseases such as cataract. the screening and diagnosing criteria’s might vary from some studies giving different outcome. however utmost care was taken during the whole studydiscrepancies in the results might have occurred due to some reasons. firstly, the effect of certain factors might have been priti singh et al. pattern of ocular morbidity amongst patients of elderly age group in central india panacea journal of medical sciences, january-april 2018;8(1):34-39 39 exaggerated or suppressed by other interactive susceptible factor, both genetic and environmental. secondly, a low no. of patients in several diseases might have led to the statistical insignificance with the associated factors. thirdly, there were no control subjects so the risk factors were not studied separately but as combined. fourthly, the screening and diagnosis of patients some humanitarian errors might be possible. references 1. park k, editor. park’s textbook of preventive and social medicine; 22nd ed. bhanot publishers, 2015. 2. chandwani h, jivarajani p, jivarajani h. health and social problems of geriatric population in an urban setting of gujarat, india. the internet j health. 2008;9(2):1-9. 3. singh mm, murthy gv, venkatraman r, rao sp, nayar s. a study of ocular morbidity among elderly population in rural area of central india. indian j opthalmol 1997;45: 61-5. 4. baride jp, kulkarni ap, editors. textbook of community medicine, 3rd ed. vora medical publications, 2006. 5. harrison. harrisson’s principles of internal medicine, 18th ed. mcgraw-hill professional;august 11, 2011. 6. radhika tandon. parsons’ diseases of the eye, 21st ed. elsevier january 1 2011. 7. agrawal d, singh jv, sharma mk, mitthal s. ocular morbidity pattern of an urban population of meerut. indian j prev med 2011;42(1):74-8. 8. shrote vk, thakre ss, thakre sb, brahmapurkar kp, giri vc. study of some epidemiological determinants of ocular morbid conditions in the rural area of central india. iosr jdms 2012;2(1):34-8. 9. rizyal a, shakya s, shrestha rk, shrestha s. a study of ocular morbidity of patients attending a satellite clinic in bhaktapur, nepal. nepal med coll j. 2010 jun;12(2):879. 10. ukponmwan cu. pattern of ocular morbidity in nigeria. asian pac j trop dis 2013;3(2):164-6. 11. singh a, dwivedi s, dabral sb, bihari v, rastogi ak, kumar d. ocular morbidity in rural areas. nepal j ophthalmol 2012;4(7):49-53. 12. normalina m, zainal m. the dimensions of ocular morbidity amongst the nursing home geriatrics population. med j malaysia 1998;53(3):239-44. 13. khadse a, narlawar u, humne a, ughade s, dhanorkar ak. prevalence of ocular morbidities in an urban slum of central india. sch j app med sci 2014;2(2b):636-41. 14. garg p, bundela rk, lal bb, misra s, chawla s. clinical profile of age related ocular changes in elderly people attending a tertiary care teaching hospital. journal of international academic research for multidisciplinary 2014;2(1):339-47. 15. haq i, khan z, khalique n et al(2009). prevalence of common ocular morbidities in adult population of aligarh. indian j community med,34(3):195-201. 16. singh jp. geriatric morbidity profile in an urban slum, central india. indian journal of community health 2013;25(2):164-70. 17. nirmalan pk, krishnadas r, ramakrishnan r, thulasiraj rd, katz j, tielsch jm, et al. lens opacities in a rural population of southern india: the aravind comprehensive eye study. invest ophthalmol vis sci 2003;44:4639–43. 18. mitchell p, hayes p, wang jj. visual impairment 10 nursing home residents: the blue mountains eye study. mja 1997;166:73-6. 19. sahai a, malik p. dry eye: prevalence and attributable risk factors in a hospital –based population. indian j ophthalmol 2005 jun;53(2):87-91. 20. martinez gs, campbell aj, reinken j, allan bc. prevalence of ocular disease in a study of subjects 65 years old and older. am j ophthalmol 1982 aug;94(2):181-9. 21. hussain a, awan h, khan md. prevalence of nonvision-impairing conditions in a village in chakwal district, punjab, pakistan. ophthalmic epidemiology 2004;11(5):413-26. https://www.ncbi.nlm.nih.gov/pubmed/15976462 https://www.ncbi.nlm.nih.gov/pubmed/15976462 https://www.ncbi.nlm.nih.gov/pubmed/?term=martinez%20gs%5bauthor%5d&cauthor=true&cauthor_uid=7114140 https://www.ncbi.nlm.nih.gov/pubmed/?term=campbell%20aj%5bauthor%5d&cauthor=true&cauthor_uid=7114140 https://www.ncbi.nlm.nih.gov/pubmed/?term=reinken%20j%5bauthor%5d&cauthor=true&cauthor_uid=7114140 https://www.ncbi.nlm.nih.gov/pubmed/?term=allan%20bc%5bauthor%5d&cauthor=true&cauthor_uid=7114140 https://www.ncbi.nlm.nih.gov/pubmed/7114140 original research article http://doi.org/10.18231/j.pjms.2019.016 panacea journal of medical sciences, may-august, 2019;9(2):60-65 60 autonomic manifestations in diabetes mellitus: a case control study in rural population kailash s mottera1, shiva kumar2* 1,2consultant physician, dept. of internal medicine, 1lotus hospitals, hsr layout, bangalore, karnataka, 2suryodaya healthcare, malur, karnataka, india *corresponding author: shiva kumar email: drkailash.81@gmail.com abstract autonomic dysfunction is one which is often a disabling complication of diabetes mellitus. failure to recognize the symptoms in a diabetic autonomic dysfunction may lead to a substantial morbidity and mortality, however insidious the onset may be. thus, knowing its importance, this study features the various clinical manifestations of autonomic dysfunction in diabetes, in the rural area, and by simple bedside tests. this study aims to detect cases of autonomic dysfunction and its significant correlation with diabetes. this study was carried out on 50 patients with diabetes mellitus and 50 healthy controls. autonomic function bedside tests were conducted on all study participants and the autonomic scores were calculated. electrocardiograms were taken to calculate the corrected qt-interval. glycemic profile was measured in all the subjects. comparison of these parameters were done between the diabetic and control group. significant positive autonomic scores were observed in all the tests in diabetic group when compared to the study group. impotence (36%), postural giddiness (30%) and sweating disturbances (26%) were the common symptoms noted among the diabetic group. prolonged qtc interval of value greater than >0.44 was seen in 18 subjects (36%) in the diabetic group where it is seen only in 4 subjects (4%) in the control group. among the diabetic group mean hba1c for those with negative autonomic scores was 5.98±1.41% as compared to 7.24±2.42% with positive autonomic scores. thus, there is an increased incidence of autonomic dysfunction among diabetic patients. the increased autonomic scores are suggestive of the same. keywords: autonomic function tests, diabetes mellitus, hba1c, qt interval, autonomic neuropathy. introduction india is the diabetic capital of the world. diabetes is definitely a growing menace in our society, with a growing worldwide incidence. diabetes is continued to be known to man for centuries but yet to be fully understood. the number of people with diabetes has increased alarmingly since 1985. in 1985, an estimated 30 million people world-wide had diabetes; by 2003, it was estimated that approximately 194 million people had diabetes, and this figure is expected to rise to almost 350 million by 2025.1 to beat it all, though diabetes can be easily detected and diagnosed overall, it’s actual ‘hold’ over the various systems in the form of complications are seldom fully recognized. most people link diabetes to major manifestations of the eyes or heart that they overlook its grasp on the nerves, and the dreaded neuropathic complications. all forms of diabetes are characterized by hyperglycemia, due to relative or absolute lack of insulin or the malfunctioning of insulin. this hyperglycemia progresses onto the development of diabetes-specific microvascular pathology in the retina, glomerulus, and peripheral nerves.2 autonomic dysfunction is another disabling complication in diabetics. significance of autonomic dysfunction in diabetes is huge as it has 5-year mortality of 50%, it is common cause of sudden death, has been correlated with greater complications after elective surgery and increased danger with general anesthesia.3 the significant increase in major microvascular complications makes it important to screen diabetes at a younger age of 45 years. failure to recognize the symptoms in a diabetic, as due to autonomic dysfunction and later lead to lot of unnecessary investigations and wasteful treatment. thorough understanding of diabetic autonomic dysfunction on the various systems is necessary.4 common clinical presentations with autonomic dysfunctions are postural hypotension, gastrointestinal disturbances, sweating abnormalities, bladder dysfunction, erectile dysfunction and other symptoms.5,6 among these complications, cardiac manifestation seems to more common and dreadful. autonomic nerves provide the heart with very fine control mechanism; variations in vagal tone very rapidly alter heart rate on a beat-to-beat basis while stimulation of the sympathetic tone has a more gradual accelerator effect. there are several investigations to assess the cardiac autonomic functions. heart rate variability in most widely accepted predictor of functional status of the heart. the actual measurement of heart rate variability has been achieved via multiple different modalities. it is usually calculated by analyzing the time series of beat-to beat intervals from ecg or arterial pressure tracings, i.e. standard deviation of beatto-beat intervals. it consists of time domain and frequency domain parameters. other conventional tests are generally used to measure cardiac autonomic function tests are recording the heart rate and blood pressure changes during maneuvers.7,8 the objective of the study was to observe the presenting manifestations of autonomic dysfunction in diabetes mellitus and compare it with the normal subjects. materials and methods the study was conducted in patients who presented in the opd of general medicine in the rural medical college. the institutional ethical clearance was obtained for the study. the study was conducted in november, 2008 to april, 2010. diabetic group consisted of 50 subjects who were randomly selected and consisted of 34 males and 16 females. the study also involved 50 controls, i.e. non-diabetic patients. inclusion criteria for the diabetic group are patients with fasting (of more than 8 hours) blood glucose levels of more than 126 kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 61 mg/dl and/or two-hour post-prandial blood glucose levels of more than 200 mg/dl.9-10 patients with severe anemia, congestive cardiac failure, gross nutritional deficiency, exposure to alcohol, lead, neurotoxic drugs (like inh) and drugs affecting the autonomic function, renal failure, on antihypertensive medication, chronic obstructive lung disease, central or peripheral neuropathies due to cause other than diabetes, liver diseases, cardiac arrhythmias were excluded from the study. the selected 50 diabetic patients were questioned about the presence of symptoms reported to be related to autonomic neuropathy, viz. postural giddiness, and nocturnal polyuria, disturbances of bladder sphincter, constipation, diarrhea, impotence and bouts of localized sweating. all the patients were subjected to a detailed clinical examination. glycosylated hemoglobin levels were assessed in all the subjects. the following tests were performed to assess the autonomic functions in the above patients.11-12 tests reflecting parasympathetic function and sympathetic functions are listed in the table 1 with their scoring system.13 heart rate variation during deep breathing deep breathing, at six breaths a minute, is the most convenient and reproducible technique. the patients breathe deeply at six breaths a minute (five seconds in and five seconds out) for one minute. an electrocardiogram is recorded throughout the period of deep breathing, with a marker used to indicate the onset of each inspiration & expiration. the shortest r-r interval during inspiration and longest r-r interval during expiration was measured to calculate the difference in heart rate. heart rate response to valsalva maneuver the patient is asked to blow into the sphygmomanometer tube to maintain a pressure of 40 mm of hg for 15 seconds, with continuous recording of electrocardiogram. during each maneuver, the electrocardiogram is recorded during the strain, and for 15 seconds following the release. the results are expressed as valsalva ratio, which is the ratio of longest r-r interval after the maneuver to the shortest r-r interval during the maneuver. immediate heart rate response to standing during the change of position from lying to standing a characteristic immediate rapid increase in heart rate occurs, which is maximal at about the 15th beat after standing. a relative overshoot bradycardia then occurs, maximal at about the 30th beat. this response is mediated by the vagus nerve. the test is performed with patient lying quietly on a bed, while the heart rate is recorded continuously on an electrocardiograph. the patient is asked to stand up unaided and the point, at which the patient starts to assume an erect posture, is marked on the electrocardiogram. the shortest rr interval at around the 15th beat and longest r.-r interval at around 30th beat are measured. the characteristic heart rate response is expressed by the 30.15 ratio. blood pressure response to standing the test is performed by measuring the patient's blood pressure while he is lying down quietly, and after he stands up at one minute intervals. three readings were obtained, and the average drop in the systolic blood pressure was taken. blood pressure response to sustained handgrip the patients were asked to maintain 1/3rd of maximal voluntary contraction for 5 minutes, and blood pressure is recorded in the non-exercising arm, at rest, and during oneminute interval during the grip. the result is expressed as the difference between the highest diastolic blood pressure during the handgrip, and the mean of the three diastolic blood pressure readings, before the handgrip began. a corrected qt interval (qtc interval) resting ecg is recorded in all the patients and qt interval in seconds is detected. the qtc interval (in seconds) = qt interval (in seconds)/ √r-r interval (in seconds) (13). based on the results of the above tests, the autonomic manifestations in diabetics were ascertained, and further analyzed using statistical test, student t test. results total of 100 subjects participated the study with 50 subjects each in diabetic and control group. impotence is the commonest symptom of autonomic dysfunction and polyneuropathy the commonest complication with the incidence of 36% in the diabetic group. the other common symptoms are sweating disturbances (26%), postural giddiness (30%). the occurrence of symptoms between diabetic group and control group is compared and presented in the table 2. incidence of cataract in the diabetic group was 20% and in control group was 12%. the average of participants in the study was 54.43±15.12 years and the mean duration of diabetic in the participants was 10.96±6.95 years. table 1: normal, borderline and abnormal values in tests for autonomic functions tests normal values borderline values abnormal values a. parasympathetic function tests 1. heart rate variation during deep breathing (beats/min) 15 or more 11-14 10 or less 2. immediate heart rate response to standing (30:15 ratio**) 1.04 or more 1.01-1.03 1.00 or less 3. heart rate response to valsalva maneuver (valsalva ratio*) 1.21 or more 1.11-1.20 1.10 or less b. sympathetic function tests kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 62 1. b.p response to standing (fall in systolic blood pressure) (mm of hg) 10 or less 11-29 30 or more 2. b.p response to handgrip (increase in diastolic blood pressure) (mm of hg) 16 or more 11-15 10 or less scores* 0 1 2 *of total sum of 10, if total score obtained from tests is >5, i.e 6 or above, it is considered positive autonomic score table 2: presenting complaints among the diabetic and control group presenting complaints diabetic group (n=50) control group (n=50) p value no % no % postural giddiness/syncope 15 30.0 2 4.0 0.001** constipation 10 20.0 0 0.0 0.001** diarrhea 4 8.0 5 10.0 1.000 sweating disturbances 13 26.0 0 0.0 <0.001** pupillary changes 9 18.0 0 0.0 0.003** bladder disturbances 10 20.0 0 0.0 0.001** urinary tract infections 5 10.0 1 2.0 0.204 impotence 18 36.0 0 0.0 <0.001** cholelithiasis 8 16.0 3 6.0 0.110 cataract 10 20.0 6 12.0 0.275 dermopathy 5 10.0 0 0.0 0.058+ ulcers on foot 10 20.0 0 0.0 0.001** pulmonary tuberculosis 2 4.0 2 4.0 1.000 the heart rate and bp responses in the two group in depicted in table 3. significant positive autonomic cardiovascular reflex tests among diabetic group than control group. autonomic scores were compared between the groups and there statistically more significant positive autonomic scores in diabetic group than control group. the results are depicted in fig. 1 and table 4. table 3: comparison of heart rate and bp response in two groups of patients diabetic group control group p value heart rate response to deep breathing 12.26±4.95 21.04±5.26 <0.001** heart rate response to valsalva maneuver 1.07±0.27 1.28±0.19 <0.001** immediate heart rate response to standing 1.01±0.15 1.27±0.19 0.001** b.p response to standing 14.88±7.51 10.96±9.31 0.030* b.p response to handgrip 14.40±5.57 18.24±3.95 <0.001** table 4: distribution of autonomic scores among the subjects autonomic score diabetic group control group no % no % negative (<=5.0) 22 44.0 44 88.0 positive (>5.0) 28 56.0 6 12.0 total 50 100.0 50 100.0 inference autonomic positive cases are significantly more in cases compared to controls with p<0.001** fig. 1: distribution of autonomic scores among the subjects the mean corrected qt interval (qtc) is 0.419 ± 0.05 seconds in the diabetic group and 0.394 ± 0.04 seconds in the control group. the statistically significant difference between diabetic and control group with p=0.003*. qtc interval of value greater than >0.44 was seen in 18 subjects (36%) in the diabetic group where it is seen only in 4 subjects (4%) in the control group. comparison of corrected qtc intervals by kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 63 e.c.g (in seconds) in two groups of patients is depicted in table 5. table 5: comparison of corrected qtc intervals by e.c.g (in seconds) in two groups of patients corrected qt interval diabetic group (n=50) control group (n=50) 0.35-0.40 25(50.0%) 34(68.0%) 0.41-0.45 7(14.0%) 12(24.0%) 0.46-0.50 18(36.0%) 4(16.0%) mean ± sd 0.419±0.05 0.394±0.04 inference corrected qtc interval is significantly increased in cases with p=0.003** mean glycosylated haemoglobin (hba1c) was in the diabetic group was 8.24±2.59%. mean hba1c was 7.24±2.42% in the subjects with positive autonomic scores and it was 5.98±1.41% in subjects with negative autonomic scores. discussion incidence of varied symptoms of autonomic dysfunction in diabetic group is described as follows. in this study, 46 out of the 50 diabetes patients studied, presented with symptoms suggestive of autonomic neuropathy in the form of impotence, postural giddiness, constipation, sweating disturbances, bladder disturbances and diarrhea. impotence was the most common symptom in this study. it was encountered in 18 out of the 50 patients (36%). out of this, it was encountered in 10 out of the 34 males, mainly in the form of erectile dysfunction. rundles14 found impotence in 19 patients out of 125 diabetic patients. noronha jl et al15 found impotence in 52% of their study diabetic subjects, being the commonest symptom. gupta et al16 in their study found 12 patients with impotence in 50 diabetic patients. postural giddiness was the next common symptom seen in 15 out of the 50 diabetic patients (30%). this is statistically significant. the findings in this study were similar to that of nijhawan et al17 who found an incidence of 28% (7 out of 25 patients). goel a et al18 in their observation, have made a fact that postural giddiness, is the commonest symptom (21.3%), others being impotence (9.3%), diarrhea (9.3%), abnormal sweating and dysphagia. sweating disturbances in the form of decreased sweating were seen in 26% of the patients 13 out 50 diabetics. no control had symptoms of sweating disturbances, making this a significant symptom of autonomic neuropathy. bladder disturbances, in the form of incontinence and retention of urine, were seen in 10 out of 50 patients (20%). rundles14 observed 32 out of 125 diabetics (25.6%) with bladder disturbances while gupta et al16 observed bladder disturbance in 5 out of 50 diabetics (10 %). constipation was also a common symptom seen in 10 out the 50 diabetic patients (20%). aaron i et al19 says that constipation is the most common lower g.i symptom in diabetics. diarrhea, which was nocturnal, profuse and watery, was seen in 4 out of the 50 diabetic patients (8%). rundles14 reported 21.6% patients with diarrhea 26 out of 125 patients, chowdary d et al20 in their update article on “approach to case of autonomic neuropathy”, states that diabetes mellitus is the most important cause of autonomic neuropathy. autonomic features, which involve the cardiovascular, gastrointestinal, urogenital, sudomotor and pupillomotor systems, occur in varying combinations, of which, orthostatic hypotension is often the first recognized and most disabling symptom. comparison of autonomic dysfunction in diabetic group and control group is described as follows. ewing’s autonomic test scoring system as used to evaluate if a patient had autonomic dysfunction. this system is described in the methods. it has maximum total score of 10 to a minimum of 0, a score of more than 5, i.e. 6 or more was considered as positive autonomic scores. among the 50 diabetic patients, 28 patients had positive autonomic scores (56%). only 6 among 50 controls had an autonomic score of more than 5, indicating a strong association between autonomic dysfunction and its manifestations in diabetes. the incidence of autonomic neuropathy in diabetics, ranged from 17 to 68% in other studies. pappachan m21 et al in their study, showed a prevalence of cardiovascular autonomic neuropathy in 60% of the 100 cases of diabetics studied. goel a et al18 have reported 29 out of 75 diabetic patients (39%) to have dysautonomia. similar results were seen with oluranti b. familoni et al22 have showed a prevalence of 37% of dysautonomia among the diabetics under study. duration of diabetes vs incidence of autonomic dysfunction the incidence of autonomic neuropathy increased with the increasing duration of diabetes. among those with positive autonomic scores, the average age was 54.43±15.12 years as compared to 42.91±12.59 years in those with negative scores, indicating the increased prevalence of autonomic dysfunction in diabetics among the older age groups. also we see that in those cases that had positive autonomic scores, the average duration of diabetes was 10.96±6.95 years as compared to 5.39±3.06 years in those who had negative scores. this clearly indicates the correlation between increasing duration of diabetes and the occurrence of autonomic neuropathy. roy freeman et al23 reported an incidence of 15% autonomic neuropathy in diabetics of duration up to 10 years and 62% in diabetics of more than 10 years.9 lakhotia m et al13 showed a great incidence of dysautonomia with increasing duration (up to 80% in those with duration of more than 5 years). glycemic control and autonomic dysfunction poor glycemic control is associated with diabetic complications and notably with autonomic neuropathy. the mean value of glycosylated hemoglobin in most of these patients at the time of recruitment for study was 7.24±2.42%. it was noticed that the cases with positive autonomic scores had uncontrolled blood sugars (fasting and post-prandial blood sugars) than those with negative scores. among the cases, those with positive scores had a mean value of glycosylated hemoglobin of 8.24±2.59% as against that of 5.98±1.41% in those with negative scores. the target kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 64 glycosylated haemoglobin in normal individuals is 7.0%, and for diabetics is 6.5%.21 this clearly indicates that these patients had a poor glycemic control over the previous 3 months or more, also indicating the significant correlation between poor glycemic control and prevalence of diabetic autonomic neuropathy. pappachan jm et al21 in their study, also showed that incidence of diabetic autonomic neuropathy increased with increasing duration and poor glycemic control. gupta rc et al16 studied cardiovascular reflexes after 6 months of strict metabolic control and found that 22% patients showed significant symptomatic improvement and 18% showed improved test score. sympathetic v/s parasympathetic tests in the present study, the tests used to evaluate parasympathetic system where found to be more sensitive indicators of autonomic neuropathy. more than 80% of the diabetics with positive autonomic scores had at least one parasympathetic test abnormal or borderline, and at least 60% had at least two tests abnormal or borderline. goel a et al18 observed that 50% of the diabetics with dysautonomia had both abnormal sympathetic and parasympathetic tests. noronha jl15 reported 45.5% of their diabetic subjects had inadequate heart rate response to standing. in this study, 48% cases had abnormal or borderline values for the heart rate response to standing, results almost matching with their study. corrected qt interval in e.c.g. v/s diabetic autonomic neuropathy a corrected qt interval of more than 0.44 seconds was present in diabetic autonomic dysfunction and was more prominent in cases with significant risk factors, like advanced age, longer duration and peripheral neuropathy. in this study, it was ascertained that the corrected qt interval was statistically significantly increased among diabetic cases compared to controls. oluranti b. familoni et al22 showed a prevalence of 30% of diabetic autonomic neuropathy in the cases with prolonged corrected qt interval. pappachan jm et al21 in their study, showed a significant association between can and prolonged corrected qt interval (or 5.55s). roy freeman, in his article, “autonomic peripheral neuropathy”, roy freeman 200523 says that mortality in diabetics due to cardiovascular autonomic neuropathy is 27-56% in 5-10 years period. conclusion there were increased number of abnormal parasympathetic (heart rate variability) tests as compared to sympathetic (blood pressure variability) tests. there was a statistically significant effect of duration of disease and glycemic state (based on fasting blood sugar/ post-prandial blood sugar/ hba1c) on autonomic neuropathy among the cases. there were statistically significant prolongations in corrected qtintervals in diabetics compared to controls. it is necessary to anticipate the early autonomic dysfunction in diabetic patients and accord necessary treatment. source of funding none. conflict of interest none. references 1. michael brownlee, lloyd. p. aiello, mark e. cooper, william’s textbook of endocrinology, 11th edition, chapter 32, 1418-1490. 2. tarsy daniel, freeman roy. “the nervous system and diabetes”, joslin’. diabetes mellitus, 13th edition 794-798. 3. harrison’s principles of internal medicine, autonomic neuropathy in diabetes mellitus, chapter 338, 17th edition, pg.2289-2293. 4. michael e. farkouh, elliot j. rayfield, valentin fuster: “diabetes and cardiovascular disease” hurst’s the heart, 12th edition, pp 2073-2103. 5. adams d raymond, victor morris; principles of neurology, 9th edition, pp 505-527. 6. api textbook of medicine, diagnosis of diabetes mellitus, 8th edition, vol. 2, pages 1049-1051. 7. suraj kupa, virend k. somers, “cardiovascular manifestations of autonomic disorders”, braunwald’s heart disease: a textbook of cardiovascular diseases, 8th edition, wb saunders, 2008, pp 2171-2183. 8. robertson rh, robertson d. “cardiovascular manifestations of autonomic disorders”, braunwald’s heart disease: a textbook of cardiovascular diseases, 7th edition, wb saunders, 2008, pgs 2173-2184. 9. american diabetes association standards of medical care in diabetes—2007. diabetes care 2007;30 (suppl 1):s4-s41. 10. gabir mm, hanson rl, dabela d. the 1997 american diabetic association and 1999 world health organization criteria for hyperglycemia in the diagnosis and prediction of diabetes. diabetes care 2000;23:1108-1112. 11. ewing dj, clarke bf. diagnosis and management of diabetic autonomic neuropathy. br med j 1982;285:916-8. 12. ewing dj, campbell iw, murray a, neilson jmm, clarke bf. immediate heart-rate response to standing: simple test for autonomic neuropathy in diabetes. br med j 1978;1:145-7. 13. lakhotia m, shah pkd, vyas r, jain ss, yadav a, parihar ma. clinical dysautonomia in diabetes mellitusa study with seven autonomic reflex function tests. japi 1997;45:4. 14. rundle rw. diabetic neuropathy. medicine (baltimore) 1945;24:111-60. 15. noronha jl, bhandarkar sd, shenoy pn, retnam vj. autonomic neuropathy in diabetes mellitus. j postgrad med 1981;27:1-6. 16. gupta rc, chittora md, jain a. a study of autonomic neuropathy in diabetes mellitus in relation to its metabolic control. japi 1995;43(7):1-3. 17. nijhawan s. autonomic and peripheral neuropathy in insulin dependent diabetes. joint association of physicians of india 1993;41(a):565-6. 18. goel a, ruchika agarwal, singla s, lakhani kk, sonigra dt, agarwal sb. a clinical study on autonomic nervous system manifestations in diabetes mellitus. j assoc physicians india 2005;53:999. 19. aaron i. vinik, raelene e. maser, braxton d. mitchell, roy freeman. diabetic autonomic neuropathy. diabetes care 2003;26(5):1553-79. 20. chowdary d, patel n. update article on approach to a case of autonomic peripheral neuropathy. japi 2006;54:727. 21. pappachan m, sebastian j, bino bc. cardiac autonomic neuropathy in diabetes mellitus: prevalence, risk factors and utility of corrected qt interval in the ecg for its diagnosis. postgrad med j 2008;84(990):205-10. https://www.ncbi.nlm.nih.gov/pubmed/16515247 https://www.ncbi.nlm.nih.gov/pubmed/18424578 kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 65 22. oluranti b. familoni, olatunde odusan, taiwo h. raimi. the relationship between qt intervals and cardiac autonomic neuropathy in nigerian patients with type 2 diabetes mellitus. nigerian med pract 2008;53(4):48-51. 23. roy freeman. autonomic peripheral neuropathy. lancet 2005;365:1259-70. original research article doi: 10.18231/2348-7682.2017.0036 panacea journal of medical sciences, september-december 2017;7(3):136-139 136 clinical and hematological profile of sickle cell disorder patients in a tertiary care hospital of central india vidhyanand gaikwad1,*, meenal kulkarni2, sadhana mahore3, pradnya gaikwad4 1resident, 2associate professor, 3hod, 4director, 1,2dept. of community medicine, 3dept. of pathology, 1,2,3nkp salve institute of medical sciences & research centre, nagpur, maharashtra, 4ngo, savitribai phule sickle cell foundation, nagpur, maharashtra, india *corresponding author: email: drvidhya75@rediffmail.com abstract sickle cell anemia is the best known hereditary blood disorder; there are serious complications associated with the condition. it is an autosomal recessive genetically transmitted hemo-globinopathy responsible for considerable morbidity and mortality. vasoocclusive pain episodes are one of the predominant clinical features associated with sickle cell anemia. the study was conducted to study clinical and hematological profile of sickle cell disorder patients of lata mangeshkar hospital. blood was collected in edta test tube and hematological indices were measured by c.b. counter machine along with blood smear examination and confirmed by sickling method and electrophoresis test. out of total 110 cases, 13 (11.81%) and 97(88.18%) cases were of sickle cell disease (ss) and sickle cell trait (as) respectively. females were more affected. hematological profile showed decreased values of hb%, hematocrit (hct), red blood cell (rbc) count, mean corpuscle hemoglobin (mch), mean corpuscle hemoglobin concentration (mchc) and raised values of red blood cell distribution width (rdw).platelet count, mean corpuscle volume (mcv), mean platelet volume (mpv) was found to be normal. peripheral smear showed anisopoikilocytosis (60%) and hypochromic cells (74.54%). approximately half of the patients reported weakness and fatigue. keywords: electrophoresis test, hematological profile, sickle cell disease, sickle cell trait, sickling test. introduction sickle cell disorder is a group of diseases caused by a point mutation at sixth position in beta globin chain, valine substituting glutamic acid due to which in deoxygenated state, shape of erythrocytes change to sickle shape and also the fragility of cell membrane increases.(1) it is a hereditary disorder characterized by the production of abnormal sickle-shaped red cells, with variable degree of hemolytic anemia and acute and chronic tissue damage due to vaso-occlusion leading to many serious complications.(2) taking into our huge population size, more than 50 % of the world’s sickle cell anemia cases are in india. it is estimated that most of the cases are in the central and south india.(3) in individuals with sickle cell anemia (ss),the hbs level is more than 90% while in sickle cell trait, the hbs level is less than 50% and hence the clinical manifestations of disease are usually absent or mild among sickle cell trait patients as compared to with sickle cell disease.(4) in india, sickle cell disease is more common hemoglobinopathy, next to thalassemia. it is an autosomal recessive genetically transmitted hemoglobinopathy responsible for considerable morbidity and mortality.(5) although the sickle cell disease is present from birth, symptoms are rare before the age of the three to six months due to persistence of fetal hemoglobin (hbf). sickle cell anemia was first described in south indian tribal groups and subsequently in central india.(6) the clinical manifestations of sickle cell anemia (sca) begin early in life and continue with an increased incidence of adverse events coincident with the physiologic decline in fetal hemoglobin (hbf).(7) vaso-occlusive pain episodes are one of the predominant clinical features associated with sca.(8) the study was conducted to analyze clinical symptoms and hematological profile of sickle cell disorder patients. materials and methods after taking permission from institutional ethical committee, record based cross sectional study of diagnosed patients of sickle cell disorder was conducted in department of pathology of nkpsims nagpur from consecutive records of 5 months from 01/01/2017 to 31/05/2017. confidentiality of participants was maintained. out of 112 patients of sickle cell disorder, 110 patients were included in this study and 2 patients were excluded because of one patient was on hydroxyurea medication and the other had received blood transfusion 7 days earlier. the cases were selected by using non-probability (convenient) sampling technique. blood sample was collected in edta test tube and hematological indices hb%, hct, platelet, mcv, mch, rdw, mpv were measured by c.b. counter machine (horiba abx, micros 60) along with blood smear examination and confirmed by sickling method and electrophoresis test. sickling test was done by slide method test and electrophoresis test done by using cellulose acetate strip at alkaline ph to differentiate and confirmation of sickle cell disease and sickle cell trait. vidhyanand gaikwad et al. clinical and hematological profile of sickle cell disorder patients in a …. panacea journal of medical sciences, september-december 2017;7(3):136-139 137 sampling method: inclusion criteria: all diagnosed patients of sickle cell disorder. exclusion criteria: 1. patient on hydroxyurea medication. 2. patient received blood transfusion recently within 3 months. the data was entered into an ms excel spreadsheet and imported into epi-info software for statistical analysis was done by calculating frequencies and proportions for qualitative variables and mean were calculated for quantitative variables. results in our study, total 110 cases were diagnosed as sickle cell disorder. among them 97 (88.18%) were heterozygous (sickle cell trait, as) and 13 (11.81%) were homozygous (sickle cell disease, ss). females (93 cases, 84.54%) were more affected than males (17 cases, 15.45%). most of the cases were in the age group from 11 to 30 years. screening of females during antenatal period and screening of girls in school camps, might be the reason for present findings. (table 1 and 2) table 1: age wise distribution of sickle cell disorder patients age in yrs as n=97 ss n=13 total (%) n=110male female male female 0-10 3 3 0 1 7 (6.36) 11-20 2 34 0 3 39 (35.45) 21-30 5 35 1 3 44 (40) 31-40 2 3 0 3 8 (7.27) 41-50 1 7 1 1 10 (9.09) 51 and above 1 1 0 0 2 (1.8) total 14 83 2 11 110 (100) table 2: sex wise distribution of sickle cell disorder patients gender ss type (%) n=13 as type (%) n=97 total (%) n=110 male 2 (15.38) 14(14.43) 16 (14.54). female 11 (84.61) 83(85.56) 94 (85.54) total 13(100) 97(100) 110(100) ss-sickle cell disease (homozygous), as-sickle cell trait (heterozygous) hematological profile showed decreased value of mean hb%. mean hb% value for sickle cell trait was 10.2 gm/dl and for sickle cell disease patient was 7.72 gm/dl. in this study values of hct, total rbc count, mch, mchc were decreased with normal mcv, mpv and platelets count. value of rdw was high due to variation in red blood cell size. (table3) table 3: hematological profiles of sickle cell disorder patients s. no. parameters normal reference range mean value (as+ss) mean value as ss 1 hb (gm/dl) male: 13-18 female: 11.5-16.5 9.87 10.2 7.72 2 hct (%) 35-47 31.106 32 24.33 3 rbc (millions/cmm) m : 4.74 -5.49 f: 4.14-4.79 4.105 4.24 3.10 4 platelet (lacs/cmm) 1.5-4.0 3.02 3.05 2.82 5 mcv (fl) 75-100 76.90 76.9 76.92 6 mchc (%) 31-38 24.25 31.48 30.94 7 mch (pgm) 25-35 24.30 24.2 24.87 8 rdw (%) 11-5-16.5 18.6 18.6 18.85 9 mpv (fl) 6.5-11.0 8.09 8.07 8.28 among 13 patients of sickle cell disease, peripheral smear showed anisocytosis (90.32%) and poikilocytosis (90.32%), hypochromic cells (90.32 %). among 97 patients of sickle cell trait, peripheral smear showed anisocytosis (55.67%) and poikilocytosis (55.67 %), hypochromic cells (71.39%). (table 4) table 4: peripheral smear examination of sickle cell disorder patients s. no. parameters sickle cell disorder (as+ss) n=110 as (n=97) ss (n=13) cases percentage cases percentage cases percentage 1 normocytic 36 32.72 35 36.08 1 7.69 2 normochromic 29 26.36 28 28.86 1 7.69 3 hypochromic 81 74.54 69 71.13 12 90.32 vidhyanand gaikwad et al. clinical and hematological profile of sickle cell disorder patients in a …. panacea journal of medical sciences, september-december 2017;7(3):136-139 138 4 anisocytosis 66 60 54 55.67 12 90.32 5 poikilocytosis 66 60 54 55.67 12 90.32 among 13 patients of sickle cell disease, main complaints were weakness and fatiguability in 11 patients (84.61%), recurrent fever with bone pain in 6 patients (46.15%), recurrent periodic abdominal pain in 4 patients (30.76%). recurrent jaundice, breathlessness, recurrent fever with cough and pleuritic chest pain were observed in 1 patient each. one patient of one day old newborn baby had difficulty to suck breast milk. one patient was hospitalized 4-5 times in tertiary care hospital during vasooclusive crises. among 97 patients of sickle cell trait (as), main complaints were weakness and fatiguability in 44 patients (45.36%), painful and swollen disease in 8 patients (8.24%). other observed symptoms were recurrent abdominal pain in 6 patients (6.18%), recurrent fever with cough and pleuritic chest pain in 3 patients (3.09%), breathlessness in 3 patients (3.09%), having headache in 2 patients (2.06%). (table 5) table 5: clinical manifestations of sickle cell disorder patients symptoms as (%) n=97 ss (%) n=13 total (%) n=110 weakness and fatigue 44 (45.36) 11 (84.61) 54 (49.09) recurrent fever with cough, plueritic chest pain 3 (3.09) 1 (7.69) 4 (3.63) recurrent fever with bone pain 1 (1.03) 6 (46.15) 7 (6.36) breathlessness 3 (3.09) 1 (7.69) 4 (3.63) painful, swollen digits of hands and feet 8 (8.24) 1 (7.69) 9 (8.18) recurrent jaundice 0 1 (7.69) 1 (0.9) recurrent, periodic abdominal pain 6 (6.18) 4 (30.76) 10 (9.09) headache 2 (2.06) 0 2 (1.8) feeding problem (inability to suck) 0 1 (7.69) 1 (0.9) recurrent hospitalization 0 1(7.69) 1 (0.9) discussion in our study 97 cases (88.18%) were diagnosed as sickle cell trait (as) and 13 cases (11.81%) were diagnosed as sickle cell anemia (ss) by electrophoresis test. cases of sickle cell trait (as pattern) were more than trait (ss pattern). deshmukh pr at al. (2006),(9) found more cases of sickle cell trait (as pattern) than sickle cell disease (ss pattern).in their study out of total samples found positive on solubility test, 94.4% were having hbas pattern while 5.6% had hbss pattern. deore at al. (2014),(10) found more cases of sickle cell trait than sickle cell disease. in their study 46 cases (82.60%) were diagnosed as sickle cell trait and 37 cases (21.51%) were diagnosed as sickle cell disease.(10) these findings are nearly similar to present study. chavda j.at. (2015),(11) found 30 cases (66.66%) of sickle cell disease (ss pattern) and 15 cases (33.33%) were sickle cell trait (as pattern) by electrophoresis. cases of sickle cell disease were found more than sickle cell trait. study conducted by kamble m et al. (2000),(12) reported 61.6% cases of hb ss and 38.4% cases of hb as.(12) these studies are contradictory to present study. in present study proportion of females was more than males due to screening of females during antenatal period. screening of females in girls school might be the another reason. in most of the studies proportion of males was more as compared to females. deore at al. (2014),(10) reported out of 46 cases of sickle cell disorder, males were 27 and females were 19. in study conducted by chavda j.at al. (2015),(11) total 45 cases were diagnosed as sickle cell disorder, males were more commonly affected than female with male: female ratio 2:1. in studies conducted by shrikhande et al. (2007),(6) mandot et al. (2016)(4) found proportions of males more than females. mean hb% value was 9.87 gm/dl that was nearby to other study which was 8.6gm/dl.(11, 6) values of hct, total rbc count, mch, mchc were found to be low in present study which are comparable to other studies.(11,13,14) mean rdw value was found to be high i.e.18.85 %. study conducted by roberts gt et al. (1985)(15) found elevated mean rdw values in anemic patients, with the highest value seen in sickle cell anemia, sickle cell thalassemia, sickle cell trait, thalassemia trait, and iron deficiency anemia in decreasing order of magnitude. it was found that the rdw was proportional to the reticulocyte count, with the highest values in the patients with the highest reticulocyte count (sickle cell anemia). one clinical value of the rdw therefore may lie in its capacity for reflecting active erythropoiesis. this is similar to present study. on peripheral smear anisocytosis, poikilocytosis, hypochromic cells were commonly seen in both sickle cell trait and sickle cell disease. study conducted by silvestroni e et al.(1952)(16) found anisocytosis, poikilocytosis, hypochromic, normocytic, target cells on peripheral smear in sickle cell disorder patients. this finding is nearly similar to present study. in present study weakness, fatigability, pain, fever were more common in both sickle cell disease and sickle cell trait patients. the majority of cases had mild to moderate anemia. study conducted by mandot at al. (2016)(4) reported pain, fatigability, fever and anemia. this findings nearly similar to present study. vidhyanand gaikwad et al. clinical and hematological profile of sickle cell disorder patients in a …. panacea journal of medical sciences, september-december 2017;7(3):136-139 139 conclusion this study showed that hematological profile of sickle cell disorder patients has low value of hb%, hct, total rbc count, mch, mchc with normal mcv, mpv and platelets count and high rdw. peripheral smear showed predominantly hypochromic and anisopoikilocytosis cells. symptoms like weakness and fatigability were mostly seen in sickle cell disease patients, same symptoms were also commonly seen in sickle cell trait patients. some patients of sickle cell trait had also same clinical features of sickle cell disease along with anemia. so patients having weakness and fatigability, recurrent fever with cough, breathlessness, bone pain, painful, swollen digits of hands and feet, periodic abdominal pain, jaundice along with low values of hb%, hct, total rbc count, mch, mchc and high value of rdw in presence of anisopoikilocytosis, hypochromic cells on peripheral smear strongly suspect sickle cell disorder. acknowledgement we thank mrs. pratibha ingole, laboratory technician, department of pathology, nkpsims nagpur for providing necessary laboratory record and data during present investigations. references 1. ingram vm. a specific chemical difference between the globins of normal human and sickle-cell anaemia haemoglobin. nature. 1956;178(4537):792–4. 2. mahesh k, aggarwal a, bhasker mv, mukhopadhyay r, saraswathy kn. distribution pattern of hbs and β-globin gene haplotypes among koya dora tribe of andhra pradesh. int j hum genet. 2011;11(2):123–6. 3. kate sl, lingojwar dp. epidemiology of sickle cell disorder in the state of maharashtra. int j hum genet. 2002;2(3):161–7. 4. mandot s, ameta g. prevalence, clinical, and hematological profile of sickle cell disease in south rajasthan. indian j child health. 2016;3(3):248–50. 5. shukla rn, solanki br. sickle-cell trait in central india. lancet. 1958;271(7015):297–8. 6. shrikhande a v, dani aa, tijare jr, agrawal ak. hematological profile of sickle cell disease in central india. indian j hematol blood transfus. 2007;23(3):92– 8. 7. negi rs. sickle cell trait in india. a review of known distribution. bull anthr surv india. 1972;17:439–49. 8. maier-redelsperger m, de montalembert m, flahault a, neonato mg, ducrocq r, masson m-p, et al. fetal hemoglobin and f-cell responses to long-term hydroxyurea treatment in young sickle cell patients. blood. 1998;91(12):4472–9. 9. garg b, garg n, prajapati n, bharambe m, deshmukh p. prevalence of sickle cell disorders in rural wardha. indian j community med (internet). 2006;31(1):26. available from: http://www.ijcm.org.in/text.asp?2006/31/1/26/54928. 10. deore au, zade sb. distribution of sickle cell gene in korku tribe of central india. natl j community med. 2014;5(3):270–2. 11. chavda j, goswami p, goswami a. hematological profile of sickle cell disorder in tertiary care hospital. vol. 14, j dent med sci. 2015. p.51–4. 12. kamble m, chaturvedi p. epidemiology of sickle cell disease in a rural hospital of central india. indian pediatr. 2000;37(4):391–6. 13. roy b, dey b, balgir rs, dash bp, chakraborty m, bhattacharya sk, et al. identification of sickle cell homozygotes using haematological parameters. j indian anthr soc. 1996;31:191–9. 14. tshilolo l, wembonyama s, summa v, avvisati g. hemogram findings in congolese children with sickle cell disease in remission. med trop rev du corps sante colon. 2010;70(5–6):459–63. 15. roberts gt, el badawi sb. red blood cell distribution width index in some hematologic diseases. am j clin pathol. 1985;83(2):222–6. 16. silvestroni e, bianco i. genetic aspects of sickle cell anemia and microdrepanocytic disease. blood. 1952;7(4):429–35. panacea journal of medical sciences 2020;10(3):222–226 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article epidemiology of benign breast diseases in women bhavuk kapoor1, mayank kapoor2, parul vaid3,*, bharat b kapoor4, sharda kapoor5 1dept. of neurosurgery, government medical college and hospital, jammu, jammu and kashmir, india 2dept. of medicine, all india institute of medical science, rishikesh, uttrakhand, india 3dept. of obstetrics and gynaecology, smgs hospital gmc, jammu, jammu & kashmir, india 4dept. of anaesthesia and icu, government medical college, jammu, jammu and kashmir, india 5rbsk jammu division, jammu, jammu & kashmir, india a r t i c l e i n f o article history: received 29-07-2020 accepted 07-09-2020 available online 29-12-2020 keywords: benign breast disease fibroadenoma fibrocystic disease duct ectasia breast abscess a b s t r a c t background: benign breast diseases are a common problem. this study was done to evaluate the different types of benign breast diseases in females based on their epidemiological characteristics, clinical, radiological and pathological findings. aims: to evaluate the different types of benign breast diseases in females based on their epidemiological characteristics, clinical, radiological and pathological findings. settings and design: the epidemiological characteristics of patients of benign breast diseases were observed. methods: a study of 35 female patients of benign breast disease was done and their characteristic findings were recorded. statistical analysis: statistical calculations were performed. results: the age group of 30-39 years had the highest incidence of the cases (34.28%). lump in the breast was the most common (51.42%) presenting symptom. most commonly involved quadrant was upper outer quadrant (60%). fibroadenoma (51.42%) the most common lesion in our study and presented mostly as lump in the breast in the upper outer quadrant and occurred in the age group of 20-29 years mostly. conclusions: benign breast diseases are fairly common in the younger age group. fibroadenoma is the most common benign breast condition. proper assessment and investigations are necessary for its diagnosis. the patient needs assurance regarding the benign nature of their disease by appropriate clinical, radiological and pathological diagnosis to allay their anxiety. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction benign breast diseases are a common problem in a day to day surgical practice. these disorders usually occur in the reproductive period of life and there is a dramatic fall in the incidence after menopause. 1 benign pathology is depicted in almost 80% of breast biopsies. 2 up to 30% of women will suffer from a benign breast disorder which requires treatment. * corresponding author. e-mail address: kapoorbhavuk14@gmail.com (p. vaid). benign breast diseases as such are not life threatening. proper understanding of these disorders is important so as to give a clear explanation to the patient and to institute an appropriate treatment. awareness about benign breast diseases amongst general population is very crucial. there are many types of benign breast diseases like fibroadenoma, fibrocystic disease, galactocele, mastitis etc. these diseases usually presents with symptoms of pain, lumpiness or a lump in breast. fibroadenoma commonly occurs in adolescents and is one of the most common benign breast disorders. https://doi.org/10.18231/j.pjms.2020.047 2249-8176/© 2020 innovative publication, all rights reserved. 222 https://doi.org/10.18231/j.pjms.2020.047 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:kapoorbhavuk14@gmail.com https://doi.org/10.18231/j.pjms.2020.047 kapoor et al. / panacea journal of medical sciences 2020;10(3):222–226 223 fibrocystic disease occurs mostly in the age group of 20-50 years and presents bilaterally. 3 there occurs cyclic bilateral breast pain, increased engorgement and density of the breasts. in mastitis, the breast is indurated, red and painful. nipple retraction may also occur. fever may also be present. galactocele is commonly seen in lactating women and this typically present with a painless breast lump. in duct ectasia there is dilatation of subareolar ducts. usually presents with a palpable mass and nipple discharge. we did the study to evaluate the different types of benign breast diseases in females based on their epidemiological characteristics, clinical, radiological and pathological findings. 2. materials and methods total thirty five female patients of benign breast diseases were included in this study. their epidemiological characteristics, clinical, radiological and pathological findings were observed. 2.1. inclusion criteria female patients clinically diagnosed as having benign breast diseases were included in this study after obtaining their written consent and on guidelines as per the institute’s ethical committee. 2.2. exclusion criteria 1. cases diagnosed as having malignant breast disease were excluded. 2. women who were previously treated for breast malignancy. a detailed history and clinical examination of the patients was done – general physical, systemic and local examination of both breasts. usg and/or mammography of both breasts were done. fnac and/or histopathology of benign breast lesion was done. 2.3. statistical analysis at the end of the study, statistical calculations were performed using the spss 16.0 software. 3. results in our study, age group of 30-39 years had most of the cases (34.28%) of benign breast diseases [table 1]. lump in breast was the most common (51.42%) presenting symptom [table 2]. in our study, most of the patients were having duration of symptoms of 1-6 months (45.71%). table 1: age distribution of benign breast diseases age groups ( years) no of cases percentage (%) <20 2 5.71 20-29 7 20 30-39 12 34.28 40-49 10 28.57 >49 4 11.42 table 2: symptoms of benign breast disease symptom no of cases percentage (%) lump 18 51.42 pain 5 14.28 lump + pain 8 22.85 nipple discharge 4 11.42 the patients in our study commonly presented with lesion in the left breast (48.57%), followed by the lesion in the right breast (40%) and bilateral lesions (11.42%). as shown in figure 1, the upper outer quadrant was the most common quadrant involved (60%), followed by central quadrant (17.14%). fig. 1: quadrant involved as shown in table 3, the highest number of cases of benign breast diseases were of fibroadenoma (51.42%), followed by fibrocystic disease (22.85%). table 3: disease pattern of benign breast diseases diseases no of cases percentage (%) fibroadenoma 18 51.42 fibrocystic disease 8 22.85 galactocele 2 5.71 phyllodes tumor 1 2.85 duct ectasia 4 11.42 breast abscess 2 5.71 most of the cases of fibroadenoma were in the age group of 20-29 yrs and cases of fibrocystic disease mostly occurred in the age group of 40-49 yrs. cases of duct ectasia commonly presented in the age group of 40-49 yrs. breast abscess cases presented in the age group of 30-39 yrs 224 kapoor et al. / panacea journal of medical sciences 2020;10(3):222–226 and >49 yrs. respectively. galactocele and phyllodes tumor occurred in the age group of 30-39 yrs [figure 2]. fig. 2: breast pathology in different age groups most common presentation in fibroadenoma cases was lump in the breast. in fibrocystic disease common presentation was pain in the breast. galactocele presented as lump in the breast. in case of phyllodes tumor and breast abscess, the presentation was lump and pain in the breast. nipple discharge was the presenting symptom in duct ectasia. in our study, most cases of fibroadenoma presented with duration of symptoms of 1-6 months. in cases of fibrocystic disease duration of symptom was > 12 months in most of the cases. galactocele and phyllodes tumor presented with symptoms of the duration of 7-12 months. duct ectasia presented with symptoms of the duration of 1-6 months mostly. breast abscess presented with the symptoms of the duration of < 1 month in all cases. most common quadrant of the breast involved in fibroadenoma was the upper outer quadrant. in case of fibrocystic disease also upper outer quadrant was commonly involved. galactocele and duct ectasia involved the central quadrant. phyllodes tumor involved the upper inner quadrant and breast abscess involved the upper outer quadrant. 4. discussion in our study, the age group of 30-49 years had maximum incidence of benign breast diseases (62.85%). this was also noticed in the study conducted by najeeb s jabbo, in which incidence of benign breast diseases was more in the age group of 30-49 years (56.92%). 4 other studies also concluded that the incidence of benign breast lesions begins to rise during 2nd decade of life and peaks in the 4th and 5th decades. 5–7 median age in our study was 35 years which was also observed in study conducted by najeeb s jabbo (2010), in which the median age was 35.39 years. 4 lump in the breast was the most common presenting symptom in our study (51.42%). lump and pain was the presenting symptom in 22.85% of cases in our study. in other study also breast lump was the most common symptom having incidence of 49% followed by lump and pain having incidence of 28%. 8 in another study also, the most common symptom was breast lump having incidence of 54.5% followed by lump and pain having incidence of 28.9%. 4 pain in the breast as the only presenting symptom was seen in 14.28% cases of our study. nipple discharge was present in 11.42% of cases in our study. the study conducted by najeeb s jabbo (2010) showed an incidence of nipple discharge as 8.8%. 4 in our study, left breast and right breast were involved in 48.57% and 40% of the patients respectively and only 11.42% of the patients had bilateral benign breast diseases. in a study conducted by onukak ee(1989), the incidence of benign breast diseases was more on left (48%) as compared to right (43.8%) and bilateral (8.2%). 8 in 60% of patients in our study, the upper outer quadrant of the breast was involved. in other studies also the upper outer quadrant was the most commonly involved. 9,10 the most common benign breast lesion (51.42%) was fibroadenoma in our study. this was also observed in other studies, where the incidence of fibroadenoma was found to be 61.4% and 57% respectively. 4,11 pawan tiwari in his study found that fibroadenoma was the predominant lesion in benign breast disease. 12 fibrocystic disease was the second most common (22.85%) benign breast lesion seen in our study. this was in agreement with study conducted by pawan tiwari (2013), in which fibrocystic disease was the second common (25.7%) benign breast lesion. 12 najeeb s jabbo (2010) also observed fibrocystic disease as the second common benign breast lesion in his study. 4 in our study, duct ectasia was present in 11.42% of cases. this was in accordance with the study conducted by najeeb s jabbo (2010), in which duct ectasia was present in 8.78% of cases. 4 in the studies conducted by pawan tiwari (2013) and mima mbs et al (2013), the incidence of duct ectasia was 4.4% and 6% respectively. 12,13 in our study, non-lactational breast abscess accounted for 5.71% of benign breast lesions. this was in accordance with the study by siddiqui ms et al (2003), in which breast abscess accounted for 6.8% of cases. 14 this was also observed in the study by bagale p (2013), which had 6.5% of benign breast lesions as breast abscess. 15 incidence of galactocele was 5.71% in our study. in the study conducted by pawan tiwari (2013), the incidence of galactocele was 1.3%. 12 in our study, phyllodes tumor accounted for 2.85% of benign breast lesions. in our study, most of the cases of fibroadenoma were seen in the 3rd decade of life (38.88%). second highest number of cases of fibroadenoma was seen in the 4th decade of life (22.22%). in another study, most cases of fibroadenoma were in the 3rd decade of life (38.57%) followed by the 4th decade (30%). 5 in another study, most cases of fibroadenoma (52.3%) were in the 3rd decade of kapoor et al. / panacea journal of medical sciences 2020;10(3):222–226 225 life. 12 in our study, maximum cases of fibrocystic disease were in the age group of 40-49 years. this was in agreement with the study conducted by chaudhary et al (2003), in which most of the cases of fibrocystic disease were in the 5th decade of life. 16 in our study, the mean age of presentation for non-lactational breast abscess was 43.5 years. study conducted by akhator a (2007) showed that the mean age of presentation for breast abscess was 39 years. 17 in our study, 50% of cases of duct ectasia were seen in the 5th decade of life. this was not in accordance with the study by pawan tiwari (2013), in which most cases (50%) of duct ectasia were seen in the 3rd decade of life. 12 in our study, cases of both phyllodes tumor and galactocele were seen in the 4th decade of life. in our study, fibroadenoma cases commonly presented as lump in the breast (88.88%). common presentation of fibrocystic disease was pain in the breast (62.5%). cases of galactocele presented as lump in the breast. in case of phyllodes tumor, presentation was lump and pain in the breast. in all cases of duct ectasia, nipple discharge was the presenting complaint. cases of breast abscess presented with lump and pain in the breast. in our study, most cases of fibroadenoma presented with duration of symptoms of 1-6 months. in cases of fibrocystic disease duration of symptom was > 12 months in most of the cases. galactocele and phyllodes tumor presented with symptoms of the duration of 7-12 months. duct ectasia presented with symptoms of the duration of 1-6 months mostly. breast abscess presented with the symptoms of the duration of < 1 month in all cases. usually benign breast diseases have long duration of symptoms but in cases of breast abscess, presentation is earlier because of severe pain and fever. in our study, fibroadenoma frequently involved the upper outer quadrant of the breast (72.22%). but in 22.22% of cases of fibroadenoma, lower quadrants both outer and inner were equally involved. in case of fibrocystic disease in our study, upper outer quadrant was involved in 75% of cases. but in 25% of cases inner quadrants both upper and lower were equally involved. all cases of duct ectasia involved the central quadrant. cases of breast abscess involved the upper outer quadrant. all cases of galactocele involved the central quadrant. case of phyllodes tumor involved the upper inner quadrant. overall upper outer quadrant was involved in most of the cases in our study. this was also seen in other studies. 9,10 5. conclusions benign breast diseases are fairly common in the younger age group. patients may be unaware of their problems in the initial stages till symptomatology becomes fairly constant. fibroadenoma is the most common benign breast condition. it can be diagnosed appropriately by proper clinical, radiological and pathological examination. fibrocystic disease is also fairly common benign breast disease. proper assessment and investigations are necessary for its diagnosis. duct ectasia commonly presents as nipple discharge. breast abscess can be diagnosed easily by correlating the symptoms and requires immediate management. the patient needs assurance regarding the benign nature of their disease by appropriate clinical, radiological and pathological diagnosis to allay their anxiety. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. hughes le. benign breast disorders—introduction fibrocystic disease? nondisease? or andi? world j surg. 1989;13(6):667–8. doi:10.1007/bf01658411. 2. sickles ea. detection and diagnosis of breast cancer with mammography. perspect radiol. 1988;1:36–65. 3. miltenburg dm, speights vo. benign breast disease. obstet gynecol clin north am. 2008;35(2):285–300. doi:10.1016/j.ogc.2008.03.008. 4. jabbo ns, jassim ha. pattern of benign female breast disease in ai-yarmouk teaching hospital. mmj. 2010;9:21–4. 5. bartow sa, pathak dr, black wc, key cr, teaf sr. prevalence of benign, atypical, and malignant breast lesions in populations at different risk for breast cancer. a forensic autopsy study. cancer. 1987;60(11):2751–60. doi:10.1002/10970142(19871201)60:11<2751::aid-cncr2820601127>3.0.co;2-m. 6. london sj. a prospective study of benign breast disease and the risk of breast cancer. jama . 1992;267(7):941–4. doi:10.1001/jama.267.7.941. 7. mcdivitt rw, stevens ja, lee nc, et al. histologic types of benign breast disease and the risk for breast cancer. cancer. 1992;69:1408– 14. 8. onukak ee, cederquist ra. bbd in non-western populations: part iii bbd in north nigeria. wjs. 1989;13(6):750–2. 9. gupta jc. breast lumps in jabalpur area. ind j surg. 1983;5:268–73. 10. iyer sp. epidemiology of benign breast diseases in females of childbearing age group. bombay hosp jr. 2000;42:10. 11. rangabhashyam n, gnanaprakasm d, krishnaraj b. spectrum of benign breast lesions in madras. j roy coll surg edinb. 1983;28:369– 73. 12. tiwari p, tiwari m. the current scenario of benign breast diseases in rural india. a clinicopathological study. jemds. 2013;2(27):4933–7. doi:10.14260/jemds/932. 13. mima mbs, keshori p, simon d. a clinico-pathological study on benign breast diseases. j clin diagn res. 2013;7(3):503–6. 14. siddiqui ms, kayani n, gill ms. breast diseases: a histopathological analysis of 3279 cases at a tertiary care centre in pakistan. j pak med assoc. 2003;53(3):5. 15. bagale p, dravid, bagale s. clinicopathological study of benign breast diseases. int health sci res. 2013;3(2):47–54. 16. chaudhary ia, qureshi sk, rasul. pattern of benign breast diseases. j surg pak. 2003;8:5–7. 17. akhator a. benign breast masses in nigeria. nieg jr surg sci. 2008;17(2):105–8. doi:10.4314/njssci.v17i2.38414. http://dx.doi.org/10.1007/bf01658411 http://dx.doi.org/10.1016/j.ogc.2008.03.008 http://dx.doi.org/10.1002/1097-0142(19871201)60:11<2751::aid-cncr2820601127>3.0.co;2-m http://dx.doi.org/10.1002/1097-0142(19871201)60:11<2751::aid-cncr2820601127>3.0.co;2-m http://dx.doi.org/10.1001/jama.267.7.941 http://dx.doi.org/10.14260/jemds/932 http://dx.doi.org/10.4314/njssci.v17i2.38414 226 kapoor et al. / panacea journal of medical sciences 2020;10(3):222–226 author biography bhavuk kapoor, lecturer mayank kapoor, post graduate parul vaid, senior resident bharat b kapoor, former professor and head sharda kapoor, former divisional nodal officer cite this article: kapoor b, kapoor m, vaid p, kapoor bb, kapoor s. epidemiology of benign breast diseases in women. panacea j med sci 2020;10(3):222-226. introduction materials and methods inclusion criteria exclusion criteria statistical analysis results discussion conclusions source of funding conflict of interest panacea journal of medical sciences 2020;10(3):250–257 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article outcome of intrapleural fibrinolytic therapy with streptokinase in loculated pleural effusion patientsan experience from zonal hospital of eastern india rajat shukla1, a k singh2, sumeet arora2, a r rajan3, rachana warrier4, ajai kumar tentu5,* 1dept. of gastroenterology, military hospital namkum, ranchi, jharkhand, india 2dept. of radiology, military hospital namkum, jharkhand, ranchi, india 3dept. of paediatrics, military hospital namkum, ranchi, jharkhand, india 4dept. of medicine, military hospital namkum, ranchi, jharkhand, india 5dept. of respiratory medicine, military hospital namkum, ranchi, jharkhand, india a r t i c l e i n f o article history: received 17-07-2020 accepted 06-08-2020 available online 29-12-2020 keywords: intrapleural fibrinolytic therapy loculated pleural effusion fibrinolytics a b s t r a c t background: loculated pleural effusion is one of the most common clinical entities which are usually caused by empyema, tubercular pleural effusion, malignancy, and hemothorax. the role of intra-pleural fibrinolytic therapy (ipft) with various fibrinolytics has been studied, however its clinical, radiological and functional outcomes are not assessed completely. objective : this is a pre and post intervention study conducted at tertiary care hospital to assess the role of ipft with streptokinase in patients with loculated pleural effusion. results: 102 patients underwent ipft with streptokinase. out of 102 patients, 84 patient were male and 18 were females. main preprocedure diagnosis were tuberculosis (n=70), pneumonia (n=21) and malignancy (n=11). the patients were subdivided into three groups based on sonologically assessed amount of intrapleural fluid group 1 (<100ml), group 2 (100-200ml) and group 3 (>200ml). during pre and post ipft procedure the number of patients identified in group 1 were 30 and 80, group 2 were 40 and 22, group 3 were 32 and none respectively. the mean residual pleural fluid drained before and after ipft were 190.80ml and 57.84ml (p value<0.001), which had statistically significant reduction after ipft. mean fvc before and after ipft were 46.43% and 69.56% (p value<0.05). chest x-ray resolution was observed in 80 of the 102 patients with postprocedure ipft (p value<0.05). adverse effects noticed were chest pain, fever, tachycardia and bleeding. however no major bleeding was observed. conclusion: ipft with streptokinase is a safe option in loculated pleural effusion with no major adverse effects. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction loculated pleural effusions are a common sequelae of complicated parapneumonic effusions and empyema followed by tubercular pleural effusions, haemothorax and malignant effusions. loculations develop due to delayed initiation and inadvertent use of antibiotics and due to prolonged pleural effusion in the setting of inflammation due to various causes. this results in fibrosis in the pleural * corresponding author. e-mail address: drtentu@gmail.com (a. k. tentu). cavity leading to pleural thickening and loss of pulmonary function in due course. the use of intrapleural fibrinolytics is a safer, easier and economical option and studies have shown it to be a useful alternative 1 of the difficult surgical procedures like vats (videoassisted thoracoscopic surgery), thoracotomy and decortication. if the intercostal drainage tube is positioned correctly and there appears to be pleural fluid left in the cavity, then the reasons for failed drainage are loculated pleural fluid collection or tube https://doi.org/10.18231/j.pjms.2020.052 2249-8176/© 2020 innovative publication, all rights reserved. 250 https://doi.org/10.18231/j.pjms.2020.052 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:drtentu@gmail.com https://doi.org/10.18231/j.pjms.2020.052 shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 251 obstruction due to viscous fluid. 2 the other treatment modalities are; flushing with saline, placement of more catheters in loculi after ultrasound localisation, debridement thoracoscopically, thoracotomy along with decortication. the initial two treatment modalities are not so effective in removal of pleural fluid. 3 the other surgical modalities are more invasive, not accessible and if accessible, are not affordable by patients in india and other developing countries. 4 therefore early use of fibrinolytic agents in loculated pleural effusion will result in breaking of loculi and hence increasing pleural space drainage. 2,3 the bts guidelines have also recommended consideration of intrapleural fibrinolytics in failed drainage in complicated parapneumonic effusion and empyema. 5 tillet and sherry were the pioneers in using fibrinolytics along with anti dnase intra-pleurally. they employed instillation of these agents in 23 patients who had complicated pleural effusion in the form of loculations or haemothorax. these compounds were synthesised from streptococci lancefield group ‘c’. there was significant improvement in drainage of fluid. 4–6 this therapy was discontinued until bergh et al. used purified streptokinase which resulted in significant improvement in 10 of 12 patients who had empyema. this was without the need for any major surgical intervention and decrease in major side effects. 7 the newer agents such as urokinase, alteplase, reteplase have overtaken streptokinase for thrombolytic therapy. the answer to successful drainage using fibrinolysis of complicated effusions is correct placement of tubes or catheters under ultrasound guidance as early as possible in patients with complicated pleural effusions, followed by frequent monitoring (more than once daily) of tube placement and fibrinolytic effectiveness by assessing the volume of tube drainage and immediate re-instillation of the fibrinolytic agent if necessary. in the properly selected patient, attention to detail using a strict protocol will be critical in determining a successful outcome. 8 the present study is to assess the outcome of intrapleural fibrinolytic therapy with streptokinase in patients with loculated pleural effusion. 2. materials and methods 2.1. place of study department of respiratory medicine in a tertiary care zonal hospital. 2.2. duration of study three year. 2.3. study population all cases diagnosed as loculated pleural effusion in a tertiary care zonal hospital. 2.4. inclusion criteria 1. persistent fluid and poor chest tube drainage despite an appropriately positioned and patent drain. 2. multiple loculi or fibrin strands in pleura as depicted by ultrasonography or ct scan chest. 2.5. exclusion criteria 1. patients who are less than 18 years of age. 2. known sensitivity to streptokinase. 3. contraindication to thrombolytic therapy haemorrhagic stroke, intracranial neoplasm, cranial surgery or head trauma within 14 days, major thoracic or abdominal surgery within 10 days and pt inr greater than 2. 4. haemothorax and haemorrhagic pleural effusion. 2.6. study design it is a pre-post intervention study which was carried out at tertiary care zonal hospital. the study was approved by the institutional ethics committee and informed consent was obtained from the study participants. 2.7. sample size 102 patients were selected for the study from a tertiary care centre, using suitable sampling technique and when patient satisfied the eligibility criteria. 2.8. methodology diagnosis of a patient with suspected pleural effusion was confirmed initially by chest radiography. baseline spirometry of the patient was recorded. ultrasonography of chest was done for quantification of fluid, presence of loculations and marking of chest wall for site of insertion of intercostal drainage tube (icd). chest tube or pigtail thoracostomy catheter was inserted and fluid drained daily. amount of fluid drained was noted in a chart. if the patient has persistent fluid and poor tube drainage despite an appropriately positioned and patent drain (confirmed by ultrasonography) or multiple loculi or fibrin strands depicted by ultrasonography or ct scan of chest, then the patient was included in the study and ipft was initiated. six doses of streptokinase (2.5 lakh iu in 50 ml normal saline) was instilled in the chest tube at 8 hours interval. tube was clamped for 2 hours after instillation of each dose. clinical response along with daily and cumulative drainage of the tube was noted. x-ray and ultrasonography of chest was done after 48 hours after the instillation of last dose of 252 shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 streptokinase. if there is insignificant drainage and reduction in amount of fluid radiologically (less than 50%), then another cycle of streptokinase was given. the chest tube was removed after daily drainage of pleural fluid is less than 50 ml and is clear and ultrasonography chest also confirms presence of less than 50 ml of fluid in pleural cavity. the cumulative amount of pleural fluid drained after administration of all doses of streptokinase through the thoracostomy tube was calculated and entered in a chart. the expansion of the lung was assessed radiologically by chest x-ray taken before and after the administration of streptokinase. the reduction in the amount of residual pleural fluid by ultrasonography after ipft was calculated. spirometry was done after 48 hours of removal of chest tube. forced vital capacity (fvc) before and after the administration of ipft was calculated. all patients who undergo the study was observed for complications of intrapleural streptokinase therapy. 2.9. statistical analysis the study protocol followed in the patients was depicted in flow chart (supplemental file 1). on completion of the study analysis of data was carried out by paired ‘t’ test, using spss inc. pasw statistics for windows, version 18.0. chicago: usa. all continuous variables were summarized in terms of mean ± standard variation and other categorical variables were calculated as percentage. p < 0.05 was considered statistically significant. 3. results 3.1. demographic profile a total of 102 patients admitted to the tertiary care centre who had radiologically proven loculated pleural effusion were enrolled in the study. the subjects fulfilling the criteria for exclusion were not included. • age distribution-the age of patients was between 18 and 72. the number of patients with age more than 50 is 22 (21.56%). however patients of less than 30 years of age and between 30 and 50 were evenly distributed, 41% and 45% respectively (table 1). • gender distribution84 patients were males (82.35%) and 18 patients were females. this skewed distribution is due to admission of exclusively males in this hospital, where the study was conducted (table 1). 3.2. site of pleural effusion 61 patients had right sided pleural effusion (59%), 32 patients had left sided pleural effusion (31%). however, 9 patients had bilateral pleural effusion and out of them 6 were more than 50 years of age and 3 between 30 and 50 (table 1). 3.3. cause of pleural effusion the cause of pleural effusion is tuberculosis in 69% of patients due to predominantly young soldiers and recruits being treated at this hospital. however, there were 21 cases of pneumonia with complicated parapneumonic effusion and 11 cases of malignant pleural effusion (table 1). the indications of icd insertion in all cases of malignant pleural effusion were to improve the symptoms and to prevent residual pleural thickening. amount of fluid in chest before and after icd insertion on ultrasonography: 30 patients had < 100 ml of pleural fluid followed by 50 and 58 patients who had more than >100 and >200 ml of pleural fluid respectively. however, the ultrasonography method of estimation of fluid is an approximate method and hence fluid extracted were usually more than the fluid estimated by ultrasound. as shown in the graph the patients who had pleural fluid more than 100 and 200 ml were 50 & 58 who were reduced to 40 and 48 after icd insertion. there were 10 patients with less than 100ml pleural fluid who increased to 30 after icd insertion (figure 1a). 70 patients and 48 patients had >100 ml and >200ml of pleural fluid respectively. out of 48 patients, the chest tube was repositioned and residual fluid drained in 16 of 48 patients and in remaining 32 patients ipft was administered. but the cases in whom icd was repositioned were not included in the study. 3.4. amount of residual pleural fluid preprocedure and postprocedure ipft on ultrasonography the patients who had residual fluid with loculations were given streptokinase in six doses as per study protocol and reassessed for the amount of remaining pleural fluid. the ultrasonography chest was performed after the chest tube stopped draining fluid in order to assess the amount of residual pleural fluid and loculation. the number of patients who had residual pleural fluid drastically decreased after ipft, 80 patients had <100ml of fluid left after streptokinase therapy. however around 22 patients had residual pleural fluid more than 100ml after the therapy. the amount of pleural fluid estimated by ultrasound didn’t correlate with the actual amount of fluid drained. hence the patients were grouped into three groups i.e. <100 ml, 100200 ml, 200-300ml preprocedure and postprocedure ipft. the graph plotted against three groups of the patients were depicted in figure 1b. 3.5. mean residual pleural after ipft the mean amount of residual pleural fluid present before the study is 190.80 ml with a standard deviation of 83.26. the mean amount of residual pleural fluid present after administration of streptokinase was 57.84 ml with a standard deviation of 53.14 (figure 2a). shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 253 by using paired t-test p-value < 0.05, therefore there is significant difference between mean amount of residual pleural fluid before and after ipft. this reduction in residual pleural fluid also resulted in improved lung function (figure 2a). moreover the use of ipft for patients with malignant pleural effusion also resulted in improvement of symptoms and these patients underwent chemical pleurodesis as per the standard recommendation. 3.6. lung function before and after ipft the patients underwent fvc maneuver to assess the functional response to ipft. since the patients were on icd in-situ they were made to undergo this procedure with suboptimal effort. they were not made to repeat the procedure more than 3 times and best out of the 3 were recorded. it was found that there were 22 people who had fvc of less than 40% which decreased to 4. the patients who had fvc between 40 and 50% decreased from 50 to 28. however 30 patients had fvc between 50 and 60% which increased to 48 and there were 20 patients who were able to produce an fvc of 60-70%. the maximum fvc attained after ipft was 70% (figure 2b and figure 3). 3.7. number of cycles of ipft most of the patients in study required only one cycle of ipft(six doses of streptokinase) 54% of the study population required one cycle of ipft followed by 36% required 02 cycles of ipft and 10 % required 03 cycles of ipft(figure 4). 3.8. chest x-ray resolution apparent chest x ray resolution was present in 80 out of102patients after administration of ipft. by using paired t-test p-value < 0.05, therefore there is significant resolution of chest x ray before and after ipft (figure 5). 3.9. adverse effects of ipft most common among them were chest pain at the site of icd and fever which was 14% and 10% respectively, followed by tachycardia and bleeding (figure 6). 4. discussion this study represents an institutional experience of intrapleural fibrinolytic therapy. these patients represent those individuals who usually do not respond to traditional modes of treatment for tubercular/parapneumonic/malignant pleural effusion. the first study by bergh et al. 9 and further studies by taylor et al. 10 sanchez et al. 11 clearly showed that intra-pleural streptokinase is safe and effective in improving chest-tube drainage and reducing the hospital stay of patients with complicated parapneumonic effusion and empyema. the above studies 9–11 showed that the patients who receive intra-pleural streptokinase have a reduced necessity for further surgery and a decreased need for hospitalization. hence these results support the hypothesis that streptokinase acts through the lysis of pleural adhesions, and not through the volume of the instilled fluid. this formed the basis of intra-pleural fibrinolysis with streptokinase in loculated pleural effusion. 102 patients underwent this study and was done in hospital patients irrespective of the etiology of effusion. the patients were admitted and observed regarding the outcome of fibrinolytic therapy. the age of patients were between 18 and 72. the number of patients with age more than 50 is 16(16%). however, patients of less than 30 years of age and between 30 and 50 were homogenously distributed, 41% and 45% respectively. the patients with extremes of age were less in the study since this study was done in consecutive 102 patients with the diagnosis of loculated pleural effusion who satisfied the inclusion criteria. out of 102 patients, 84 patients were males (82%), although female gender and characteristics were not exclusion. this skewed distribution is due to admission and observation of male soldiers in a military hospital, where the study was conducted. the cause of pleural effusion is tuberculosis in 69% of patients due to predominantly younger population being treated at this hospital. however there were 21 cases of pneumonia with parapneumonic effusion and 11 cases of malignant pleural effusion. the indication of icd insertion in all cases was to improve the symptoms and to prevent residual pleural thickening in those patients with loculated pleural effusion. the patients with malignant pleural effusion were more than 40 years of age. among them there were 08 smokers and three nonsmokers and 6 were females. two of the patients underwent diagnostic thoracoscopy to establish the diagnosis of malignant pleural effusion. one patient was a case of carcinoma breast with metastasis while the other patient was primary carcinoma lung. sixty one patients had right sided pleural effusion (59%), 32 patients had left sided pleural effusion (31%). however, 9 patients had bilateral pleural effusion and out of them 6 were more than 50 years of age and 3 between 30 and 50. total 118 patient’s underweight icd insertion in the present study. 70 patients had <100 ml of pleural fluid left after icd insertion. however around 48 patients had pleural fluid more than 200 ml of intrapleural fluid. the ultrasonography chest done post procedure revealed persistence of loculi in a different site of chest than the loculi in which icd is placed. the tube was repositioned and residual fluid drained in 16 of 48 patients and in rest 32 patients streptokinase was used to break the loculi. 254 shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 these patients had residual fluid along with loculations or septations and hence were taken up for the study. in 90 of the 102 patients the pleural fluid extracted was more than estimated volume. the patients who had residual fluid with loculations were administered ipft with streptokinase. the patients who had residual fluid along with loculations were included in the study and in most of the patients residual pleural effusion had drastically decreased with 80 patients showing <100 ml of fluid left after ipft and while 22 patients had only >100 ml after ipft. the mean amount of intrapleural fluid present before the study is 190.80 ml with a standard deviation of 83.26. the mean amount of intrapleural fluid present after administration of streptokinase was 57.84ml with a standard deviation of 53.14 (table 3), similar findings were reported in earlier study. 12 there is significant difference between mean amount of intrapleural fluid before and after ipft. thus, the use of ipft with streptokinase in loculated pleural effusion results in statistically significant reduction in the residual amount of intra pleural fluid (p value <0.001). the use of ipft in malignant pleural effusion patients relieved their respiratory symptomatology and also facilitated the patients recuperate for chemical pleurodesis before icd removal. 13 the use of streptokinase in usual six doses resulted in suboptimal drainage of pleural fluid in few patients. the cases with multiple loculi on ultrasound and increased viscosity of pleural fluid on appearance resulted in reduced pleural fluid drainage. these patients were administered 2 or 3 cycles of ipft to break loculi and to aid drainage. each cycle consisted of 6 doses of streptokinase administered in 8 hourly intervals as mentioned earlier. however, it was also found that patients did not require more than 3 cycles of streptokinase to remove the fluid. eleven out of 102 cases that is 10% of patients required 3 cycles of ipft. among them 6 were malignant pleural effusion and 5 were tubercular pleural effusion. apparent chest x-ray resolution was present in 80 out of 102 patients after administration of ipft. by using paired t-test p-value < 0.05, therefore there is significant resolution of chest x-ray before and after ipft. the patients underwent fvc maneuver to assess the functional response to ipft. the maximum fvc attained after ipft was 70%. the mean fvc before ipft was 46% with a standard deviation of 11. the mean fvc post ipft showed an increase of 46% to 70% which is statistically significant (p<0.05) and were comparable to previous study 12 (table 3). most of the patients (76%) did not complain of any perceivable side effects to the fibrinolytic therapy to streptokinase. the side effects recorded were new onset side effects after fibrinolytic therapy and not those complaints which were present before streptokinase therapy. all patients experienced pain at the site of icd, but only those patients who had new onset chest pain or fever were accounted for as the adverse effect of streptokinase. the most common among them were chest pain at the site of icd which was 14%. the incidence of bleeding post-ipft in the literature ranges between 2% and 15% 14–17 which was comparable to our present study. in the mist ii trial, 18 rahman and maskell report on five cases of bleeding, including two cases of intra-pleural bleeding and one case of haemoptysis that occurred in the tpa and dnase arm (5.76%). apropos there were few and transient side effects to the application of intra-pleural streptokinase. fig. 1: a: amount of pleural fluid before and after icd drainage, b: amount of pleural fluid before and after ipft fig. 2: a: mean amount of residual pleural fluid, b: mean fvc before and after ipft fig. 3: fvc before and after ipft shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 255 fig. 4: number of cycles of ipft fig. 5: chest x-ray resolution fig. 6: adverse effects table 1: demographic, anatomical, and etiological profile (n=102) characteristic number percent age (years) <30 41 40.19 30-50 45 44.11 >50 16 15.68 gender male 84 82.35 female 18 17.64 site of pleural effusion right 61 59.80 left 32 31.37 bilateral 9 8.82 final diagnosis tuberculosis 70 68.62 pneumonia 21 20.58 malignancy 11 10.70 table 2: ipft with streptokinase: intervention, outcome, and adverse effect profile (n=102) characteristic number percent number of ipft cycle 1 54 55 2 36 35 3 10 10 chest radiography resolution after ipft yes 80 78.43 no 22 21.56 adverse effects associated with ipft fever 10 10.0 tachycardia (heart rate > 100/min) 4 4.0 chest pain 13 12.7 bleeding 3 3.0 none 72 70.3 table 3: mean residual intra-pleural fluid and mean fvc before and after ipft (n=102) parameter mean sd difference in mean 95% cl of difference in mean p value intrapleural fluid-before ipft 190.80 83.26 132.96 116.6149.3 <0.001 intrapleural fluid-after ipft 57.84 53.14 fvcbefore ipft 46.43 11.04 23.13 20.9625.3 <0.05 fvcafter ipft 69.56 9.67 256 shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 5. conclusion in our prospective intervention study conducted among the patients with loculated pleural effusion, the response of intrapleural fibrinolytic therapy with streptokinase was assessed. the mean amount of intrapleural fluid present after ipft decreased significantly due to fibrinolysis of loculations. multiple doses of ipft were required to drain the fluid in patients with multiple loculi and increased viscosity of the pleural fluid. the assessment of lung function by fvc also showed a statistically significant improvement in most of the patients. the incidence of adverse effects after ipft were low and did not require cessation of the fibrinolytic therapy. no cases of major bleeding was observed in the study population. 6. limitation however the study population was not representative in terms of age and sex distribution. the maximum number of patients who underwent the intervention were cases of tubercular pleural effusion. the intervention however showed improvement in pleural fluid drainage and lung function irrespective of the cause of effusion. there is a dearth of indian studies on the use of streptokinase for intra-pleural fibrinolysis inspite of its proven efficacy in the management of loculated pleural effusion as shown in various international studies. the outcomes of the present study cannot be applied to the general population as the sample size was small and subjects were not representative of the general population. 7. contributors authors a k singh and sumeet arora had done equal contribution to the research work in second authorship while author a r rajan had contributed solely towards third authorship /as third author. 8. acknowledgments the authors would like to thank all the faculty and technical staff of the department of respiratory medicine and department of radiology, military hospital, namkum, for the constant support during this study. 9. source of funding no financial support was received for the work within this manuscript. 10. conflict of interest the authors declare they have no conflict of interest. references 1. simpson g, roomes d, heron m. effects of streptokinase and deoxyribonuclease on viscosity of human surgical and empyema pus. chest. 2000;117(6):1728–33. doi:10.1378/chest.117.6.1728. 2. boland gw, lee mj, silverman s, mueller pr. interventional radiology of the pleural space. clin radiol. 1995;50(4):205–14. doi:10.1016/s0009-9260(05)83471-3. 3. light rw, nguyen t, mulligan me, sasse sa. the in vitro efficacy of varidase versus streptokinase or urokinase for liquefying thick purulent exudative material from loculated empyema. lung. 2000;178(1):13–8. doi:10.1007/s004080000002. 4. barthwal ms, marwah v, chopra m, garg y, tyagi r, kishore k, et al. a five-year study of intrapleural fibrinolytic therapy in loculated pleural collections. indian j chest dis allied sci. 2016;58:17–20. 5. davies cw, gleeson fv, davies rj. bts guidelines for the management of pleural infection. thorax. 2003;58(2):18–8. 6. sherry s, johnson a, tillett ws. the action of streptococcal desoxyribose nuclease (streptodornase)in vitro and on purulent pleural exudations of patients. j clin investig. 1949;28(5 pt 2):1094– 104. doi:10.1172/jci102142. 7. tillett ws, sherry s, christensen lr, johnson aj, hazlehurst g. streptococcal enzymatic debridement. ann surg. 1950;131(1):12–22. doi:10.1097/00000658-195001000-00002. 8. tillett ws, sherry s, read ct. the use of streptokinasestreptodornase in the treatment of postneumonic empyema. j thoracic surg. 1951;21:275–7. doi:10.1016/s0096-5588(20)31273-3. 9. bergh np, ekroth r, larsson s, nagy p. intrapleural streptokinase in the treatment of haemothorax and empyema. scand j thorac cardiovasc surg. 1977;11(3):265–8. 10. taylor rf, rubens mb, pearson mc, barnes nc. intrapleural streptokinase in the management of empyema. thorax. 1994;49(9):856–9. doi:10.1136/thx.49.9.856. 11. jerjes-sanchez c, ramirez-rivera a, elizalde jj, delgado r, cicero r, ibarra-perez c, et al. intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema. chest. 1996;109(6):1514–9. doi:10.1378/chest.109.6.1514. 12. subramanian n, bhattacharyya d, khan id, prasad v, kotaru a, vardhan v, et al. intrapleural fibrinolysis in post-tubercular loculated pleural effusions at a tertiary-care respiratory center: an uncontrolled blinded before-after intervention study. hosp pract res. 2018;3(2):59–63. doi:10.15171/hpr.2018.12. 13. tassi gf, cardillo g, marchetti gp, carleo f, martelli m. diagnostic and therapeutical management of malignant pleural effusion. ann oncol. 2006;17(2):ii11–2. 14. maskell na, davies cwh, nunn aj, hedley el, gleeson fv, miller r, et al. u.k. controlled trial of intrapleural streptokinase for pleural infection. n engl j med. 2005;352(9):865–74. doi:10.1056/nejmoa042473. 15. skeete da, rutherford ej, schlidt sa, abrams je, parker la, rich pb, et al. intrapleural tissue plasminogen activator for complicated pleural effusions. j trauma: injury, infect, crit care. 2004;57(6):1178–83. doi:10.1097/01.ta.0000141879.67441.52. 16. thommi g, nair ck, aronow ws, shehan c, meyers p, mcleay m, et al. efficacy and safety of intrapleural instillation of alteplase in the management of complicated pleural effusion or empyema. am j ther. 2007;14(4):341–5. doi:10.1097/01.mjt.0000208275.88120.d1. 17. froudarakis me, kouliatsis g, steiropoulos p, anevlavis s, pataka a, popidou m, et al. recombinant tissue plasminogen activator in the treatment of pleural infections in adults. respir med. 2008;102(12):1694–700. doi:10.1016/j.rmed.2008.08.012. 18. rahman nm, maskell na, west a, teoh r, arnold a, mackinlay c, et al. intrapleural use of tissue plasminogen activator and dnase in pleural infection. n engl j med. 2011;365:518–26. author biography rajat shukla, commandant & senior gastroenterologist a k singh, senior advisor (radiology) http://dx.doi.org/10.1378/chest.117.6.1728 http://dx.doi.org/10.1016/s0009-9260(05)83471-3 http://dx.doi.org/10.1007/s004080000002 http://dx.doi.org/10.1172/jci102142 http://dx.doi.org/10.1097/00000658-195001000-00002 http://dx.doi.org/10.1016/s0096-5588(20)31273-3 http://dx.doi.org/10.1136/thx.49.9.856 http://dx.doi.org/10.1378/chest.109.6.1514 http://dx.doi.org/10.15171/hpr.2018.12 http://dx.doi.org/10.1056/nejmoa042473 http://dx.doi.org/10.1097/01.ta.0000141879.67441.52 http://dx.doi.org/10.1097/01.mjt.0000208275.88120.d1 http://dx.doi.org/10.1016/j.rmed.2008.08.012 shukla et al. / panacea journal of medical sciences 2020;10(3):250–257 257 sumeet arora, senior advisor (radiology) a r rajan, senior paediatrician rachana warrier, physician ajai kumar tentu, associate professor & hod cite this article: shukla r, singh ak, arora s, rajan ar, warrier r, tentu ak. outcome of intrapleural fibrinolytic therapy with streptokinase in loculated pleural effusion patientsan experience from zonal hospital of eastern india. panacea j med sci 2020;10(3):250-257. introduction materials and methods place of study duration of study study population inclusion criteria exclusion criteria study design sample size methodology statistical analysis results demographic profile site of pleural effusion cause of pleural effusion amount of residual pleural fluid preprocedure and postprocedure ipft on ultrasonography mean residual pleural after ipft lung function before and after ipft number of cycles of ipft chest x-ray resolution adverse effects of ipft discussion conclusion limitation contributors acknowledgments source of funding conflict of interest 429 too many requests you have sent too many requests in a given amount of time. original research article doi: 10.18231/2348-7682.2018.0026 panacea journal of medical sciences, september-december, 2018;8(3):113-115 113 clinical profile of dyselectrolytemia in diabetic patients in icu at admission and its correlation with outcome arun pandey1,*, abhinav naithani2, anuj bagga3 1senior resident, 2post graduate resident, 3pg resident, 1doon government hospital and medical college, uttarakhand, 2,3shri guru ram rai institute of medical & health sciences, uttarakhand, india *corresponding author: email: arun_pandey09@yahoo.co.in abstract electrolyte imbalances are common problem in critically ill patients. diabetes mellitus (dm) is one of the diseases with increased frequency of electrolyte abnormalities which can be due to various factors most commonly due to impaired renal function, acid-base disorders, malabsorption syndromes or it can be due to multidrug regimens. this study included 40 subjects admitted in the intensive care units of sgrr institute of medical and health sciences to look at the clinical profile of dyselectrolytemia in diabetic patients admitted in icu. hyponatremia was the most common dyselectrolytemia. most of the patients with renal failure had hypermagnesemia and hyperkalemia. hypertension was the most common co-morbidity. keywords: diabetes mellitus, dyselectrolytemia, clinical profile. introduction icu is the highest mortality unit in any hospital with average mortality rate reported ranging from 8-19%.1 electrolyte disturbances are present in around 25% of patients in icu and contribute to overall mortality in icu.2 diabetes mellitus (dm) is one of the diseases with increased frequency of electrolyte abnormalities due to presence of factors like hyperglycemia, impaired renal function, malabsorption syndromes, acid-base disorders and multidrug regimens.3-6 the purpose of this study was to increase awareness of many electrolyte disturbances that can be prevented by attention to the primary illness, medications used and intravenous fluids and nutrition in icu patients. materials and methods the study was conducted in department of medicine at sgrr institute of medical and health sciences, dehradun from december 2016 to march 2017. it included 40 patients admitted in the intensive care units. the patients had type 2 diabetes mellitus presented with dyselectrolytemias, which included disturbances in serum level of sodium, potassium and magnesium, were included in the study. the patients so enrolled in the study were evaluated using a thorough clinical history in each case with special emphasis on duration of primary illness, medications used and clinical manifestations of electrolyte imbalance. serum electrolyte levels including na, k and mg levels were done at the time of admission. these patients were followed for the whole duration of stay in the icu and were observed for the serial electrolyte levels, associated comorbidities and outcome in terms of mortality. the data so obtained was analyzed by using suitable statistical methods. results out of all the patients admitted in icu with diabetes and co-morbidities during the study period, the most common cause of admission to icu was acute coronary syndromes (acs) (42.50%) followed by renal failure (15%). sepsis (10%), renal failure with sepsis (7.5%) cerebrovascular accidents cva (7.5%) and pneumonia (5%) were other causes of icu admission (fig. 1, table 1 to 3). fig. 1: diagnosis of patients admitted in icu hypertension (57.5%) was the most common comorbidity observed in the study group. anemia was present in 20% patients and hypothyroidism in 12.5% patients (fig. 2). fig. 2: co-morbidities seen with dm arun pandey et al. clinical profile of dyselectrolytemia in diabetic patients in icu at admission…. panacea journal of medical sciences, september-december, 2018;8(3):113-115 114 table 1: pattern of dyselectrolytemia single electrolyte disturbance two ectrolyte disturbances all electrolytes disturbances 17 18 5 16 had hyponatremia and 1 had hypokalemia 7 had hypernatremia with hypomagnesemia 5 had hyponatremia with hypermagnesemia 2 had hyponatremia with hyperkalemia 2 had hypernatremia with hypermagnesemia 1 had hypokalemia with hypermagnesemia 1 had hyperkalemia with hypermagnesemia 3 had hyponatremia with hypokalemia with hypomagnesemia 2 had hyponatremia with hyperkalemia with hypermagnesemia table 2: comparison of mortality between single and multiple electrolyte disturbances pattern of dyselectrolytemia total number mortality (%) total no. of dyselectrolytemia 40 6(15%) single electrolyte disurbance 17 3(17.6%) multiple electrolyte disturbance 23 3(13.0%) table 3: comparison of mortality between severity of electrolyte disturbances total number mortality (%) total no of dyselectrolytemia 40 6 (15%) severe dyselectrolytemia 3 2 had hyponatremia (na<120),1 had hyperkalemia (k>7) 1 (33.3%) mild to moderate dyselectrolytemia 37 5 (13.5%) discussion electrolyte abnormalities are common in diabetic patients and may be associated with increased morbidity and mortality.4 factors include hyperglycemia, episodes of hypoglycemia, impaired renal function, malabsorption syndromes, acid-base disorders and multidrug regimens.5 dm is linked to both hypoand hyper-natremia reflecting the coexistence of hyperglycemia-related mechanisms.6-7 a study by liamis et al showed that uncontrolled dm can induce hypovolemic-hyponatremia due to osmotic dieresis.8 beukhof cm et al proved drug-induced hyponatremia to be due to hypoglycemic agents (chlorpropamide, tolbutamide, insulin) or other medications (e.g. amitriptyline for the treatment of diabetic neuropathy).9,10 kadowaki t and moses am et al showed that elderly patients concomitantly using diuretics have greater risk of developing hyponatremia.11,12 but in our study, out of 10 patients (all hyponatremic) taking diuretics (torsemide in 8 and furosemide in 2) only 2 patients had decrease in serial sodium concentration. biff f. palmer et al showed increased or normal plasma sodium concentrations in the presence of hyperglycemia as an indicator of clinically significant deficit in total body water.7 uribarri j showed in his study that incidence of hyperkalemia is higher in diabetic patients than in the general population.13,14 chronic hyperkalemia in diabetics is most often attributable to hyporeninemic hypoaldosteronism. many drugs that interfere with k+ excretion are associated with hyperkalemia, including angiotensin-converting enzyme inhibitors, angiotensin ii receptor blockers, renin inhibitors, beta blockers and potassium-sparing diuretics. in our study 5 patients had hyperkalemia and their potassium returned to normal with drugs like insulin and salbutamol. while 2 patients with normal potassium level at admission developed hyperkalemia without any medicine or presence of renal failure. the causes of hypokalemia in diabetics include shift hypokalemia due to insulin administration, gastrointestinal loss of k+ due to diabetic-induced motility disorders and renal loss of k+ (due to osmotic diuresis and/or coexistent hypomagnesemia). the increased secretion of epinephrine due to insulin-induced hypoglycemia may also play a contributory role.15 in our study, 5 patients had hypokalemia at admission. 3 had hypomagnesemia at admission, 1 had normal and 1 had high magnesium level. all were on insulin therapy but only 2 of them had further fall in potassium level. hypomagnesemia is a frequent electrolyte disorder in diabetic patients.16 recently, dm was identified as an independent risk factor for hypomagnesemia.2 osmotic diuresis was the prominent underlying mechanism followed by diarrhea (as a result of diabetic autonomic neuropathy or metformin) and intracellular shift by insulin and epinephrine (during hypoglycemic episode).17-20 in our study 10 patients had hypomagnesemia at admission, i.e. 25%, reflecting contribution of solely the disease on magnesium level. although various studies have reported decreased levels of magnesium in type 2 diabetes patients, in our study 11 patients had hypomagnesaemia, i.e. more common than hypomagnesemia. this could be explained due to presence of renal failure in 9 patients, 1 had septic shock and other had periampullary carcinoma, both without renal failure. arun pandey et al. clinical profile of dyselectrolytemia in diabetic patients in icu at admission…. panacea journal of medical sciences, september-december, 2018;8(3):113-115 115 conclusion mortality was 15% in our study. hypertension was the most common co-morbidity. hyponatremia was the most common dyselectrolytemia. besides 2 patients, all patients with renal failure had hypomagnesaemia and 3 of 5 patients with hyperkalemia had renal failure. severity of dyselectrolytemia seems to affect mortality. presence of more than one electrolyte imbalance did not seem to affect mortality in this study. conflict of interest: none. references 1. philip r. lee. icu outcomes (mortality and length of stay) methods, data collection tool and data. 2. buckley ms, leblanc jm, cawley mj. electrolyte disturbances associated with commonly prescribed medications in the intensive care unit. crit care med 2010;38(suppl.):s253-s264. 3. elisaf ms, tsatsoulis aa, katopodis kp, siamopoulos kc. acid-base and electrolyte disturbances in patients with diabetic ketoacidosis. diabetes res clin pract 1996;34:23–27. 4. george liamis, evangelos liberopoulos, fotios barkas, moses elisaf. diabetes mellitus and electrolyte disorders. world j clin cases 2014;2(10):488–496. 5. elisaf ms, tsatsoulis aa, katopodis kp, siamopoulos kc. acid-base and electrolyte disturbances in patients with diabetic ketoacidosis. diabetes res clin pract 1996;34:23–27. 6. biff f. palmer, deborah j. clegg. electrolyte and acid–base disturbances in patients with diabetes mellitus. n engl j med 2015;373:548-559. 7. liamis g, milionis hj, elisaf m. hyponatremia in patients with infectious diseases. j infect 2011;63:327–335. 8. liamis g, milionis h, elisaf m. a review of drug-induced hyponatremia. am j kidney dis 2008;52:144–153. 9. beukhof cm, hoorn ej, lindemans j, zietse r. novel risk factors for hospital-acquired hyponatraemia: a matched casecontrol study. clin endocrinol 2007;66:367–372. 10. kadowaki t, hagura r, kajinuma h, kuzuya n, yoshida s. chlorpropamide-induced hyponatremia: incidence and risk factors. diabetes care 1983;6:468–471. 11. moses am, howanitz j, miller m. diuretic action of three sulfonylurea drugs. ann intern med 1973;78:541–544. 12. palmer bf. managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. n engl j med 2004;351:585–592. 13. uribarri j, oh ms, carroll hj. hyperkalemia in diabetes mellitus. j diabet complications 1990;4:3–7. 14. petersen kg, schlüter kj, kerp l. regulation of serum potassium during insulin-induced hypoglycemia. diabetes 1982;31:615–617. 15. pham pc, pham pm, pham sv, miller jm, pham pt. hypomagnesemia in patients with type 2 diabetes. clin j am soc nephrol 2007;2:366–373. 16. liamis g, liberopoulos e, alexandridis g, elisaf m. hypomagnesemia in a department of internal medicine. magnes res 2012;25:149–158. 17. svare a. a patient presenting with symptomatic hypomagnesemia caused by metformin-induced diarrhoea: a case report. cases j 2009;2:156. 18. paolisso g, sgambato s, passariello n, giugliano d, scheen a, d’onofrio f, et al. insulin induces opposite changes in plasma and erythrocyte magnesium concentrations in normal man. diabetologia 1986;29:644–647. 19. matsumura m, nakashima a, tofuku y. electrolyte disorders following massive insulin overdose in a patient with type 2 diabetes. intern med 2000;39:55–57. https://www.ncbi.nlm.nih.gov/pubmed/?term=liamis%20g%5bauthor%5d&cauthor=true&cauthor_uid=25325058 https://www.ncbi.nlm.nih.gov/pubmed/?term=liberopoulos%20e%5bauthor%5d&cauthor=true&cauthor_uid=25325058 https://www.ncbi.nlm.nih.gov/pubmed/?term=barkas%20f%5bauthor%5d&cauthor=true&cauthor_uid=25325058 https://www.ncbi.nlm.nih.gov/pubmed/?term=elisaf%20m%5bauthor%5d&cauthor=true&cauthor_uid=25325058 https://www.ncbi.nlm.nih.gov/pubmed/?term=elisaf%20m%5bauthor%5d&cauthor=true&cauthor_uid=25325058 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4198400/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4198400/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4198400/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4198400/ 429 too many requests you have sent too many requests in a given amount of time. original research article doi: 10.18231/2348-7682.2018.0017 panacea journal of medical sciences, may-august, 2018;8(2):70-78 70 morphological spectrum of intracranial meningiomas on computed tomography (ct) and magnetic resonance imaging (mri) rishi philip mathew1,*, kumar muthukumar2, praveen kumar natesan3, muthukalathi karunakaran4 1consultant, 2,3,4senior consultant, dept. of radio-diagnosis, k.g. hospital and postgraduate medical institute, coimbatore, tamil nadu, india *corresponding author: email: dr_rishimathew@yahoo.com abstract meningiomas are the most common extra axial and non-glial primary neoplasms of the central nervous system. they account for nearly 15% of all intracranial neoplasms. the present study was planned to identify and describe the morphological and imaging characteristics of both typical and atypical meningiomas on ct and mri, including diffusion weighted imaging (dwi) and mr spectroscopy (mrs). ct and mri images of 43 patients histologically proven to have meningioma were retrospectively evaluated. the images were evaluated fortumor location, imaging characteristics, atypical patterns of presentation and as well as advanced imaging features. statistical analysis used included percentage and frequency. institutional ethical committee clearance was obtained prior to commencement of the study. our study population comprised of 23 females and 20 males. the bulk of our population belonged to 5th decade group (44%). the most common tumor site was the frontal lobe (40%). features seen on imaging includedwell defined margins (100%), broad dural base (67%), calcification-84% (n=36/43) and peritumoral edema (51%). on mri, 84% and 67% of the lesions were t1 isointense and t2 mildly hyperintense respectively, when compared to the brain parenchyma, diffusion restriction was variable (benign meningiomas46% and atypical meningiomas-100%). choline (100%) and alanine peaks (28%) were observed on mrs. on post contrast imaging, homogeneous enhancement was seen in 95%, while a dural tail was seen in only 51% of the cases. benign meningiomas present with typical extra-axial features (broad dural base, white matter buckling, csf cleft, dural tail etc.), while atypical meningiomas have varied presentations which include-cystic/necrotic areas, significant vasogenic edema with mass effect and diffusion restriction on dwi. keywords: meningioma, extra-axial lesion, dural tail. introduction meningiomas are the most common extra axial and non-glial primary neoplasms of the central nervous system. they account for nearly 15% of all intracranial neoplasms. the majority of meningiomas are benign and up to 10% are atypical or malignant, characterised histologically by necrosis, nuclear disorganization, prominent nucleoli and increased mitosis1. meningiomas are more commonly seen in the middle and late decades of life with a strong female predilection (2:1).2 early detection of meningiomas with accurate diagnosis has considerably improved over the years with advancement of multi-detector computed tomography (mdct) and magnetic resonance imaging (mri) technology. these crosssectional imaging modalities not only provide useful information regarding the meningioma structure and composition but also inputs regarding their functional aspect. once a meningiomas has been detected imaging plays a crucial role in pre-operative planning and postoperative evaluation.3 materials and methods images (ct and mri) of 43 patients with histologically proven intracranial meningiomas were retrospectively evaluated from our hospital database from 2010 to 2016 following approval from our institutional ethics committee board. ct scan was carried out by a 128 slice mdct siemens (somatom as+) scanner with standard ct protocol for head and neck. non-ionic iodinated contrast material was administered in all patients to evaluate the lesion enhancement pattern and characteristics. mr imaging was carried out on a 1.5 tesla scanner (siemens magnetom avanto, erlangen, germany) by a using a dedicated head coil. the imaging protocol used were-axial and sagittal t1 weighted (w) spinecho (se) (tr/te: 500/50 ms), axial and coronal t2w turbo se (tr/te: 4000/90 ms), axial and coronal postcontrastt1wse (tr/te:500/50 ms) imaging after intravenous contrast injection (gadopentetate dimeglumine_0.1 mmol/kg), with a 5mm thickness and 10% interslice gap. all studies also included a single shot echo planar dw imaging (applied three b values with a maximum of 1000s/mm2 and a tr/te of 3500/94 ms; matrix of 256–512, 5mm slice thickness) in the axial plane. adc maps were automatically generated on site and transferred to the picture archiving and communication systems (pacs).the conventional images were evaluated forthe tumor site, presence/absence of edema, presence/absence of extraaxial signs (eg. csf cleft, displaced and expanded subarachnoid vessels, gray-white matter buckling, broad dural base and bony hyperostosis), presence of signal voids on t1 and t2 (calcification/ vessels/ fibrosis), presence of haemorrhage, heterogeneity, presence of necrosis/cystic areas, presence of calcification, margins (well defined or ill-defined) and bone changes. adc values were calculated by using a software available on the workstation provided by the rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 71 manufacturer. to minimize variability, intratumoral adc values were obtained by placing manually the region of interest (rois) in the solid part of the tumor, excluding cystic or calcific areas. for large lesions, mean values of 3 rois were obtained. control adc values were recorded by placing rois in the normal white matter of brain parenchyma on the contralateral side unaffected by the tumor. the adc ratio was calculated using the formulae: adc ratio= adc of the tumor ÷ adc of normal white matter. single voxel point resolved mr spectroscopy (mrs) was performed after conventional mr imaging examination using a standard head coil in all cases. a volume of interest of 1.0 to 8.0 ml was selected from the centre of the lesion with edges of the voxel well within the solid tumoral portion, avoiding cystic or necrotic areas when present, and with minimum contamination from the surrounding non-tumoral tissue. four proton mr spectra were acquired from the same volume of interest for every case: 1) water-suppressed spin-echo short te (2000/30/ 92–184) (tr/te/averages); 2) water-suppressed spin-echo long te (2000/136/126 –252); 3) unsuppressed water spinecho long te (2000/136/16); and 4) unsuppressed water spin-echo short te (2000/30/16). a total of 512 data points was collected over a spectral width of 1000 hz. spectrum analysis was performed off-line with the available software. assignment of resonances of interest includedlipids(lip09) at 0.90 ppm, lipids (lip13) at 1.30 ppm, lactate (lact) as a doublet centred at 1.35 ppm, alanine (ala) as a doublet centred at 1.47 ppm, n-acetylaspartate and other n-acetylcontaining compounds (nacc) at 2.02 ppm, glutamate and glutamine (glx) at 2.35 ppm, creatine plus phosphocreatine (cr) at 3.03 ppm, choline and other trimethylaminecontaining compounds (cho) at 3.20 ppm, and glycine or myo-inositol (gly/mi) at 3.55 ppm. the assignment of resonances was based on previous documented studies of brain tumors and phantom studies. statistical analysis included percentage frequency. results females formed the bulk of our patients (53%, i.e. n= 23/43). majority of the patients belonged to the 5th decade age group (44%), followed by the 6th decade (23%) (fig. 1). fig. 1: age distribution of study population with regards to the tumour site (fig. 2), majority of the meningiomas in our study were located in the frontal lobe (n= 17/43 i.e. 40%), parietal lobe (n= 14/43 i.e. 33%), temporal lobe (n= 8/43 i.e. 19%). all the lesions in our study population presented with welldefined margins. solid density was observed in 95% of the lesions, with cystic/ necrotic areas noted in only 2 cases. calcification was observed in 84% of the cases (n=36/43), of which two cases (one benign and one atypical) showed intense or hyper-calcification (fig. 3). rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 72 fig. 2: meningiomas and their various sites seen in our study populationparasagittal (2a), olfactory groove (2b), left frontal lobe (2c), right parietal lobe (2d), left tentorial (2e), left temporal lobe, (2f), meckel’s cave (2g), 4th ventricle (2h) fig. 3: ct axial (3a), coronal (3b) and mr swi (3c) and gre source (3d) images showing a right parietal lobe meningioma (who grade 1) with hyper-calcification in a 62 year old female patient all of the lesions (95%) except for two showed homogeneous enhancement after contrast administration. 80% of the cases showed intense homogeneous enhancement. on plain ct, all of the cases except for one were hyperdense compared to brain parenchyma. the one case where the lesion was isodense to brain parenchyma was located in the left temporal lobe, obliterating the left sylvian fissure and adjacent gyri raising the suspicion of a possible mass, which was confirmed following intravenous contrast administration. on t1-wi, 84% of the cases (n=36/43) were isointense to the adjacent grey matter, while the other cases were hypointense. on t2-wi, 67% (n= 29/43) of the cases were mildly hyperintense when compared to adjacent grey matter, while the remaining cases were isointense. extra-axial features that were observed in our study includeda broad dural base 67% (n= 29/43), white matter buckling-74% (n=32/43), a csf cleft56% (n=24/10) and a dural tail-51% (n=22/43). adjacent subarachnoid vessels were displaced in 35% (n= 15/43) of the cases. peritumoral edema was noted in 50% of the cases, of which two cases (5%) presented with severe vasogenic edema and mass effect. on dwi, 41 of the benign meningiomas had variable single intensity, hypointense (n=7), isointense (n=15) and hyperintense (n=19). two atypical cases of meningiomas showed hyperintensity on dwi. the mean adc values were0.96 ±0.4×10−3mm2/s for benign meningiomas and 0.82 ±0.1×10−3mm2/s for atypical meningiomas. on mrs, a rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 73 choline peak (100%) was noted in all of the cases, while a discernible alanine peak was observed in 28% (n=12/43) of the cases. two cases which had atypical imaging featurescystic/necrotic areas, heterogenous enhancement and extensive vasogenic edema with mass effect in the form of midline shift, were histologically proven to be atypical (grade 2) meningiomas (fig. 4). fig. 4: a right temporallobe atypical meningioma (who grade 2) in a 65-year-old male patient, showing cystic/necrotic areas, with heterogenous enhancement, significant mass effect and strong peritumoral edema a summary of the morphological features of intracranial meningiomas seen in our study group has been summarized in table 1. table 1: summary of the morphological features of meningioma in our study group males vs females 47% (n= 20/43) vs. 53% (n =23/43) commonest age group 5th decade (44%) commonest tumor location frontal lobe= 17/43 (40%) tumor margin well defined (100%) tumor density solid density= 41/43 (95%) solid-cystic density= 2/43 (5%) calcification n=36/43 (84%) hyper-calcification= 2 cases enhancement pattern homogenous= 41/43 (95%) heterogenous= 2/43 (5%) extra axial features white matter buckling: n=32 (74%) signal void pseudocapsule: n=5 (12%) csf cleft: n= 24 (56%) dural tail: n=10 (23%) subarachnoid vessel displacement: n=15 (35%) broad dural base: n=38 (88%) peritumoral edema n= 22/43 (51%) who grade of meningioma grade i (benign meningioma) = 95% grade ii (atypical meningioma) = 5% grade iii (anaplastic meningioma) =0 imaging features of atypical meningiomas (n=2) in our study group cystic/necrotic areas: n= 2/2 (100%) ring enhancement: n=1/2 (50%) hyper-calcification: n=1/2 (50%) severe peritumoral edema with midline shift: n= 2/2 (100%) intraventricular location: n=1/2 (50%) rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 74 discussion meningiomas are the most common non-glial primary intracranial tumors. these extra-axial neoplasms arise from arachnoid cap cells located along the dural venous sinuses, however they may also arise from meningothelial cells located in spinal or ectopic locations.4 although they may be seen in any region of the central nervous system (cns), the majority are commonly seen over the cerebral convexities or at the cranial base. the overall incidence of meningiomas in the general population is roughly about 2.3/ 100,000 people.5 the incidence of intracranial meningiomas increases with every decade and peaks in the 7th decade in men (6/100,000 people) and in the 8th decade among women (9.5/100,000 people).5,6 meningiomas are rare in young adults and children, they have an incidence of about of 1-3% of all intracranial tumors in people aged up to 20 years and 13.5% up to the age of 20-34 years, which is considerably lower than the incidence seen in patients greater than 40 years of age. meningiomas are more common among males in patients aged less than 20 years while they have a female predominance among patients aged more than 20.2,7 meningiomas are graded into 3 subtypes (grade i, ii and iii) based on the world health organization (who) classification. approximately 78% of all meningiomas are benign (who grade i), 20.4% are who grade ii or atypical with a high tendency to recur and 1.6% are who grade iii or anaplastic.8 benign meningiomas (fig. 5) have been further subclassified based on their histopathological features as-meningothelial, fibrous (fibroblastic), transitional (mixed), psammomatous, angiomatous, microcystic, secretory, lymphoplasmacyte-rich and metaplastic.9 fig. 5: histology showing a benign meningioma with psammoma bodies a rare entity called benign metastasizing meningioma has also been reported.10 a high percentage of meningiomas in patients under the age of 20 years have been reported to be histologically atypical or anaplastic, displaying an aggressive pattern of growth and recurrence. the most common intracranial site for meningiomas includecerebral convexities (20-34%), parasagittal location (18-22%) and the sphenoid ridge (17-25%). cerebellopontine angle (cpa) is another common site for meningiomas, and these tumors account for nearly 10-15% of all cpa tumours.4,11 intraventricular meningiomas account for only 0.53%,12 while extracranial meningiomas are extremely rare, accounting for less than 2% of all meningiomas, of which nearly 68% have calvarial involvement. intraosseous meningiomas have rarely been reported in the frontoparietal and orbital regions.13 the exact etiology of meningiomas have not been understood. however, they have been known to be associated with neurofibromatosis type 2, radiation and trauma.14 other genetic conditions that may predispose to meningiomas includemeningioangiomatosis (ma), gorlin syndrome and down’s syndrome.15 plain radiography has been superseded by advanced modalities such as mdct and mri. in majority of the patients, plain radiographs are normal. findings when present includehyperostosis, calcification, and osteolysis associated with the tumours.16 on plain mdct, meningiomas appear as lobulated, homogenous hyperdense masses when compared to the brain parenchyma. following contrast administration, these tumours usually show intense and homogenous enhancement. calcification is seen in 20-27% of all cases and is usually punctated, but can be large, conglomerate, peripheral or central. additional features include hyperostosis (18-50%) of the adjacent calvarial bone or skull base and rarely bone destruction may be seen in approximately 3% of the cases.17 on noncontrast mri, meningiomas appear as well defined, lobular, extra axial masses with inward displacement of cortical gray matter. the tumors appear hypoto isointense on t1 weighted images (t1-wi) and isoto hyper-intense on t2 weighted images (t2-wi). on post contrast images following administration of gadolinium, the masses show early homogenous enhancement persisting late into the venous phase, also known as the ‘mother in law’ phenomenon.3,18 the ‘dural tail’ sign, although is seen in approximately 60% of all cases of meningioma on post contrast ct and mr images. it refers to the linear dural enhancement seen adjacent to the lesion. the ‘dural tail’ sign is not specific for meningioma and may be seen with other tumours such aschloroma, lymphoma, sarcoidosis, vestibular schwannoma, metastases, syphilitic gumma and aggressive papillary middle ear tumor.19,20 goldsher et al in 1990 adopted criteria to establish the presence of a dural tail on imaging. these were(a) the tail should be seen on two successive imaging sections through the tumor, (b) the tail should taper smoothly away from the tumor, and (c) the tail must enhance more than that of the tumour itself.21 other additional findings which may be seen on mri include perilesional edema and hyperostosis. imaging findings confirming the extra-axial location of the lesion includepresence of a csf cleft, pseudocapsule and gray-white matter buckling of underlying brain parenchyma.22 diffusion weighted imaging may be rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 75 useful to differentiate grade i meningiomas from grade ii/iiii meningiomas. nagar va and et al23 retrospectively compared conventional and dw mr images (b-value 1000 s/mm2) between 25 atypical/malignant and 23 benign meningiomas and found that the mean adc of atypical/malignant meningiomas (0.66 ± 0.13 × 10−3 mm2/s) were significantly lower when compared to benign meningiomas (0.88 ± 0.08 × 10−3 mm2/s). in addition to this, the mean nadc (normalized adc) ratio in the atypical/malignant group (0.91 ± 0.18) were also significantly lower than the benign group (1.28 ± 0.11), without overlap between groups. surov a and et al24 conducted a similar study in 2015 and found that the mean adcmean value were higher in grade i meningiomas in comparison to grade ii/iii tumors (0.96 vs 0.80 × 10− 3 mm2s− 1 and grade ii/iii meningiomas showed lower nadc values when compared to grade i tumors (1.05 vs 1.26). it was also noted that a decrease in adc and nadc on follow-up imaging could suggest dedifferentiation to a higher tumor grade. magnetic resonance spectroscopy (mrs) of typical and atypical meningiomas show characteristic prominent choline peak, absent or reduced amount of n-acetyl aspartate (naa) and creatinine (cr) and presence of alanine (ala) peaks. mrs cannot reliably differentiate typical from atypical meningiomas.25 patients with atypical meningioma (who grade ii) may show a lactate peak on mrs26. kousi and et al27 in their mr spectroscopic data analysis of 50 intracranial lesions (comprising 17 meningiomas, 24 high grade gliomas and 9 metastases) using 3 tesla (3t) mri, noted meningiomas to have a distinct signal at 3.8 ppm, enabling the differentiation of meningiomas from other cerebral lesions. they also noted that when long te was performed meningiomas had the highest mean cho/cr ratio and the highest cho/naa ratio among all intracranial tumours. the various metrics of diffusion tensor imaging (dti) may be useful in differentiating the subtypes of meningioma. jolapara and et al28 retrospectively evaluated the various dti metrics (tumor mean diffusivity (dav), fractional anisotropy (fa), linear anisotropy (cl), planar anisotropy (cp), spherical anisotropy (cs) and eigen values (e1, e2, e3)) in 21 patients with meningioma (benign-16 and atypical-5). they noted that among the various dti metrics both atypical and fibroblastic meningiomas showed statistically significant higher cp values and lower e3 values when compared with transitional meningiomas. toh et al29 in their evaluation of 24 cases of meningioma (12 classic and 12 atypical) with dti noted that classic meningiomas significantly had lower fractional anisotropy (fa) when compared to atypical meningiomas, and concluded that the intratumoral microscopic water motion is less organized in classic than in atypical meningiomas. single photon emission computed tomography (spect) and positron emission tomography (pet) may be useful to provide information regarding the various cellular processes and characteristics of meningiomas. numerous radiopharmaceuticals used in spect and pet are available for imaging of meningiomas, each having their own advantage and disadvantages (table 2).30 table 2: a summary of the spect and pet radiopharmaceuticals used in the evaluation of meningiomas tracer imaging modality advantages disadvantages thallium-201 spect information of tumor biological characteristics limited imaging properties, serial brain spect studies 99mtc-labelled compounds spect viability marker, prediction of anticancer drug resistance related to pgp small series of patients, the correlation between tracer uptake and tumor grading or other biological characteristics, needs validation with further studies 111in-octreide and 99mtc-depreotide spect high sensitivity and negative predictive value, differential diagnosis from somatostatin receptor-negative and orbital tumours, differentiation between postoperative scar and recurrence, selection of patients for somatostatin analogue-based therapies specificity depends on the bbb integrity, difficulty in detecting small tumors, limited imaging properties of 111in, few studies with 99mtcdepreotide 18f-fdg pet prognostic information (prediction of recurrence and survival) high uptake in normal gray matter not tumor specific 11c or 18f labelled amino acids pet high tumor/background ratio, identification of skull base meningiomas, improve target volume definition for rt not useful for grading, few studies rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 76 11c-choline pet meningioma grading few studies 1-11c-acetate pet accurate tumor delineation, guiding the stereotactic biopsy, optimizing treatment planning before radiosurgery not useful for grading, few studies 13n-nh3 pet high tumor/background ratio not useful for grading, few studies 68ga-dotatoc pet high tumor/background ratio, identification of skull base and en plaque meningioma and local osseous invasiveness, improvement of target volume definition for rt, recurrent disease, selection of patients for hormonal treatment or the use of dotatoc labelled with βemitting radionuclides uptake in parasellar lesions lee et al31 evaluated 59 patients with intracranial meningiomas who underwent pre-operative fdg-pet and subsequent surgical resection, all of whom who underwent clinical followup for tumor recurrence. they noted that the tumor to gray matter ratio (tgr) of fdg uptake in who grade ii/iii meningiomas were significantly higher than in low grade (who grade i) meningiomas, which significantly correlated with the mib-1 labelling index and mitotic count of the tumor. they concluded from their study that fdg uptake in meningioma was a significant predictive factor for tumor recurrence that significantly correlated with the proliferative potential of the tumor. the role of fdgpet for the evaluation of metastatic meningioma is limited in literature in the form of a few case reports. ghodsian et al32 described a hypermetabolic sacral metastatic mass by fdg-pet/ct which was a grade iii malignant meningioma on histology. meirelles et al33 noted a pulmonary meningioma that manifested as a solitary pulmonary nodule that had a very high metabolic activity on pet scan. brennan and et al34 reported a case of metastatic pulmonary meningioma that presented in the form of two lung nodules, 22 years following the resection of an intracranial meningioma. however, they noted that the pulmonary nodes showed avid uptake of fdg in the periphery (standard uptake values (suv) of 8.7 and 7.1), while the uptake was less centrally. treatment: treatment for meningiomas include surgery, radiation therapy, stereotactic radiosurgery, external beam radiation therapy (ebrt). surgery can be gross total resection alone (gtra) or subtotal resection alone (sra). the simpson grading system (table 2) defined by simpson, (35) is a predictive system for meningioma recurrence. it is based on brain mr imaging following resection, and correlated with histopathological findings at the time of surgical resection. prognostic factors which can predict the survival of patients with meningiomas includeextent of resection, histological grade, patient’s age and tumor location.36 radiation therapy (rt) needs to be considered following partial resection of a meningioma or after resection of an atypical or malignant meningioma. rt improved local control of the tumor. several literatures exist substantiating rt as a beneficial adjunct to surgery following subtotal resection, as treatment for meningioma recurrence or as a primary therapy. stereotactic radiosurgery (srs): srs is best reserved for meningiomas measuring < 3-4 cm in diameter, with well-defined margins and with enough distance from vital healthy tissues to allow for normal dose restrictions and as well as the adequate target dose.37 the most common adverse effects related to srs are cranial nerve defects and peritumoral edema, while serious but rare side effects include peritumoral cyst formation, radiation necrosis, hypothalamic dysfunction and carotid artery stenosis.38 hormonal therapy: studies have shown that meningioma growth may be hormone dependant (30% of meningiomas are oestrogen receptor positive and 70% are progesterone receptor positive).39,40 in addition to this, about 60% of meningiomas show positive prolactin receptor staining.41 hence, a hormonal therapy option for treatment has been proposed for those meningiomas which are benign and recurrent and not amenable to surgery or radiotherapy. the various drugs that have been used with limited or no success in the past includeoral progesterone agonistmegestrol acetate (megace),42 progesterone antagonist mifepristone (ru-486)43 and an oestrogen receptor antagonistoral tamoxifen.44 biotherapy and chemotherapy: some studies have shown that drugs such as recombinant interferon-α,45 hydroxyurea (an oral chemotherapeutic agent)46 and calcium channel antagonists47 inhibit growth of human meningioma cell lines cultured in vitro. however, these studies need to be analysed with caution since no large cohorts have been studied on humans. differential diagnosis: dural based lesions that can mimic meningioma includesolitary fibrous tumour, hemangiopericytoma, leiomyosarcoma, dural metastases, lymphoma, plasmocytoma, rosai-dorfman disease (sinus histiocytosis), neurosarcoidosis, rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 77 melanocytic neoplasms, plasma cell granuloma, erdheim chester disease, leukemia, and rarely amyloid and rheumatoid nodules.48 conclusion intracranial meningiomas are usually hypo/isointense on t1 weighted mr images and iso/hyperintense on t2 weighted mr images. on post contrast administration, these lesions tend to show strong enhancement. the frontal and parietal lobes are most commonly affected, and associated findings include the ‘dural tail’ sign, edema and hyperostosis. it is important to differentiate between benign and malignant meningiomas prior to surgery for both management planning and as well as for the prognostic evaluation. although some identifiable features on convention mr images do exist, no specific feature has been found to reliably predict the tumour grade. some vital features that favour malignancy includethe absence of visible calcium aggregates, tumour extending or ‘mushrooming’ away from the mass, nonhomogeneous enhancement and the presence of illdefined margins. references 1. russell ds, rubinstein u. pathology of tumors of the nervous system. 5th ed. baltimore: williams and wilkins, 1989;449-483. 2. claus eb, bondy ml, schildkraut jm, wiemels jl, wrensch m, black pm. epidemiology of intracranial meningioma. neurosurgery. 2005;57:1088-1095. 3. saloner d. modern meningioma imaging techniques. j neurooncol. (2010) 99:333–340 4. buetow mp, buetow pc, smirniotopoulos jg. typical, atypical, and misleading features in meningioma. radiographics. 1991;11:1087-106. 5. bondy m and ligon bl. epidemiology and etiology of intracranial meningiomas: a review. j neurooncol. 1996;29:197-205. 6. wiemels j, wrensch m and claus eb. epidemiology and etiology of meningioma. j neurooncol. 2010;99:307-14. 7. drake jm, hendrick eb, becker le, chuang sh, hoffman hj and humphreys rp. intracranial meningiomas in children. pediatr neurosci. 1985;12:1349. 8. toh ch, castillo m, wong am, wei kc, wong hf, ng sh, et al. differentiation between classic and atypical meningiomas with use of diffusion tensor imaging. am j neuroradiol. 2008;29:16305. 9. perry ld, scheithauer bw, budka h, von diemling a. meningiomas. in: louis dn, ohgaki h, wiestler od, et al., editors. world health organization classification of tumours of the central nervous system. 4th ed. lyon: iarc; 2007. 10. mittal a, layton kf, finn ss, snipes gj, opatowsky mj. cystic meningioma: unusual imaging appearance of a common intracranial tumor. proc (bayl univ med cent). 2010;23:429–31. 11. saleh ea, taibah ak, achilli v, aristegui m, mazzoni a, sanna m. posterior fossa meningioma: surgical strategy. skull base surg. 1994;4:202-12. 12. nakamura m, roser f, bundschuh o, vorkapic p, samii m. intraventricular meningiomas: a review of 16 cases with reference to the literature. surg neurol. 2003;59:491–503. 13. tokgoza n, onera y a, kaymazb m, ucara m, yilmazc g, tali te. primary intraosseous meningioma: ct and mri appearance. am j neuroradiol. 2005;26:2053-6. 14. mittal a, layton kf, finn ss, snipes gj, opatowsky mj. cystic meningioma: unusual imaging appearance of a common intracranial tumor. proc (bayl univ med cent). 2010;23:429–31. 15. rushing ej, olsen c, mena h, rueda me, lee ys, keating rf, packer rj and santi m. central nervous system meningiomas in the first two decades of life: a clinicopathological analysis of 87 patients. j neurosurg. 2005;103:489-95. 16. ricci pe. imaging of adult brain tumours. neuroimaging clin n am. 1999;9:651-69. 17. rohninger m, sutherland gr, louw df, sima aaf. incidence and clinicopathological features of meningioma. j neurosurg. 1989;71:665672. 18. zimmerman rd, fleming ca, saintlouis la, lee bcp, manning jj, deck mdf. magnetic resonance imaging of meningiomas. ajnr. 1985;6:149-157. 19. bourekas ec, wildenhain p, lewin js, et al. the dural tail sign revisited. ajnr am j neuroradiol 1995; 16:1514–1516. 20. tien rd, yang pj, chu pk. “dural tail sign”: a specific mr sign for meningioma? j comput assist tomogr. 1991;15:64–66. 21. goldsher d, litt aw, pinto rs, bannon kr, kricheff ii. dural "tail" associated with meningiomas on gd-dtpaenhanced mr images: characteristics, differential diagnostic value, and possible implications for treatment. radiology. 1990;176(2):447-50. 22. drevelegas a. extra axial brain tumors. eur radiol. 2005;15:453–67. 23. nagar va, ye jr, ng wh, chan yh, hui f, lee ck, lim cc. diffusion-weighted mr imaging: diagnosing atypical or malignant meningiomas and detecting tumor dedifferentiation. ajnr am j neuroradiol. 2008;29(6):1147-52. 24. surov a, gottschling s, mawrin c, et al. diffusionweighted imaging in meningioma: prediction of tumor grade and association with histopathological parameters. translational oncology. 2015;8(6):517-523. 25. demir mk, iplikcioglu ac, dincer a, arslan m, sav a. single voxel proton mr spectroscopy findings of typical and atypical intracranial meningiomas. eur j radiol. 2006;60(1):48-55. 26. buhl r, nabavi a, wolff s, hugo hh, alfke k, jansen o, mehdorn hm. mr spectroscopy in patients with intracranial meningiomas. neurol res. 2007;29(1):43-6. 27. kousi e, tsougos i, fountas k, et al. distinct peak at 3.8 ppm observed by 3t mr spectroscopy in meningiomas, while nearly absent in high-grade gliomas and cerebral metastases. molecular medicine reports. 2012;5(4):1011-1018. 28. jolapara m, kesavadas c, radhakrishnan vv, thomas b, gupta ak, bodhey n, patro s, saini j, george u, sarma ps. role of diffusion tensor imaging in differentiating subtypes of meningiomas. j neuroradiol. 2010;37(5):277-83. 29. toh ch, castillo m, wong am, wei kc, wong hf, ng sh, wan yl. differentiation between classic and atypical meningiomas with use of diffusion tensor imaging. ajnr am j neuroradiol. 2008;29(9):1630-5. 30. valotassiou v, leondi a, angelidis g, psimadas d, georgoulias p. spect and pet imaging of https://www.ncbi.nlm.nih.gov/pubmed/?term=goldsher%20d%5bauthor%5d&cauthor=true&cauthor_uid=2367659 https://www.ncbi.nlm.nih.gov/pubmed/?term=litt%20aw%5bauthor%5d&cauthor=true&cauthor_uid=2367659 https://www.ncbi.nlm.nih.gov/pubmed/?term=pinto%20rs%5bauthor%5d&cauthor=true&cauthor_uid=2367659 https://www.ncbi.nlm.nih.gov/pubmed/?term=bannon%20kr%5bauthor%5d&cauthor=true&cauthor_uid=2367659 https://www.ncbi.nlm.nih.gov/pubmed/?term=kricheff%20ii%5bauthor%5d&cauthor=true&cauthor_uid=2367659 https://www.ncbi.nlm.nih.gov/pubmed/2367659 https://www.ncbi.nlm.nih.gov/pubmed/?term=nagar%20va%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=ye%20jr%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=ng%20wh%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=chan%20yh%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=hui%20f%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20ck%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20ck%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=lim%20cc%5bauthor%5d&cauthor=true&cauthor_uid=18356472 https://www.ncbi.nlm.nih.gov/pubmed/18356472 https://www.ncbi.nlm.nih.gov/pubmed/18356472 https://www.ncbi.nlm.nih.gov/pubmed/?term=demir%20mk%5bauthor%5d&cauthor=true&cauthor_uid=16844335 https://www.ncbi.nlm.nih.gov/pubmed/?term=iplikcioglu%20ac%5bauthor%5d&cauthor=true&cauthor_uid=16844335 https://www.ncbi.nlm.nih.gov/pubmed/?term=dincer%20a%5bauthor%5d&cauthor=true&cauthor_uid=16844335 https://www.ncbi.nlm.nih.gov/pubmed/?term=arslan%20m%5bauthor%5d&cauthor=true&cauthor_uid=16844335 https://www.ncbi.nlm.nih.gov/pubmed/?term=sav%20a%5bauthor%5d&cauthor=true&cauthor_uid=16844335 https://www.ncbi.nlm.nih.gov/pubmed/16844335 https://www.ncbi.nlm.nih.gov/pubmed/16844335 https://www.ncbi.nlm.nih.gov/pubmed/?term=buhl%20r%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=nabavi%20a%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=wolff%20s%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=hugo%20hh%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=alfke%20k%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=jansen%20o%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=jansen%20o%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=mehdorn%20hm%5bauthor%5d&cauthor=true&cauthor_uid=17427274 https://www.ncbi.nlm.nih.gov/pubmed/17427274 https://www.ncbi.nlm.nih.gov/pubmed/?term=jolapara%20m%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=kesavadas%20c%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=radhakrishnan%20vv%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=thomas%20b%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=thomas%20b%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=gupta%20ak%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=bodhey%20n%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=patro%20s%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=saini%20j%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=george%20u%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=george%20u%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=sarma%20ps%5bauthor%5d&cauthor=true&cauthor_uid=20381865 https://www.ncbi.nlm.nih.gov/pubmed/20381865 https://www.ncbi.nlm.nih.gov/pubmed/20381865 https://www.ncbi.nlm.nih.gov/pubmed/?term=toh%20ch%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=castillo%20m%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20am%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=wei%20kc%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=wong%20hf%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=ng%20sh%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=ng%20sh%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=wan%20yl%5bauthor%5d&cauthor=true&cauthor_uid=18583409 https://www.ncbi.nlm.nih.gov/pubmed/18583409 https://www.ncbi.nlm.nih.gov/pubmed/?term=valotassiou%20v%5bauthor%5d&cauthor=true&cauthor_uid=22623896 https://www.ncbi.nlm.nih.gov/pubmed/?term=leondi%20a%5bauthor%5d&cauthor=true&cauthor_uid=22623896 https://www.ncbi.nlm.nih.gov/pubmed/?term=angelidis%20g%5bauthor%5d&cauthor=true&cauthor_uid=22623896 https://www.ncbi.nlm.nih.gov/pubmed/?term=psimadas%20d%5bauthor%5d&cauthor=true&cauthor_uid=22623896 https://www.ncbi.nlm.nih.gov/pubmed/?term=psimadas%20d%5bauthor%5d&cauthor=true&cauthor_uid=22623896 https://www.ncbi.nlm.nih.gov/pubmed/?term=georgoulias%20p%5bauthor%5d&cauthor=true&cauthor_uid=22623896 rishi philip mathew et al. morphological spectrum of intracranial meningiomas… panacea journal of medical sciences, may-august, 2018;8(2):70-78 78 meningiomas. scientific world journal. 2012;2012:412580. 31. lee jw, kang kw, park sh, lee sm, paeng jc, chung jk, lee mc, lee ds. 18f-fdg pet in the assessment of tumor grade and prediction of tumor recurrence in intracranial meningioma. eur j nucl med mol imaging. 2009;36(10):1574-82. 32. ghodsian m, obrzut sl, hyde cc, watts wj, schiepers c. evaluation of metastatic meningioma with 2-deoxy2(18f) fluoro-d-glucose pet/ct. clin nucl med. 2005;30:717–20. 33. meirelles gs, ravizzini g, moreira al, akhurst t. primary pulmonary meningioma manifesting as a solitary pulmonary nodule with a false-positive pet scan. j thorac imaging. 2006;21:225–7. 34. brennan c, o'connor oj, o'regan kn, keohane c, dineen j, hinchion j, sweeney b, maher mm. metastatic meningioma: positron emission tomography ct imaging findings. br j radiol. 2010;83(996):e25962. 35. simpson d. the recurrence of intracranial meningiomas after surgical treatment. j neurol neurosurg psychiatry. 1957;20:22–39. 36. kondziolka d, lunsford d, coffey rj, flickinger jc: stereotactic radiosurgery of meningiomas. j neurosurg. 1991;74:552–559. 37. ganz jc, backlund eo, thorsen fa. the results of gamma knife surgery for meningiomas, related to size of tumor and dose. stereotact funct neurosurg. 1993;61(suppl 1):23–29. 38. hudgins wr, barker jl, schwartz de, nichols td. gamma knife treatment of 100 consecutive meningiomas. stereotact funct neurosurg. 1996;66 (suppl 1):121–128. 39. jhawar bs, fuchs cs, colditz ga, stampfer mj: sex steroid hormone exposures and risk for meningioma. j neurosurg. 2003;99:848–853. 40. longstreth wt jr, dennis lk, mcguire vm, drangsholt mt, koepsell td: epidemiology of intracranial meningioma. cancer. 1993;72:639–648. 41. muccioli g, ghé c, faccani g, lanotte m, forni m, ciccarelli e: prolactin receptors in human meningiomas: characterization and biological role. j endocrinol. 1997;153:365–3731. 42. grunberg sm, weiss m: lack of efficacy of megestrol acetate in the treatment of unresectable meningioma. j neurooncol. 1990;8:61–65. 43. grunberg sm, weiss mh, spitz im, ahmadi j, sadun a, russell ca, et al: treatment of unresectable meningiomas with the antiprogesterone agent mifepristone. j neurosurg. 1991;74:861–866. 44. goodwin jw, crowley j, eyre hj, stafford b, jaeckle ka, townsend jj: a phase ii evaluation of tamoxifen unresectable or refractory meningiomas: a southwest oncology group study. j neurooncol. 1993;15:73–77. 45. kaba se, demonte f, bruner jm, kyritsis ap, jaeckle ka, levin v, et al: the treatment of recurrent unresectable and malignant meningiomas with interferon alpha-2b. neurosurgery. 1997;40:271–275. 46. schrell umh, rittig mg, anders m, koch uh, marschalek r, kiesewetter f, et al.: hydroxyurea for the treatment of unresectable and recurrent meningiomas. ii. decrease in the size of meningiomas in patients treated with hydroxyurea. j neurosurg. 1997;86:845–852. 47. jensen rl, origitano tc, lee ys, weber m, wurster rd. in vitro growth inhibition of growth factorstimulated meningioma cells by calcium channel antagonists. neurosurgery. 1995;36:365–374. 48. smith ab, horkanyne-szakaly i, schroeder jw, rushing ej. from the radiologic pathology archives: mass lesions of the dura: beyond meningioma-radiologic-pathologic correlation. radiographics. 2014;34(2):295-312. https://www.ncbi.nlm.nih.gov/pubmed/22623896 https://www.ncbi.nlm.nih.gov/pubmed/22623896 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20jw%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=kang%20kw%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=park%20sh%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20sm%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=paeng%20jc%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=chung%20jk%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=chung%20jk%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20mc%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=lee%20ds%5bauthor%5d&cauthor=true&cauthor_uid=19377904 https://www.ncbi.nlm.nih.gov/pubmed/19377904 https://www.ncbi.nlm.nih.gov/pubmed/19377904 https://www.ncbi.nlm.nih.gov/pubmed/?term=brennan%20c%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=o%27connor%20oj%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=o%27regan%20kn%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=keohane%20c%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=keohane%20c%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=dineen%20j%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=hinchion%20j%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=sweeney%20b%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=maher%20mm%5bauthor%5d&cauthor=true&cauthor_uid=21088084 https://www.ncbi.nlm.nih.gov/pubmed/21088084 https://www.ncbi.nlm.nih.gov/pubmed/?term=smith%20ab%5bauthor%5d&cauthor=true&cauthor_uid=24617680 https://www.ncbi.nlm.nih.gov/pubmed/?term=horkanyne-szakaly%20i%5bauthor%5d&cauthor=true&cauthor_uid=24617680 https://www.ncbi.nlm.nih.gov/pubmed/?term=schroeder%20jw%5bauthor%5d&cauthor=true&cauthor_uid=24617680 https://www.ncbi.nlm.nih.gov/pubmed/?term=rushing%20ej%5bauthor%5d&cauthor=true&cauthor_uid=24617680 https://www.ncbi.nlm.nih.gov/pubmed/?term=rushing%20ej%5bauthor%5d&cauthor=true&cauthor_uid=24617680 https://www.ncbi.nlm.nih.gov/pubmed/24617680 case report doi: 10.18231/2348-7682.2017.0014 panacea journal of medical sciences, january-april,2017;7(1): 51-52 51 a rare case: episiotomy scar endometriosis with anal sphincter involvement divya dewani1,*, madhuri gawande2, rasika pise3, preksha jain4 1,3,4junior resident, 2assistant professor, dept. of obstetrics & gynaecology, nkp salve institute of medical sciences & research institute & lata mangeshkar hospital, nagpur, maharashtra *corresponding author: email: disha.dewani@gmail.com abstract endometriosis is defined as the presence of functioning endometrial tissue outside uterine cavity. scar endometriosis being a rare disease is difficult to diagnose. incisional or scar endometriosis is an even rarer type with an incidence of less than 1%. the quoted episiotomy scar endometriosis incidence is about 0.06-0.07%. present case is of a 38years old female, married since 15years with one para. she presented with cyclical pain and swelling at episiotomy site. she underwent surgical excision of mass which was suggestive of endometriosis in histopathology. keywords: scar endometriosis, episiotomy scar endometriosis, anal sphincter reconstruction. introduction endometriosis was 1st described by von rokitansky 1860 as presence of the functional endometrial tissue outside uterine cavity.(1) various theories of endometriosis are retrograde menstruation, direct implantation, coelomic metaplasia, lymphatic dissemination, hematogenous spread, activation of embryonic cell rest, metaplasia of urothelium and hereditary and immunologic factor.(2)scar endometriosis is a rare disease and usually difficult to diagnose. incisional or scar endometriosis is a rare type with an incidence of less than 1%. the quoted episiotomy scar endometriosis incidence is about 0.060.07%. the diagnosis and complete treatment of scar endometriosis can be challenging. medical and surgical modalities both play an important role in managing cases of endometriosis depending on site of involvement.(3) case history a 38-year-old female married since 15yrs, belonging to low socioeconomic status came with complaints of pain and swelling at vulva right side since 3 years, with increased in intensity during menstruation. pain was initially cyclical and later it was present throughout the menses with increased intensity. the swelling started to appear 2 years back and gradually increased in size to attain the present size of 3x3cms.there was no history of weight loss, loss of appetite, nausea and vomiting. no history suggestive of difficulty in defecation. patient took treatment at other places but did not get relief. on menstrual history her cycles were regular with average flow. there was associated history of dysmenorrhoea during the regular cycles. obstetric history, she was para one and had a full term vaginal delivery 12years back. her past, family and personal histories were not significant. on examination her vitals were stable. there was no lymphadenopathy. per abdomen examination was normal, inguinal lymph nodes were not palpable. her local examination revealed a tender mass of 3 cm x 3 cm on right side of anus which was hard in consistency, with irregular margins. the skin over the mass was pigmented and puckered. on per speculum examination, cervix and vagina was healthy. per vaginal examination, uterus was normal in size, freely mobile, no tenderness, both fornices were free. on per rectal examination was same and rectal mucosa was loculated. the differential diagnosis thought were scar endometriosis, abscess, granuloma or malignancy. along with necessary routine investigations, the investigations like fnac and mri pelvis and perineum added in diagnosis. on mri, the lesion measured approximately 2cm×3.1cm in transverse and antero-posterior dimensions and extended craniocaudally approximately 3.6cm (fig.1). the lesion showed spiculations, irregular margins with peripheral strands. the lesion also involved the right external anal sphincter and puborectalis muscles (fig. 2). fig. 1: on mri, lesion measured approximately 2 cm × 3.1 cm in transverse and antero-posterior dimension fig. 2: lesion showed spiculations, irregular margins with peripheral strands divya dewani et al. a rare case: episiotomy scar endometriosis with anal sphincter involvement panacea journal of medical sciences, january-april,2017;7(1): 51-52 52 a decision to excise the lesion and to reconstruct the sphincter with was taken. intra-operatively, a 3 cm fibrotic mass involving the external anal sphincter and puborectalis muscle was present (fig. 3) which was excised along with 1cm of healthy margin and external anal sphincter was reconstructed. in the post operative period patient was kept nil by mouth for 24 hours, followed by liquid diet and soft diet with laxatives. adequate antibiotic cover and perineal care were given. she was relieved of her symptoms. histopathology confirmed the diagnosis of scar endometriosis as it showed endometrial glands, stroma and hemosiderin laden macrophages (fig.4). she was followed up for six months and had total relief from her symptoms. there were no signs of recurrence of the disease. fig.3: intra-operative 3 cm fibrotic mass involving external anal sphincter and puborectalis muscle fig. 4: histopathology showed endometrial glands, stroma and hemosiderin laden macrophages (confirmed diagnosis of scar endometriosis) discussion endometriosis is a clinical and pathological entity which is characterised by presence of tissue resembling functioning endometrial glands and stroma outside the uterine cavity. the quoted incidence of episiotomy scar endometriosis is 0.06-0.07% while that of malignant transformation is 0.3-1% of cases.(4) the involvement of anal sphincter is infrequent in endometriosis. there is no role of conservative management, hormonal therapy is ineffective, thus the sphincter involvement should be diagnosed prior to surgery so as to avoid injury to external anal sphincter which can be reconstructed, so treatment of choice is surgical excision with margin of safety 1cm to prevent local recurrence.(5) conclusion scar endometriosis with anal sphincter involvement is a rare type. magnetic resonance imaging helps in diagnosing the extent of disease. the main modality of management is surgical excision with reconstruction of external anal sphincter. references 1. teresa tam, stella huang. perineal endometriosis in an episiotomy scar: case report and review of literature. journal of endometriosis and pelvic pain disorders, vol. 4 issue 2, apr-jun 2012, page 57-108. 2. lutrek k, barcz e. bablok l, wierzbicki z. giant recurrent perineal endometriosis in an episiotomy scara case report. ginekologia polska journal; august 1 2013;84(8);726-9. 3. mustafa demir, askin yildiz, irfan ocal, mehmet hakan yatimdar, deryakilic, ozcan yavasi, et al. endometriosis in episiotomy scar; a case report. journal of cases obstetrics gynecology 2014(1);8-10. 4. mustafa kapianoglu, dilek kaya kaplanoglu, ceren dincer ata, selim buyukkurt. obstetric scar endometriosis: retrospective study of 19 cases and review of literature. international scholarity research notes, vol. 2014, article id417042, 5 pages. 5. kanellaos i, kelpis t, zaraboukas t, betis d. perineal endometriosis in episiotomy scar with anal sphincter involvement. techniques in coloproctology, aug 1 2001;5(2);10-8. jan june 2012 for pdf for website 3 laryngo-pharyngeal reflux laryngo-pharyngeal reflux (lpr), also extraesophageal reflux disease (eerd) refers to retrograde flow of gastric contents to the upper aero-digestive tract, which causes a variety of symptoms, such as cough, hoarseness, and asthma, among others (1). although heartburn is a primary symptom among people with gastro-esophageal reflux disease (gerd), heartburn is present in fewer than 50% of the patients with lpr. other terms used to describe this condition include atypical reflux, and supra-esophageal reflux (2). gastro-esophageal reflux disease (gerd) was recognized as a clinical entity in the mid-1930s and now is the most prevalent upper gastrointestinal (gi) disorder in clinical practice. acid-related laryngeal ulcerations and granulomas were first reported by chery in 1968 (3). subsequent studies suggested that acid reflux might be a contributory factor in other laryngeal and respiratory conditions. in 1979, pellegrini and demeester (4) were the first to document the link between these airway symptoms and reflux of gastric contents. they also proved that treatment of reflux disease results in elimination of these airway symptoms. laryngo-pharyngeal reflux or a typical gerd syndrome or commonly known as extra esophageal reflux is a controversial subject. the available literature remains controversial regarding the pathophysiology, investigations and management of patients presenting with symptoms of extra-esophageal disease. the terms acid laryngitis was coined 40 years ago as most of the extra-esophageal reflux manifestations affect the laryngopharynx (1). the recent research work shows the possibility of cellular mechanisms, whereby reflux might affect the upper airway. acidified pepsin damages inter cellular spaces and pepsin is taken by human laryngeal ephithelial cells by receptor mediated endocytosis (5). pathogenesis laryngo-pharyngeal reflux differs from gastroesophageal reflux disease (gerd) in that it is often not associated with heartburn and regurgitation symptoms. the larynx is vulnerable to gastric reflux, so patients often present with laryngo-pharyngeal symptoms in the absence of heartburn and regurgitation (6). there are 4 physiological barriers protecting the upper aero-digestive tract from reflux injury: the lower esophageal sphincter, esophageal motor function with acid clearance, esophageal mucosal tissue resistance, and the upper esophageal sphincter. the delicate ciliated respiratory epithelium of the posterior larynx that normally functions to clear mucus from the tracheo-bronchial tree is altered when these barriers fail, and the resultant ciliary dysfunction causes mucus stasis (7). the subsequent accumulation of mucus produces postnasal drip sensation and provokes throat clearing. direct refluxate irritation can cause coughing and choking (laryngospasm) because sensitivity in laryngeal sensory endings is up-regulated by local inflammation (8). this combination of factors can lead to vocal fold edema, contact ulcers, and granulomas that cause other lpr-associated symptoms: hoarseness, globus pharyngeus, and sore throat (2,9). recent investigations suggest that vulnerable laryngeal tissues are protected from reflux damage by the phlaryngo-pharyngeal refluxa review 1 vivek harkare abstract: laryngo-pharyngeal reflux or atypical gastro-esophageal reflux disease (gerd) syndrome commonly known as extra-esophageal reflux is a controversial subject. the available literature remains non-conclusive regarding the patho-physiology, investigations and management of patients presenting with symptoms of extra-esophageal disease. it remains unknown whether symptoms are caused by direct exposure to refluxate or are via a referred sensation or cough reflex or both. mucosal changes are not specific to laryngo-pharyngeal reflux although laryngeal pseudo-sulcus has a positive predictive value of 6790 % for laryngo-pharyngeal reflux. the symptoms of laryngopharyngeal reflux include hoarseness of voice, throat clearing, dysphagia, increased phlegm and globus sensation; patients may also have asthma like symptoms. physical findings which may be secondary to associated smoking, alcohol, allergic, asthma, viral illness and vocal abuse, include laryngeal edema, erythema, leukoplakia, granulation or even malignancy. the aims of the treatment include decreasing reflux, improving esophageal clearance and protecting esophageal and laryngo-pharyngeal mucosa. lifestyle modification like weight loss, avoiding sweets, tomatoes, onions, alcohol and caffeine and finishing dinner 3 hours before going to bed may help. antacids, h2 receptor antagonists, proton pump inhibitors, prokinetic drugs and anti-reflux surgery like fundoplication and injection of biopolymers in lower esophageal sphincter are used. key words : laryngopharygeal reflux, laryngeal pseudosulcus, h2 receptor antagonists, prokinetic drugs. 1 professor & hod department of ent nkpsims & rc, digdoh hills, hingna road, nagpur-440019 viv_harkare@rediffmail.com pjmsvolume 2 number 1: january-june 2012 review article 4 regulating effect of carbonic anhydrase in the mucosa of the posterior larynx (10). carbonic anhydrase catalyzes hydration of carbon dioxide to produce bicarbonate; this protects tissues from acid refluxate. in the esophagus, there is active production of bicarbonate in the extracellular space that functions to neutralize refluxed gastric acid. there is no active pumping of bicarbonate in laryngeal epithelium and carbonic anhydrase isoenzyme iii, expressed at high levels in normal laryngeal epithelium, was absent in 64% (47/75) of biopsy specimens from laryngeal tissues of lpr patients (11). measurement of exposure to refluxateit remains unknown whether symptoms are caused by direct exposure to refluxate or are via referred sensation or cough reflex or both. upto 50% controls have measurable ph drop to < ph 4, 2cm above the upper esophageal sphincter. techniques of measuring refluxate exit are varied and yet not standardized across specialties (10). mucosal changesmucosal changes are not specific to laryngo-pharyngeal reflux although laryngeal pseudosulcus has a positive predictive value of 67 -90% for laryngopharyngeal reflux. exposure of laryngeal mucosa to biliary secretions for many years post gastrectomy appears to be carcinogenic. the role of helicobacter pylori is not clear. treating reflux may reduce the risk of recurrence of laryngeal cancer, but there is no prospective evidence (12). clinical features the symptoms of laryngo-pharyngeal reflux includes hoarseness of voice, throat clearing, dysphagia, increased phlegm and globus sensation. many patients may have asthma like symptoms. laryngo-pharyngeal reflux may be suspected if the onset of asthma comes in adults without any family history and heart burn precedes onset of asthma. physical finding which may be secondary to associated smoking, alcohol, allergic asthma, viral illness and vocal abuse, include laryngeal edema, erythema, leukoplakia, granulation or even malignancy. laryngoscopic findings such as erythema, edema, laryngeal granulomas, and interarytenoid hypertrophy have been used to establish the diagnosis, but these findings are very nonspecific, and have been described in the majority of asymptomatic subjects undergoing laryngoscopy (9,11). response to acid suppression therapy has been suggested as a diagnostic tool to confirm diagnosis of lpr, but studies have shown that the response to empirical trials of such therapy (as with proton-pump inhibitors) in these patients is often disappointing. several studies have emphasized the importance of measuring proximal esophageal, or, ideally, pharyngeal acid exposure in patients with clinical symptoms of lpr, to document reflux as the cause of the symptoms (10). diagnosis of laryngopharyngeal reflux historyit is important for physicians to appreciate the potential significance of hoarseness and the relative nonspecificity of laryngitis. laryngitis is a nonspecific designation of laryngeal inflammation. often, it is mild and resolves spontaneously. when persistent, laryngitis must be further defined based on probable etiologic factors: viral or bacterial infection, allergy, vocal trauma, postnasal discharge or lpr. persistent or progressive hoarseness lasting beyond 2 to 3 weeks requires examination of the laryngopharynx to rule out cancer and other serious conditions. this is generally considered good practice; however, laryngeal examination is particularly important in suspected lpr because of the apparent known association of lpr and upper aerodigestive tract cancer (12). laryngopharyngeal reflux should be suspected when clinical history and initial findings are suggestive. failure to appreciate lpr as different from gerd has been a major source of skepticism about the diagnosis in the past. koufman was the first to clearly distinguish lpr from gerd, noting that in a combined reported series of 899 patients, throat clearing was a complaint of 87% of lpr patients vs 3% of those with gerd, while only 20% of lpr patients complained of heartburn vs 83% in the gerd group(6). an international survey of american broncho-esophagological association members revealed that the most common lpr symptoms were throat clearing (98%), persistent cough (97%), globus pharyngeus (95%), and hoarseness (95%) (11). since there is no pathognomonic lpr finding, belafsky et al (13) developed an 8-item clinical severity scale for judging laryngoscopic findings, the reflux finding score, which appears to be useful for assessment and follow-up of lpr patients. they rated 8 lpr-associated findings on a variably weighted scale from 0 to 4: subglottic edema, ventricular obliteration, erythema/hyperemia, vocal fold edema, diffuse laryngeal edema, posterior commissure hypertrophy, granuloma, and thick endolaryngeal edema. the results could range from 0 (normal) to 26 (worst possible score). based on their analysis, one can be 95% certain that a patient with a reflux finding score of 7 or more will have lpr (14). management pat i e nt ed u cat i o n a n d l i fe st y l e c h a n ge s patients with lpr should be educated as to the nature of the problem and counseled on helpful behavioral and dietary changes (15). important behavioral changes include weight loss, smoking cessation, and alcohol avoidance. ideal dietary changes would restrict chocolate, fats, citrus fruits, carbonated beverages, spicy tomato-based products, red wines, caffeine, and late-night meals. such behavioral changes appear to be an independently significant variable in pjmsvolume 2 number 1: january-june 2012 review article determining response to medical therapy. education should include the optimal schedule for taking ppi medications (omeprazole, esomeprazole, rabeprazole, lansoprazole, and pantoprazole), which work best when taken 30 to 60 minutes before meals (16). medical managementthere are 4 categories of drugs used in treating lpr: ppis, h2-receptor antagonists, prokinetic agents, and mucosal cytoprotectants. proton pump inhibitors are considered the mainstay of medical treatment, although there is some controversy regarding their efficacy. a 3-month empirical trial is a cost-effective approach for initial assessment and management. responders can be weaned, while non-responders should undergo studies to confirm lpr (17). other drugs have been used to treat lpr. ranitidine has proved to be a more potent inhibitor of gastric secretion than cimetidine and is the h2-receptor antagonist of choice, although it has been found to be of limited value in treating lpr (18). prokinetic agents that accelerate esophageal clearance and increase lower esophageal sphincter pressure have fallen out of favor because of reported adverse effects of ventricular arrhythmias and diarrhea (19). cisapride has been discontinued because of such serious adverse effects. tegaserod is a prokinetic agent that was recently demonstrated to decrease reflux and lower esophageal sphincter relaxation events, and that was found useful in treating some lpr cases with associated esophageal dyskinesia. sucralfate is a polysulfated salt of sucrose that may be helpful as an adjunct in protecting injured mucosa from harmful effects of pepsin and acid. antacids (sodium bicarbonate–, aluminum-, and magnesium-containing overthe-counter antacids) may relieve gerd symptoms but do not play a role in lpr management (15). the aims of the treatment include decreasing reflux, improving esophageal clearance and protecting esophageal and laryngo-pharyngeal mucosa. anti reflux surgical managementwhen medical management fails, patients with demonstrable high-volume liquid reflux and lower sphincter incompetence are often candidates for surgical intervention. fundoplication, either complete (nissen or rossetti) or partial (toupet or bore), is the most common procedure performed, and the laparoscopic approach is preferred (20). the goal of surgery is to restore competence of the lower esophageal sphincter, and the outcome measures for lpr include demonstration of reduced pharyngeal reflux episodes. excellent results have been reported in 85% to 95% of reflux cases, but results with lpr are not as impressive (21). focusing on a carefully screened group of patients with demonstrable extraesophageal reflux (lpr), oelschlager et al reported a significant decrease in pharyngeal reflux (7.9 to 1.6 episodes per 24 hours; p<.05) and esophageal acid exposure (7.5% to 2.1%; p<.05) following basic laparoscopic nissen fundoplication surgery (21). in nissen's fundoplication, fundus of stomach is wrapped around les. fundoplication appears superior to medical management in preventing barrett metaplasia (22). recent developments a l t h o u g h t h e r e i s i n t e r e s t i n r e c e n t nonfundoplication endoscopic techniques like bard endocinch system for endoluminal plication, system for radiofrequency-induced thermal injury and enteryx liquid polymer injection, to improve lower esophageal sphincteric function, there are no controlled studies and there is no longterm follow-up evidence to support their use. references 1. delahunty j e. acid laryngitis. j. laryngol. 1972; otol. 86: 335342. 2. chheda n n, seybt m w, schade r r et al. normal values for pharyngeal ph monitoring. ann. otol. rhinol. laryngol. 2009; 118: 166-171. 3. cherry j, margulies s i. ‘contact ulcer of the larynx.’ laryngoscope. 1968; 78 (11): 122-125. 4. pellegrini c a, demeester t r. et al. “ gastroesophageal reflux and pulmonary aspiration: incidence, functional abnormality, and results of surgical therapy.” surgery. 1979; 86(1): 110 – 114. 5. johnston n. review article: uptake of pepsin at ph 7in nonacid reflux – causes inflammatory, and perhaps even neoplastic, changes in the laryngopharynx, aliment. pharmacol ther. 2011; 33: 13-20. 6. koufman ja. the otolaryngologic manifestations of gastroesophageal reflux disease (gerd): a clinical investigation of 225 patients using ambulatory 24-hour ph monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. laryngoscope. 1991;101(4 pt 2 suppl 53)1-78 7. koufman j, sataloff rt, toohill r. laryngopharyngeal reflux: consensus conference report. j voice. 1996; 10215-216 hanson dg, jiang jj. diagnosis and management of chronic laryngitis associated with reflux. am j med. 2000;108(suppl 4a) 112s-119s 8. axford se, sharp n, ross pe. et al. cell biology of laryngeal epithelial defenses in health and disease: preliminary studies. ann otol rhinol laryngol. 2001;1101099-1108. 9. ylitalo r, ramel s. extraesophageal reflux in patients with contact granuloma: a prospective controlled study. ann otol rhinol laryngol. 2002;111441-446 10. postma gn. ambulatory ph monitoring methodology. ann otol rhinol laryngol suppl. 2000;18410-14 11. ford cn, inagi k, khidr a, bless dm, gilchrist kw. sulcus vocalis:a rational analytical approach to diagnosis and management. ann otol rhinol laryngol. 1996;105189-200. 12. morrison md. is chronic gastroesophageal reflux a causative factor in glottic carcinoma? otolaryngol head neck surg. 5 pjmsvolume 2 number 1: january-june 2012 review article 1988;99, 370-373 13. belafsky pc, postma gn, koufman ja. the validity and reliability of the reflux finding score (rfs). laryngoscope. 2001;111, 1313-1317 14. vaezi mf. extraesophageal manifestations of gastresophageal reflux disease. clin cornerstone. 2003;532-38 15. katz po, castell do. medical therapy of supraesophageal gastresophageal reflux disease. am j med. 2000;108(suppl 4a) 170s-177s 16. steward dl, wilson km, kelly dh. et al. proton pump inhibitor therapy for chronic laryngo-pharyngitis: a randomized placebo-control trial. otolaryngol head neck surg. 2004;131, 342-350 17. williams rb, szczesniak mm, maclean jc, brake hm, cole ie, cook ij. predictors of outcome in an open label, therapeutic trial of high-dose omeprazole in laryngitis. am j gastroenterol. 2004;99, 777-785 18. fackler wk, ours tm, vaezi mf, richter je. long-term effect of h2ra therapy on nocturnalgastric acid breakthrough. gastroenterology. 2002;122625-632 19. castell do. future medical therapy of reflux esophagitis. j clin gastroenterol. 1986;8(suppl 1) 81-85. 20. fuchs kh, breithaupt w, fein m, maroske j, hammer i. laparoscopic nissen repair: indications, techniques and longterm benefits. langenbecks arch surg. 2005;390197-202 21. oelschlager bk, eubanks tr, oleynikov d, pope c, pellegrini ca. symptomatic and physiologic outcomes after operative treatment for extraesophageal reflux. surg endosc. 2002;16, 1032-1036. 22. charles n. ford, md. evaluation and management of laryngopharyngeal reflux. jama 2005, 294(12) 1534-1540. 6 pjmsvolume 2 number 1: january-june 2012 review article page 7 page 8 page 9 page 10 editorial http://doi.org/0.18231/j.pjms.2019.021 panacea journal of medical sciences, september-december, 2019;9(3):85-87 85 surgical safety: are we really concerned? nitin deosthale 1 1professor, dept. of ent, n.k.p. salve institute of medical sciences and research centre, nagpur, maharashtra, india *corresponding author: nitin deosthale email: nvdeosthale@rediffmail.com to err is human, to cover-up is unforgivable, to fail to learn is inexcusable. prof. sir liam donaldson patient safety is one of the most important goals for health care system. errors in the treatment result in significant morbidity and mortality for the affected patient population. this consequently burden the health care providers and incur disproportionately high costs to health care system due to a change in the doctor patient relationship since last few decades. medical error is a term used when there is an unintended injury or complication that results in prolonged hospital stay, disability at the time of discharge or death, caused by healthcare management rather than the underlying disease itself. medical errors can be categorized into medication error, diagnostic error, surgical error, equipment failure, infection (hospital acquired, surgical site infection, or implant related), error during blood transfusion, order misinterpretation. 10% of in-patients suffer from adverse events and almost half of these are considered to be preventable.1,2 it is difficult to get the true incidence of surgical error globally. approximately half million deaths are estimated to occur as a result of avoidable surgical error every year.3 studies in the developing countries suggest a death rate of 5–10% associated with major surgery4-6. in india, 5.2 million injuries are recorded each year due to medical errors and adverse events.7 behavior of surgical team members in operating room (o.r.) that can be considered at risk are: not checking instruments before surgery, surgeon entering into o.r. after preparation and draping of patient, surgeon running two rooms at a time, multitasking from o.r., relying on memory about pathology, radiological investigations, unannounced substitutions of assistants or nursing staff in the middle of the case, and continuing wound closure during sponge/ sharpe/ instrument search. this can lead to increase in the rate of surgical adverse effects. impact of surgical adverse effects can be in the form of patient harm, sometimes loss of organ/ life, assault on hospital staff which is nowadays common, loss of faith in healthcare provider, surgeon and hospital litigations, indefensible public image risk, blame game amongst the hospital staff etc. most of these errors are attributable to inadequate communication and lack of team work. like medical profession, aviation industry is the area where safety is a concern. they carry out briefing before each airline flight. during this, there is a team meeting in which all the information needed for the joint performance of task is exchanged and checked. same safety culture in operating room before surgery improves team cooperation, motivation, discipline and outcome. essential objectives for safe surgery 8 : to reduce the rate of surgical errors, who has defined 10 essential objectives with the purpose to facilitate patient safety policy and practice and are as follows.: 1. operate on the correct patient at the correct site. 2. prevent anaesthesia induced complications 3. prepare for airway emergencies 4. prepare for high blood loss 5. avoid adverse drug reactions 6. minimise surgical site infections 7. prevent retention of instrument/ sponges 8. accurately secure & identify specimens 9. effectively communicate critical information with the team members 10. establish surveillance of surgical safety. consent of a patient for procedure is the critical documentation. while taking consent for any invasive procedure, patient must be awake and alert and have the capacity to understand the details and implications of the procedure. consent must be obtained in a language that the patient understands or through an interpreter. it should include a clear statement of the procedure to be performed and the site of operation, including laterality or level. the consent protocol can, however, be waived in emergency cases with threat to life or limb. surgical safety checklist 8 : world health organization (who), in 2007 devised a surgical safety checklist to improve the safety of surgical care in all operative fields (fig 1). after its evaluation in a study in eight hospitals in different parts of the world, who published it in 2009 and was recommended to be used as a part of their “safe surgery saves life” campaign. surgical safety check (ssc) list consists of 19 items relating to key aspects of patient safety and split in three distinct sections: nitin deosthale surgical safety: are we really concerned? panacea journal of medical sciences, september-december, 2019;9(3):85-87 85 fig. 1: world health organization: surgical safety checklist8 i) sign inimmediately before the induction of anaesthesia ii) time outimmediately before the skin incision iii) sign outimmediately after skin closure before patient leaves operating room. every operation involves multiple steps that are to be performed correctly every time. as everyone’s role in an operation room is interdependent, it is the responsibility on the anesthesia team, the nursing staff, and surgeons to communicate effectively to prevent avoidable complications such as wrong site surgery and inappropriate antibiotic administration. verification of the correct patient, site and procedure should be done at every stage from the time a decision is made to operate to the time the patient undergoes the operation. this should be done when the procedure is scheduled; at the time of admission or entry to the operating theatre; any time the responsibility for care of the patient is transferred to another person; and before the patient leaves the preoperative area or enters the procedure or surgical room. surgeries performed on the wrong body part or wrong patient and performance of a wrong procedure are commonly categorized together as “wrong site surgery”. it is potentially devastating event to patients, families, and surgeon himself and often an indefensible case in the court of law. wrong-site surgery is more likely to occur in procedures associated with bilaterality. to avoid such mistakes, patient’s identity should be verified during sign in step. surgical site should be marked by the operating surgeon, the mark must be unambiguous, done with the consent of patient, when patient is alert & awake, in the presence of his/her relatives. it must be visible after prepping and draping the patient and removed at the end of the procedure. preoperative verification protocols have only been introduced in many parts of the world and found to reduce wrong site surgery. time out is the step when communication is to be done amongst all the team members by orienting the team to the individual patient, site of surgery, procedure to be carried out, alerting each member to potential complications and encouraging team members to inform others when they notice an error is occurring. whether prophylactic antibiotic has been given pre-operatively is also to be confirmed during this step to avoid surgical site infection. essential imaging display also has to be confirmed. when 2 or more procedures are performed on the same patient and the person performing the procedure changes, time out must be performed before each procedure. before patient leaves the operating room (sign out), counting of sponges, sharps and instruments must be given in an audible voice with minimal distraction. surgical specimen should be labelled properly including correct name of patient’s, his id number, specific origin of the specimen and laterality (e.g. right buccal mucosa biopsy), quantity, descriptive information about the specimen (e.g. suture tag for anatomical orientation of specimen) and required test to be done with the surgical specimen. nursing staff should repeat back to the surgeon about the specimen being sent to the laboratory. factors affecting the acceptance of checklist: although surgical safety checklist is easy to use and has zero harm from its use, actively using health centers are less. failure of its use can be due to the problem of hierarchy in o.r. most of the surgeons consider themselves nitin deosthale surgical safety: are we really concerned? panacea journal of medical sciences, september-december, 2019;9(3):85-87 86 that they can never be wrong. surgeon may feel insulted by the search of potential error. furthermore, culture of minimal communication and interruption of work in the operating room may be considered as hinderance of its use. there may also be economic objections, as it may be feared that operations will be prolonged and cost may go up. litigation and confidentiality may be the other reasons that can affect implementation of check list. recommendations on the implementation of who surgical safety checklist the checklist will meet the acceptance only if surgery team leaders integrate it in their safety concept and take it seriously. education and training for its use is necessary. interdisciplinary communication helps to prevent conflicts in operating room. an audit of complication rates of every surgical department to evaluate the effect of checklist before and after implementation of checklist is also helpful. once it comes in routine practice, checklist can be completed within two minutes in all its three parts. faulty implementation can give a dangerous false sense of security and thus convert the positive effect of checklist into its negative. it should not be considered just as a document to be filled for the record but each and every item should be followed as a team. it also helps to dismantle the hierarchical barriers and enables to improve frequent transfer of information and team cooperation. by simply implementing checklists and protocols from developed countries to developing countries may show its actual benefits. who has recommended for the required changes in the checklist according to the place and as per the surgical branch without altering the most essential items in it so that the main purpose of checklist of achieving patient’s safety will be followed. health care system do most of the right things on most patients, most of the time. safety culture in hospitals can make each one of us to do all the right things on all the patients all the time and surgical safety checklist is one part of it. medicine is lot harder; safety culture techniques make it easier, more efficient and more safer. references 1. de vries en, ramrattan ma, smorenburg sm, gouma dj, boermeester ma. the incidence and nature of in-hospital adverse events: a systematic review. qual saf health care 2008;17 (3):216-23. 2. thomas ej, studdert dm, burstin hr. incidence and types of adverse events and negligent care in utah and colorado. med care 2000;38(3):261-71. 3. weiser tg, regenbogen se, thomson kd, hynes ab, lipsitz sr, berry wr et al. an estimation of global volume of surgery: a modelling strategy based on available data. lancet 2008;327(9633):139-44. 4. bickler sw, sanno-duanda b. epidemiology of paediatric surgical admissions to a government referral hospital in the gambia. bulletin of the world health organization, 2000;78:1330–6. 5. yii mk, ng kj. risk-adjusted surgical audit with the possum scoring system in a developing country. br j surg 2002;89:110–3. 6. mcconkey sj. case series of acute abdominal surgery in rural sierra leone. world j surg 2002;26:509–13. 7. yadav m, rastogi p. a study of medical negligence cases decided by the district consumer court. j indian acad forensic med. 2015;37(1):50-5. 8. who guidelines for safe surgery 2009: safe surgery saves lives. available at: https://www.who.int/patientsafety/safesurgery/tools_resources/9789 241598552/en/ https://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/ https://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/ panacea journal of medical sciences 2020;10(3):276–281 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article diagnostic accuracy of hysterosalpingography in comparison to laparoscopy to detect tubal occlusion in female infertility: an observational study subrata das1,*, ajit r bhattacharyya2 1dept. of obstetrics & gynaecology, esi pgi msr & esic medical college and esic hospital & odc (ez), kolkata, west bengal, india 2dept. of obstetrics & gynaecology, r g kar medical college and hospital, kolkata, west bengal, india a r t i c l e i n f o article history: received 07-08-2020 accepted 03-09-2020 available online 29-12-2020 keywords: infertility hysterosalpingography laparoscopy chromopertubation a b s t r a c t background: an accurate diagnosis of tubal occlusion is a crucial part of infertility management of women for which hysterosalpingography is an integral part for this purpose. objective: the study is designed to find out tubal occlusion by hysterosalpingography (hsg) and comparing the findings with diagnostic laparoscopy with chromopertubation (laparoscopy) by determining validity and agreement of findings in the study group. materials and methods : in this observational study, one hundred and ninety-seven women with infertility were recruited from an infertility clinic of a tertiary care hospital of west bengal, in between april 2018 and march 2020, i.e. 24 months’ period. women, who were exposed to both of the investigations i.e. hsg and laparoscopy tests, were our study subjects. hsg findings were compared with the findings of laparoscopy to detect tubal occlusion by analyzing sensitivity, specificity, positive predictive value, negative predictive value and kappa. results: we found mean age of women with primary infertility (66%) was 27.23 years and with secondary infertility (34%) was 32.02 years. the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of hsg in comparison to laparoscopy to detect tubal occlusion were 80.85%, 74%, 49.35%, 92.5% and 75.63% respectively. findings showed statistically significant (p<0.05) detection of tubal occlusion by hsg in comparison to findings of laparoscopy. here tubal factor denotes any form of tubal obstruction i.e. unilateral or bilateral. conclusion: this study provides strong supportive evidence to utilise hsg as a screening test for diagnosing tubal occlusion in infertility work up with high accuracy, especially in low resourceful area of rural india. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction infertility is a disease of couples due to failure to achieve clinical pregnancy even after 12 months of regular unprotected intercourse. 1 it may be primary or secondary. in primary infertility clinical pregnancy was never documented and secondary infertility refer to a couple where there was documented clinical pregnancy but failed to conceive subsequently. * corresponding author. e-mail address: drsubrata02@gmail.com (s. das). in the last decade, increasing trend of infertility 2,3 was seen in global population, 4 almost 10-15% couple 4,5 needed infertility related advice. increased trends of infertility mostly due to delayed marriage with delayed child bearing, increased prevalence of sexually transmitted disease and preponderance of pelvic endometriosis. other than anovulation, tubal factor is the major contributing factor (20-30%) 3 for female infertility. 2,6 hysterosalpingography (hsg) was used as a screening test to detect infertility from tubal occlusion. 5 the test is noninvasive, economical and less expertise is needed https://doi.org/10.18231/j.pjms.2020.056 2249-8176/© 2020 innovative publication, all rights reserved. 276 https://doi.org/10.18231/j.pjms.2020.056 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:drsubrata02@gmail.com https://doi.org/10.18231/j.pjms.2020.056 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):276–281 277 but with the risk of exposure of patients to radiation and iodinated contrast medium. it is an outpatient department procedure; 7 patients are less relaxed as sedation or anesthesia is not used during the procedure. presence of ‘cornual spasm’ at the level of interstitial part of tube sometimes is evident as tubal occlusion, which could lead to false positive result. 8 laparoscopic chromopertubation is a gold standard test for confirmation of tubal blockage. 3,8 laparoscopy was carried out in cases of tubal occlusion detected by hsg and/or where patients failed to conceive even after reasonable period of six months wait following tubal patency confirmed by hsg. but laparoscopy is invasive, costly, associated with surgical risk and training required to perform and interpret. hence, objective of our study to analyze validity and relation of findings of hysteroscopy with reference standard test e.g. laparoscopy 9 is to detect tubal occlusions in women with infertility. 2. materials and methods it is a retrospective observational study performed from april 2018 to march 2020. a total of one hundred and ninety-seven women who have infertility were enrolled from an infertility clinic of a tertiary care hospital. the institutional ethics committee approved the study, and the study was performed in accordance with its recommendations and that of helsinki declaration of 1975 that was revised in 2000. all women participating in this study gave a written informed consent. 2.1. inclusion criteria women in between 21 and 40 years’ age with either primary or secondary infertility and who were subjected to both investigation i.e. hysterosalpingography (hsg) and laparoscopy were selected for study. every woman underwent detailed examination and investigations to detect the cause of infertility. women with normal hormone profile i.e. thyroid stimulating hormone (tsh), follicle stimulating hormone (fsh) and anti-mullerian hormone (amh) and normal semen analysis of husband were included as a study subject. 2.2. exclusion criteria prior history of ectopic pregnancy, pelvic inflammatory disease or history of pelvic endometriosis or uterine anomalies were excluded from the study. women who had uterine myoma of more than 5 cm or non-functional ovarian cyst, detected by pelvic ultrasonography during infertility work up, were also excluded from study. (figure 1) in this study, one hundred and ninety-seven women were evaluated by hysteroscopy and followed by laparoscopy. hysterosalpingography was done in the proliferative phase in between 7th and 10th day of menstruation in the department of radiology. pregnancy test was performed in patients with grossly irregular menstrual cycle or amenorrhea before the procedures and such tests resulted in negative test result. hysterosalpingography was performed in dorsal lithotomy position after taking antiseptic precautions. water soluble radio opaque dye was introduced after holding cervix with tenaculum and cannula introduced just beyond the internal os. under fluoroscopic guidance anterior-posterior skiagrams were obtained during the phase of uterine cavity filling and subsequently to watch for the tubal patency, tubal lumen and free spillage within the peritoneal cavity. delayed skiagram was also obtained. presence of spillage in peritoneal cavity on either or both sides, denotes as patent fallopian tube. absence of spillage and presence of obstruction within uterine cavity or irrespective of site of obstruction within the fallopian tube was recorded as tubal block on respective sides. but for the purpose of study it is grouped as unilateral and bilateral tubal obstruction or patent tube. any space occupying lesion detected within the uterine cavity or ballooning of tube due to hydro salpinx was recorded for treatment purpose but was not included as it was beyond the scope of the study. laparoscopy with chromopertubation was done on those women who did not conceive within six months after hysterosalpingography or unilateral or bilateral tubal block was detected in hysterosalpingography, were included in the study. after pre-operative evaluation, patients were put under general anesthesia at operation theatre. a small 2-3 cm incision at supra umbilical and another 2 cm incision at right or left side of lower abdomen were given for introduction of 10 mm laparoscope and hand instrument respectively. diluted methylene blue solution of 15 ml was introduced slowly through cervix after placement of cannula beyond internal os. the passage of blue coloured solution of methylene blue from the fimbriae end of fallopian tube was marked as patent fallopian tube. in absence of passage of methylene blue solution in one or both tubal end was denoted as unilateral or bilateral tubal block. during laparoscopy, presence of endometriosis, peritubal adhesion and distorted pelvic anatomy was seen in few patients and documented for treatment purpose but such data was not included as it was beyond our scope of study. following prognostic factors, we considered during collection of data i.e. age and type of subfertility (i.e. primary or secondary). we followed the guideline that was reported by deville wl et al 10 in their diagnostic trial of meta-analysis. here we considered two outcomes by hysterosalpingography and by laparoscopy, i.e. unilateral and bilateral occlusion of tube as a single group of tubal occlusion is considered as positive findings and patency found in both the is tube considered as negative finding. test error was defined whenever hysterosalpingography detect tubal occlusion (i.e. positive finding) but patency of 278 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):276–281 both tube (i.e. negative finding) was found by reference standard test i.e. laparoscopy, was considered as false negative result. false positive results were cases in which the hysterosalpingography results were positive for tubal occlusion but in the reference standard test (laparoscopy) result showed patency of both tube present (negative result). for considering tubal obstruction of both i.e. unilateral and bilateral obstruction in a single group, we compared the group with patency of tube in between hysterosalpingography and laparoscopic findings. here we used two by two table for calculating sensitivity, specificity, positive predictive value and negative predictive value and accuracy. to compare the findings of hysterosalpingography with laparoscopy, 2x2 table was constructed and findings were measured at 95% confidence level and pearson’s chi-squared test was used to see the significance level where p <0.05. for descriptive statistics and student t test was used for parametric data and pearson’s chi-squared test was used to measure for non-parametric data. for statistical analysis we used ibm spss v24 software. 3. results out of one hundred and ninety-seven women with infertility, one hundred thirties were presented with primary infertility and sixty-seven were presented with secondary infertility. according to age both types of infertility were divided into four group of ages i.e. 21-25 years, 26-30 years, 31-35 years and 36-40 years. the age group of 21-25 years was+ the most common age group of presentation of primary infertility with mean age of 27.23±4.26 years. the most common age of presentation for secondary infertility was 31-35 years with mean age of 32.03±4.17years. (table 1) the age distribution according to findings of hysterosalpingography and laparoscopy were found significant (p value<0.05). (tables 2 and 3) patent tube was found in one hundred and eleven women by both hysterosalpingography and laparoscopy (table 4figure 2). in hysterosalpingography findings, all types of tubal blockage were compared with findings of laparoscopy. here tubal block was defined as both unilateral and bilateral tubal occlusions. in the analysis of study over all sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 80.85%, 74%, 49.35%, 92.5% and 75.63% respectably and findings were significant (i.e. p value <0.05). the weighted k-statistic was 0.45 (95% cl 0.32-0.57), which indicate moderate agreement beyond chance between the test result of hysterosalpingography and laparoscopy. we found that the likelihood ratio of hysterosalpingography for positive test result to detect tubal occlusion was 3.11 (95% cl 2.30 to 4.21) and negative likelihood ratio for negative test result was 0.26 (95% cl 0.14 to 0.47). fig. 1: flow chart of cases included in the study. fig. 2: distribution of hsg and laparoscopy findings. das and bhattacharyya / panacea journal of medical sciences 2020;10(3):276–281 279 table 1: distribution of women according to infertility type and age age groups primary infertility secondary infertility no. percentage mean age no. percentage mean±sd 21-25 63 32 27.23±4.26 4 2 32.03±4.17 26-30 35 17.8 22 11.2 31-35 21 10.6 24 12.2 36-40 11 5.6 17 8.6 total (n=197) 130 66 67 34 table 2: distribution of women according to hsg test and age group age total 21-25yrs 26-30yrs 31-35yrs 36-40yrs hsg (screening diagnosis) patent 49 33 23 15 120 blocked (unilateral + bilateral) 18 24 22 13 77 total 67 57 45 28 197 □2 = 5.3769, df=1, p=0.0204 table 3: distribution of women according to laparoscopy and age group age total 21-25yrs 26-30yrs 31-35yrs 36-40yrs hsg (screening diagnosis) patent 64 39 26 21 150 blocked (unilateral + bilateral) 3 18 19 7 47 67 57 45 28 197 □2 = 12.0906, df=1, p= 0.0005 table 4: tubal factor detected by hsg was compared to the tubal factor detected by laparoscopy tubal status at hsg and laparoscopy no. of women with infertility hsg patent, laparoscopy patent 111 hsg unilateral block, laparoscopy patent 18 hsg bilateral block, laparoscopy patent 21 hsg patent, laparoscopy unilateral block 6 hsg unilateral block, laparoscopy unilateral block 7 hsg bilateral block, laparoscopy unilateral block 10 hsg patent, laparoscopy bilateral block 3 hsg unilateral block, laparoscopy bilateral block 4 hsg bilateral block, laparoscopy bilateral block 17 total patient (n) 197 table 5: accuracy of hsg in predicting tubal factors of infertility hsg findings of fallopian tubes laparoscopy findings of fallopian tubes validity of hsg to diagnose infertility from tubal factor tubal block (unilateral and bilateral) patent tube total sensitivity specificity positive predictive value negative predictive value accuracy tubal block (unilateral and bilateral 38 39 77 80.85% 74% 49.35% 92.5% 75.63% patent tube 9 111 120 total 47 150 197 □2 = 10.564, df=1, p=.00012 280 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):276–281 table 6: comparison of findings of present study with study of others authors. principle author year size of sample types of infertility primary secondary moghissi ks et al. 11 1975 132 66% 34% ikechebelu ji et al. 12 2010 57 52.63% 47.37% khetmalas et al. 8 2016 114 58.8% 41.2% singh s. et al. 13 2019 100 68% 32% in our study 2020 197 66% 34% table 7: comparison of hsg finding of present study with the study by other authors. principle author year sample size hsg sensitivity specificity ppv npv sakar mn et al. 14 2008 82 63% 89.3% 92% 55% gandotra et al. 15 2015 30 90.91% 77.78% 83.33% 87.50% rizvi sm et al. 2 2016 60 90.1 77.78 83.33 87.50 in our study 2020 197 80.85% 74% 49.35% 92.5% 4. discussion in this observational study, it was found that both investigations i.e. hysterosalpingography and diagnostic laparoscopy could diagnose tubal occlusion effectively. but hysterosalpingography is less costly, devoid of any major risk and can be incorporated with other investigations of infertility in outdoor settings and is also free from surgical and anesthetic risks. laparoscopy has higher degree of specificity and is considered as reference standard to confirm the diagnosis of tubal occlusion in the women with infertility. as an investigator, we compared our study with the studies of other authors. in our study primary and secondary infertility were 66% and 34% respectably. similar finding was found in the study performed by moghissi ks et al. 11 and singh s. et al. 13 their sample size was one hundred and thirty-two and one hundred respectively i.e. a little smaller than our sample size. (table 6) the study by choudhary a at al 16 had reported that 26-30 years was the most common presenting age (38%) with mean age were 28.40 ± 6.73 at their study, and in our study mean age of primary and secondary infertility were 27.23±4.26 and 32.03±4.17 respectively. in our study, most of the women (32%) was from 21-25 years. the most commonly (32%) affected age of primary infertility was 21-25 years. the women with secondary infertility was most common (12.2%) in 31-35 years’ age followed by 11.2%, 8.6% and 2% of women with secondary infertility were in 26-30 years, 36-40 years and 21-25 years’ age respectably in the study. our findings were very close to the reported study of choudhary a at al. 5 the sensitivity, specificity, positive predictive value and negative predictive value were 80.85%, 74%, 49.35% and 92.5% respectably in the study to detect tubal occlusion by hysterosalpingography. the compared findings were significant (i.e. p value <.05) to detect tubal occlusion by hysterosalpingography. our findings of hysterosalpingography were compared with laparoscopic findings by rizvi sm et al. 2 and gandotra et al. 15 rizvi sm et al. 2 and gandotra et al. 15 in their study sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) reported as 90.1%, 77.78%, 83.33%, 87.50% and 90.91%, 77.78%, 83.33%, 87.50% respectively. the positive likelihood ratio for positive test was 3.11(95% cl 2.30-4.21) and negative likelihood ratio for negative test was 0.26 (95% cl 0.14-0.47). in my study sensitivity of hysterosalpingography was less, which might be due to stringent criteria adopted by radiologist and bigger sample size, but the other values were quite similar to our study. (table 7) in our study weighted k-static was 0.45 (95% cl 0.32-0.57), indicating moderate agreement beyond chances between hysterosalpingography and laparoscopy. in a similar study conducted by mol bjm 9 et al found weighted k-static value was 0.42 (95% cl 0.37-0.48), showed moderate agreement between hysterosalpingography and laparoscopy beyond chances. their finding was closely similar with our findings. study reported by goynumer g. et al 17 found sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of hysterosalpingography were 0.80, 0.75, 0.91, 0.55, 3.21 and 0.26 respectively at 95% confidence level. from hysterosalpingography and laparoscopy investigations, we tried to know the tubal occlusion of women with infertility. some other additional important results may be gained from these diagnostic investigations, that was relevant to know the other aetiological factor das and bhattacharyya / panacea journal of medical sciences 2020;10(3):276–281 281 of infertility, but we did not tabulate such findings here, as it was beyond the scope of our study. laparoscopy is an accurate predictor of intra-abdominal pathologies i.e. peritubular adhesions, endometriosis 14 and pelvic inflammatory disease which cannot be detected by using hysterosalpingography alone. on the other side hysterosalpingography is more appropriate to detect intra uterine anatomy and intra luminal pathology, specially in low resource areas and rural population. limitation of our study includes, possibility of interobserver variability of hysterosalpingography results, as more than one radiologist interpreted. the time gap of six months between hysterosalpingography and laparoscopy may have contributed some bias also. reporting was not real-time hysterosalpingography and not observing dynamic nature of gradual filling and spillage of tube by radiopaque medium but was interpreted as time-shot from skiagram. it can be concluded, that although there was some constrains in our study but reliability of hysterosalpingography as screening test has seen proved from our analysis. an inference can be drawn that hysterosalpingography can be a suitable alternative to reference standard test laparoscopy in the investigations for evaluation of infertility. 5. conclusion it can be concluded that hysterosalpingography is noninvasive, economical with high degree of sensitivity and can be incorporated as screening test during involution of infertility. due to low specificity of hysterosalpingography, laparoscopy is needed for confirmation of tubal occlusion. hysterosalpingography detect intraluminal disease and laparoscopy detect extra-luminal disease by the direct vision into pelvis. both findings are required for appropriate therapy formulation. hysterosalpingography and laparoscopy can be considered as complementary to one another rather than substitute. 6. authors’ contributions the author exclusively contributed this work and have read and approved the final manuscript. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. gharekhanloo f, rastegar f. comparison of hysterosalpingography and laparoscopy in evaluation of female infertility. med res arch . 2017;5(6):1–12. doi:10.18103/mra.v5i6.1297. 2. rizvi sm, ajaz s, gulshan g, nikita n, anjum s. comparison of hysterosalpingography and laparoscopy in diagnosis of tubal occlusion. ann int med dent res. 2016;2(4):165–8. doi:10.21276/aimdr.2016.2.4.43. 3. jain p, bansal d, deodhar p. re-emerging role of hsg vs laparoscopy for infertility work -up at rural hospital set up. j res med dent sci. 2015;3(4):287–9. doi:10.5455/jrmds.2015349. 4. anuradha j, arunakumari k, sujatha a. comparative study of tubal patency by hysterosalpingography, transvaginal sonosalpingography and laparoscopy. int arch integr med. 2016;3:126–9. 5. choudhary a, tiwari s. comparison between hysterosalpingography and laparoscopic chromopertubation for the assessment of tubal patency in infertile women. int j reprod contracept obstet gynecol . 2017;6(11):4825–9. doi:10.18203/2320-1770.ijrcog20174626. 6. nahar s, jahan d, akter n, das b. laparoscopic evaluation of tuboperitoneal causes of infertility. bangladesh med j khulna. 2014;46(12):16–20. doi:10.3329/bmjk.v46i1-2.18234. 7. nigam a, saxena p, mishra a. comparison of hysterosalpingography and combined laparohysteroscopy for the evaluation of primary infertility. kathmandu univ med j. 2015;13:281–5. 8. khetmalas sm, kathaley mh. a study evaluation of tubal factors of infertility by hysterosalpingography and diagnostic laparoscopy. mvp j med sci. 2016;3(1):11–7. doi:10.18311/mvpjms/2016/v3/i1/722. 9. mol bwj, collins ja, burrows ea, veen fcd, bossuyt pmm. comparison of hysterosalpingography and laparoscopy in predicting fertility outcome. hum rep. 1999;14:1237–42. 10. devillé wl, buntinx f, bouter lm, montori vm, de vet hc, van der windt d, et al. conducting systematic reviews of diagnostic studies: didactic guidelines. bmc med res methodol. 2002;2(9):13. doi:10.1186/1471-2288-2-9. 11. moghissi ks, sim gs. correlation between hysterosalpingography and pelvic endoscopy for the evaluation of tubal factor**presented at the thirty-first annual meeting of the american fertility society, april 3 to 5, 1975, los angeles, calif. fertil steril . 1975;26(12):1178–81. doi:10.1016/s0015-0282(16)41531-1. 12. ikechebelu ji, eke no, eleje gu, umeobika j. comparism of the diagnostic accuracy of laparoscopy with dye test and hysterosalpingography in the evaluation of infertile women in nnewi, negeria. . trop j laparoendosc. 2010;1(1):39–44. 13. singh s, das l, das, das s, das pc. combined diagnostic approach of hsg and diagnostic hysterolaparoscopy in evaluation of female infertility. int j adv res. 2019;7:623–30. 14. sakar mn, gul t, atay ae, celik y. comparison of hysterosalpingography and laparoscopy in the evaluation of infertile women. saudi med j. 2008;29:1315–8. 15. gandotra n, sharma a, rizvi sm. comparison of laparoscopy and hysterosalpingography in diagnosis of tubal occlusion. j med sci clin res. 2015;3(10):7985–9. doi:10.18535/jmscr/v3i10.46. 16. dubbewar a, nath sk. observational study of hsg with laparoscopic correlation in infertility patients. int j reprod contracept obstet gynecol. 2018;7(5):1903–7. doi:10.18203/23201770.ijrcog20181926. 17. goynumer g, yetim g, gokcen o, karaaslan i, wetherilt l, durukan b. world j of laparosc surg. 2008;1:23–29. author biography subrata das, associate professor ajit r bhattacharyya, professor cite this article: das s, bhattacharyya ar. diagnostic accuracy of hysterosalpingography in comparison to laparoscopy to detect tubal occlusion in female infertility: an observational study. panacea j med sci 2020;10(3):276-281. http://dx.doi.org/10.18103/mra.v5i6.1297 http://dx.doi.org/10.21276/aimdr.2016.2.4.43 http://dx.doi.org/10.5455/jrmds.2015349 http://dx.doi.org/10.18203/2320-1770.ijrcog20174626 http://dx.doi.org/10.3329/bmjk.v46i1-2.18234 http://dx.doi.org/10.18311/mvpjms/2016/v3/i1/722 http://dx.doi.org/10.1186/1471-2288-2-9 http://dx.doi.org/10.1016/s0015-0282(16)41531-1 http://dx.doi.org/10.18535/jmscr/v3i10.46 http://dx.doi.org/10.18203/2320-1770.ijrcog20181926 http://dx.doi.org/10.18203/2320-1770.ijrcog20181926 introduction materials and methods inclusion criteria exclusion criteria results discussion conclusion authors' contributions source of funding conflict of interest panacea journal of medical sciences 2020;10(3):299–302 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article cardiovascular and atherogenic risk profile in young indian pcos patients padala ravi kumar1,*, indira palo2, s r pattanaik3 1dept. of endocrinology, mkcg medical college, berhampur, odisha, india 2dept. of obstetrics & gynecology, mkcg medical college, berhampur, odisha, india 3dept. of endocrinology, m.k.c.g. medical college, berhampur, odisha, india a r t i c l e i n f o article history: received 03-06-2020 accepted 06-07-2020 available online 29-12-2020 keywords: pcos cimt and hscrp. a b s t r a c t aim: to assess the cardiovascular risk factors and carotid intima media thickness in young indian pcos patients. materials and methods : the study group included 25 pcos patients who were diagnosed according to rotterdam criteria and 15 healthy controls who had normal menstrual cycles. the mean age and bmi in pcos (age-22.3±3years, bmi 28.1±5.4 kg/m2) and control (age 21.5±0.6yrs, bmi22.3±3.7kg/m2). in all these patients detailed clinical examination and anthropometry including height, weight were taken and bmi was calculated. fasting blood glucose and serum insulin, lipids, high sensitivity c-reactive protein (hscrp), follicle stimulating hormone, luteinising hormone, thyroid stimulating hormone, total testosterone were tested. homa-ir was calculated according to formula fpg (mmol/l)* s. insulin (µ iu/ml)/22.5. carotid intima media thickness was measured on either side or mean of three readings taken as final value. results : carotid intima media thickness was statistically significantly increased in pcos patients compared to controls (0.699±0.06 vs0.558±0.05mm, p<0.001). serum insulin, homa-ir, hscrp were significantly more in pcos compared control. however hscrp was non-significant when bmi and waist circumference were included in multivariate analysis. conclusion: present study shows that patients with pcos are at increased risk of atherosclerosis in young indian women. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction polycystic ovarian syndrome (pcos) is the most common endocrine disorder affecting 6-10% of women in the reproductive age group. 1,2 it is characterized by chronic anovulation, hyperandrogenism and or polycystic ovaries. pcos is associated with cardiovascular risk factors including dysglycemia, hypertension, hyperinsulinemia and dyslipidemia. this might substantially increases cardiovascular risk in patients with pcos. however a long term study which followed cvd in 780 pcos women for 22 years did not show increased deaths due to cvd. 3 meta-analysis by de groot et al showed that women with pcos had two times the relative risk of coronary artery * corresponding author. e-mail address: padala797@gmail.com (p. r. kumar). disease or stroke. 4 there were few studies assessing the atherogenic risk in patients with pcos in indian women and others. 5 compared to caucasians the pcos population in india are younger and leaner and more insulin resistant and their atherosclerotic burden is unclear. 6 there are very few studies comparing the cimt and hscrp. 7 present study aims to assess the carotid intima medial thickness and atherogenic profile including hscrp which is an inflammatory marker. 2. materials and methods this study was carried out in the endocrine clinic of mkcg medical college, berhampur between jan 2019 to may 2019. twenty five pcos patients attending opd for various symptoms including hirsutism, acne, menstrual https://doi.org/10.18231/j.pjms.2020.061 2249-8176/© 2020 innovative publication, all rights reserved. 299 https://doi.org/10.18231/j.pjms.2020.061 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:padala797@gmail.com https://doi.org/10.18231/j.pjms.2020.061 300 kumar, palo and pattanaik / panacea journal of medical sciences 2020;10(3):299–302 irregularities were included in this study. the pcos was diagnosed by using rotterdam criteria which included any two of three-anovulation/oligomenorrhea, clinical hyperandrogenism/ or biochemical hyperandrogenemia or polycystic ovaries with> 12 follicles of sizes 4-8mm in either ovary. 8 fifteen age matched controls who were having regular menstrual cycles and apparently healthy included in the study. participants who had history of chronic cardiovascular, hepatic, renal, hematologic or malignant disease or any acute medical illness were excluded. written informed consent was taken from all participants and the study was approved by the institutional ethics committee. 2.1. anthropometry in all these subjects detailed anthropometric measurements including their height to nearest centimeter, weight(kg), waist circumference (wc) at midpoint between iliac crest and lower rib cage at the end of expiration were recorded. the bmi was calculated by weight in kg/meter2. 2.2. biochemical analysis after an overnight fast of 8-12hr blood was collected for fasting plasma glucose (fpg), serum insulin, total cholesterol (tc), high density cholesterol (hdl), triglycerides (tg). ldl was calculated using friedewald formula. fpg and lipids (tc, hdl, tg) were measured using hitachi autoanalyser and serum insulin was measured by elisa kits. homa-1r was calculated by using the formulafasting serum insulin (µ iu/ ml) * fasting plasma glucose (mmol/l)/22.5.blood was collected and stored at -70c for lh, fsh, testosterone, prolactin and tsh. hormone analysis was done on automated chemiluminescent immunoassay. cimt was performed with 10 mhz doppler probe by a single operator blinded to subject details. the cimt of the posterior wall of common carotid arteries (1 cm proximal to the origin of the bulb) was measured at the end of the diastole. 9 average cimt was taken as the mean of 3 readings on each side. 2.3. statistical analysis the data were entered in spss-14 and analyzed. continuous variable were expressed as mean and standard deviation (sd). the variables were compared between pcos cases and controls using the unpaired student’s t test for normally distributed continuous data and mann–whitney u test for non-normally distributed data. spearman’s correlation was done to assess the relation between cimt and clinical and biochemical parameters. variables showing significant correlation were entered into stepwise linear regression to assess the magnitude of their individual effect on cimt. p value of >=0.05 was considered as significant. 3. results there were twenty-five pcos patients and fifteen control subjects in the present study. the baseline characters of both groups were shown in table 1. the mean age of pcos and control patients was not different (21.58±3.9 years vs 22.37± 8.6yrs respectively). bmi and waist circumference were significantly higher in pcos patients compared to controls whereas no difference with regard to sbp or dbp. one third (33%) of pcos patients had acne, hirsutism in 46% and skin tags in 22%. the hormonal profiles quoted elsewhere. the biochemical and other parameters are shown in table 2. there was no difference in fasting plasma glucose or serum lipids (tc, hdl, tg, ldl) statistically between the groups. serum insulin and homa-ir were significantly higher in pcos patients compared to control. homair was more than 3 times and serum insulin was more than two times higher compared to control group. the inflammatory marker hscrp and atherogenic marker cimt were higher in pcos. hscrp was correlated positively with bmi (pearson correlation 0.580, p 0.012) and wc (pearson correlation 0.718, p 0.004). hscrp which was significantly higher in pcos compared to controls lost significance when controlled for bmi and wc in multivariate analysis (p 0.907). cimt remained significant even after controlling for confounding factors like bmi, wc, hscrp and homa-1r (p 0.05). table 1: baseline characters of pcos and control groups. pcos n=25 control n=15 p age (yrs) 22.3±3.7 21.5±0.6 0.48 weight (kg) 67±15.8 53.8±9.5 0.009 bmi kg/m2 28.1±5.4 22.3±3.7 0.004 wc(cm) 90.7±12.8 72.5±9.4 <0.001 sbp mmhg 122.5±8.7 115±7.0 0.264 dbp 78.6±3.5 75±7.0 0.226 wcwaist circumference, sbp-systolic blood pressure, dbpdiastolic blood pressure, bmi-body mass index cimt-carotid intimia media thickness, hscrphigh sensitivity c-reactive protein, homa-ir-homeostatic model assessment of insulin resistance. 4. discussion the present study showed that in young pcos patients from india, cimt was significantly higher even after accounting for body weight, wc and insulin resistance. insulin resistance marker (homa-ir) as expected was higher in pcos compared to controls. hscrp was non significant when controlled other parameters like bmi and wc. cimt is an early atherosclerotic marker. some of the previous studies shown that it is significantly increased in kumar, palo and pattanaik / panacea journal of medical sciences 2020;10(3):299–302 301 table 2: biochemical parameters in pcos and control groups. pcos n=25 control n=15 p fpg(mg/dl) 88±7.9 81±6.4 0.114 tc (mg/dl) 170.4±28.9 166±24 0.680 hdl(mg/dl) 39.5±6.8 44.5±10.2 0.132 tg(mg/dl) 144±78.3 106.5±27.1 0.127 ldl(mg/dl) 101.7±24.9 102.4±21.4 0.935 s. insulin µ iu/ml 21.9±4.0 6.4±3.6 <0.05 homa-ir units 4.12±10.8 1.291±0.76 <0.05 hscrp mg/dl 4.50±3.2 1.97±1.93 0.019* cimt(mm) 0.699±0.06 0.558±0.05 <0.001 *hscrp when controlled for bmi and waist circumference was nonsignificant (p 0.907) pcos patients and may also increase cvd risk. in a similar study by karoli et al, studying the early atherosclerotic markers observed that cimt was significantly higher in 50 patients with pcos compared to age matched controls. cimt was positively correlated with age and bmi. 10 garg et al studying in 54 pcos women from south india, also observed significantly higher cimt compared to controls (0.51mm vs 0.44mm). 11 in a meta-analysis of 19 studies including 1123 pcos patients observed a mean difference in cimt was+ 0.072mm compared to controls for highest quality studies. 12 this again underscores the importance of early atherosclerotic marker in patients with pcos. however all studies are not in conformity. meyer at al in a study of 100 overweight women with pcos and 20 matched controls found no difference in cimt between the groups. 13 atherosclerosis is condition of chronic inflammation and endothelial dysfunction in pcos is possibly the result of an inflammatory state. various inflammatory markers like crp, tnf α , il6 and adiponectin have been tested in pcos with inconsistent results. present study showed that although hscrp increased in patients with pcos but when bmi and waist circumference was included in regression analysis, it lost its significance. similar to present study, ghani et al found no correlation between hscrp and pcos but was related to bmi. 7 un et al, in 75 pcos patients and similar number of controls found no correlation with hscrp and. 14 although dyslipidemia is common in pcos, the present study could not find significant lipid abnormalities between the groups. increased tg and ldl and low hdl is the common abnormality found in pcos patients and has been attributed to hyperinsulinemia due to insulin resistance and hyperandrogenemia. 15 the non significant levels in the present study could be due to small number of patients and young age group. it is well established that increase in cimt correlate with future cardiovascular outcomes. for every 0.10 increase in cimt, the risk of myocardial infarction increases by 15% and stroke by 18%. 16 this puts women with pcos at a higher risk for future cardiovascular events. the limitations of the present study include small number, lack of assessment of other inflammatory markers, no body composition analysis. 5. conclusion present study reaffirms that people with pcos are at increased risk of atherosclerosis and might need proper risk factor evaluation to decrease the risk. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. knochenhauer es, key tj, kahsar-miller m, waggoner w, boots lr, azziz r, et al. prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern united states: a prospective study. j clin endocrinol metab. 1998;83:3078–82. 2. kauffman rp, baker vm, dimarino p, gimpel t, castracane vd. polycystic ovarian syndrome and insulin resistance in white and mexican american women: a comparison of two distinct populations. am j obstet gynecol. 2002;187(5):1362–9. doi:10.1067/mob.2002.126650. 3. pierpoint t, mckeigue pm, isaacs aj, wild sh, jacobs hs. mortality of women with polycystic ovary syndrome at long-term followup. j clin epidemiol . 1998;51(7):581–6. doi:10.1016/s08954356(98)00035-3. 4. de groot pcm, dekkers om, romijn ja, dieben swm, helmerhorst fm. pcos, coronary heart disease, stroke and the influence of obesity: a systematic review and meta-analysis. hum reprod update . 2011;17(4):495–500. doi:10.1093/humupd/dmr001. 5. guleria ak, syal sk, kapoor a, kumar s, tiwari p, dabadghao p, et al. cardiovascular disease risk in young indian women with polycystic ovary syndrome. gynecol endocrinol. 2014;30(1):26–9. doi:10.3109/09513590.2013.831835. 6. norman rj, mahabeer s, masters s. ethnic differences in insulin and glucose response to glucose between white and indian women with polycystic ovary syndrome**supported by the national health and medical research council, canberra, australian capital territory, australia. fertil steril . 1995;63(1):58–62. doi:10.1016/s00150282(16)57297-5. 7. ganie ma, hassan s, nisar s. high-sensitivity c-reactive protein (hs-crp) levels and its relationship with components of polycystic ovary syndrome in indian adolescent women with polycystic ovary syndrome (pcos). gynecol endocrinol. 2014;30(11):781–4. 8. rotterdam eshre/asrm-sponsored pcos consensus workshop group 2004 revised 2003 consensus on diagnostic criteria and longterm health risks related to polycystic ovary syndrome. 2003;81:19– 25. 9. sidhu ps, desai sr. a simple and reproducible method for assessing intimal-medial thickness of the common carotid artery. br j radiol . 1997;70(829):85–9. doi:10.1259/bjr.70.829.9059301. 10. karoli r, maini s, siddiqi z, sultania ar, vatsal p, fatima j, et al. study of early atherosclerotic markers in women with polycystic ovary syndrome. indian j endocrinol metab . 2012;16(6):1004–8. doi:10.4103/2230-8210.103021. 11. dharmalingam m, garg n, prabhu v, murthy ns. carotid intimomedial thickness: a predictor for cardiovascular disorder in patients http://dx.doi.org/10.1067/mob.2002.126650 http://dx.doi.org/10.1016/s0895-4356(98)00035-3 http://dx.doi.org/10.1016/s0895-4356(98)00035-3 http://dx.doi.org/10.1093/humupd/dmr001 http://dx.doi.org/10.3109/09513590.2013.831835 http://dx.doi.org/10.1016/s0015-0282(16)57297-5 http://dx.doi.org/10.1016/s0015-0282(16)57297-5 http://dx.doi.org/10.1259/bjr.70.829.9059301 http://dx.doi.org/10.4103/2230-8210.103021 302 kumar, palo and pattanaik / panacea journal of medical sciences 2020;10(3):299–302 with polycystic ovarian syndrome in the south indian population. indian j endocrinol metab. 2016;20(5):662–6. doi:10.4103/22308210.190552. 12. meyer ml, malek am, wild ra, korytkowski mt, talbott eo. carotid artery intima-media thickness in polycystic ovary syndrome: a systematic review and meta-analysis. human reprod update. 2012;18(2):112–26. doi:10.1093/humupd/dmr046. 13. meyer c, mcgrath bp, teede hj. overweight women with polycystic ovary syndrome have evidence of subclinical cardiovascular disease. j clin endocrinol metab. 2005;90(10):5711– 6. doi:10.1210/jc.2005-0011. 14. ün b, dolapçıoğlu ks, okyay ag, şahin h, beyazıt a. evaluation of hs-crp and visseral adiposity index in patients with policystic ovary syndrome by clinical and laboratory findings. eur j obstet gynecol reprod biol. 2016;204:16–20. doi:10.1016/j.ejogrb.2016.06.022. 15. kim jj, choi ym. dyslipidemia in women with polycystic ovary syndrome. obstet gynecol sci. 2013;56(3):137–42. 16. lorenz mw, markus hs, bots ml, rosvall m, sitzer m. prediction of clinical cardiovascular events with carotid intima-media thickness. circ. 2007;115(4):459–67. doi:10.1161/circulationaha.106.628875. author biography padala ravi kumar, assistant professor indira palo, assistant professor s r pattanaik, associate professor cite this article: kumar pr, palo i, pattanaik sr. cardiovascular and atherogenic risk profile in young indian pcos patients. panacea j med sci 2020;10(3):299-302. http://dx.doi.org/10.4103/2230-8210.190552 http://dx.doi.org/10.4103/2230-8210.190552 http://dx.doi.org/10.1093/humupd/dmr046 http://dx.doi.org/10.1210/jc.2005-0011 http://dx.doi.org/10.1016/j.ejogrb.2016.06.022 http://dx.doi.org/10.1161/circulationaha.106.628875 introduction materials and methods anthropometry biochemical analysis statistical analysis results discussion conclusion source of funding conflict of interest 429 too many requests you have sent too many requests in a given amount of time. julydecember 2012 pdf for website the study of wormian bones in human skulls in vidarbha region 1 2 3 walulkar sanjay , ksheersagar d , walulkar madhavi abstract: additional ossification centers may occur in or near sutures, giving rise to isolated sutural bones. usually irregular in size and shape, and most frequent in lambdoid suture, they sometime occur at fontanelles. there are often only two or three, but they appear in great numbers in hydrocephalic skull. in present study, we aimed to find out the gross incidence and percentage frequency, and to differentiate whether it is wormian or fracture skull as seen in medicolegal cases. the study included 225 adult human skulls collected from various medical colleges of vidarbha region. the parameters were observed and were tabulated for male and female skulls separately. average values of maximum length and breadth were calculated. out of 225 adult human skulls, 161 were male skulls and 64 were female skulls. the data regarding gross incidence and percentage frequency, sexual dimorphism, incidence at various sites of the skull, shapes and size of wormian bones were noted. the gross incidence of wormian bones in the present study is found to be 34.22%, in the male skulls incidence rate is 39.13%, whereas in female it is 21.87%.the most common site for the occurrence of wormian bones is the lambdoid suture. the variable numbers of wormian bones are found in skull. the most common shape of wormian bones is found to be irregular followed by oval and least common shape of wormian bones being triangular. keywords: sutural bone, wormian bone, lambdoid suture, ossicles, sexual dimorphism. introduction: sutural bones or wormian bones also known as ossicles or supernumerary bones of the skull are multiple, small and irregularly shaped bones that develops as extra islands of bones within the calvarial sutures of skull. these bones rarely appear in the basicranial synchondrosis or facial suture (1,2,3). sutural bones represent independent centers of ossification and usually penetrate both outer and inner tables of cranial vault. the wormian bones are “stopgaps” develops in coronal suture as a response to the stressful conditions of artificial cranial deformation (4). occurrence of such ossicles in the human crania is relatively common and therefore these are considered as normal morphological variants in human crania. hooton (5) noted 79.5% incidence of wormian bones in the pecos population. torgerson (6) reported that wormian bones are inherited as autosomal dominant traits with about 50% penetrance and variable expression. berry and berry (7) stated in their study, wormian bones are most commonly present in lambdoid suture and second common site for wormian bones being lambda with least incidence at bregma. the sutural bones are compensatory ossific inclusions occurring in sutures and arising as separate ossifying centers between the main cranial elements. they vary in size from being mere normal serrations cut off from the denate edge of one of the main bones to being considerable contribution to a cranial vault, several inches in diameter. in number, they vary from complete absence to scores in a case of the enormously enlarged crania of hydrocephalus. the facts that they are present in such a large number in the rapidly enlarging cranium of hydrocephalus and that they occur regularly in cranium deformation, deliberately practice on the skulls of new born babies are evidence that their presence is largely due to demands of unusual cranial growth that cannot be fulfilled by the normal increase in size of regular cranial bones (8). wormian bone can be seen as an isolated sonographic finding in a healthy fetus or can be associated with multiple congenital anomalies. the sonographic detection of a fetus with wormian bone indicates the need for a very thorough examination and genetic counseling for the parents regarding prognosis and risk of recurrence. sutural bones as one of several discontinuous morphological characteristics are observed in human crania. since in the latter part of the nineteenth century various workers have observed these variants and have tried to explain their development in different ways. little effort has been made towards the interpretation of factors responsible for the appearance. hence this study is undertaken to find out for gross incidence, sexual dimorphism, morphology and commonest site of occurrence of wormian bones in vidarbha region. aims and objectives: 1) to find out the gross incidence and percentage frequency of wormian bones. 2) to find the ossicles either at the sites of various fontanelles or along the different cranial sutures. 3) to differentiate whether it is wormian or fracture skull as seen in medicolegal cases. 4) to find out the various shapes and sizes of the wormian bones. 5) to study variation of ossicles in their occurrence, shapes, sizes and sites in the skull for teaching purpose. 18 1 2 associate professor, professor, 3 department of anatomy, assistant professor, department of physiology, nkpsims & rc, digdoh hills, hingna road, nagpur -440019. sanjaymwalulkar@gmail.com pjmsvolume 2 number 2: julydecember 2012 original article material and methods: after obtaining institutional ethicscommittee approval, the present study was carried out in 225 adult human skulls in the department of anatomy and forensic medicine of various medical colleges. all the skulls were serially numbered from 1 to 225. in each skull the following points were made. 1) presence of wormian bones. 2) gross incidence and percentage distribution. 3) the occurrence of these bones at different sites of fontanelles and in different sutures. 4) at sites like asterion, coronal suture and lambdoid sutures, the occurrence of these bones were observed separately with respect to their unilateral or bilateral presence. 5) their occurrence at mentioned sites was tabulated for male and female skulls separately. 6) incidence of various shapes of wormian bones was noted. 7) average values of maximum length and breadth were calculated using vernier caliper (fig. 1). observations and results: in the present study of 225 adult human skulls, 161 are male skulls and 64 are female skulls. observations are made under the following heads in sequence. a) gross incidence and percentage frequency. (table i) b) sexual dimorphism.(table ii) c) incidence at various sites of the skulls.(table iii) d) incidence at various sites in male skulls. (table iv) e) incidence at various sites in female skulls.(table v) f) shapes of wormian bones. (table vi) g) size (maximum length and maximum breadth) of wormian bones (fig. 2 & 3). discussion: the present study consists of 225 (two hundred and twenty five) normal adult human skulls. various findings regarding the wormian bones are discussed in reference to similar types of observations recorded by earlier workers. sex male female skulls examined 161 64 skulls showing wormian bones 63 14 percentage 39.13 21.87 fig. 1: measurement of wormian bone fig. 2: wormian bone at lambdoid suture fig. 3: wormian bone at asterion table i: gross incidence and percentage frequency of wormian bones sexual dimorphism in incidence of wormian bones. table ii: total no. of skulls examined 225 skulls showing wormian bones 77 percentage 34.22 the percentage incidence calculated is 34.22%. the percentage incidence of these bones is calculated as 39.13 and 21.87 in male and female skulls respectively. cranial sites no. of skulls incidence total no. percentage unilateral bilateral right left coronal suture 77 01 01 1.29 sagittal suture 77 04 04 5.19 lambdoid suture 77 16 25 16 57 74.2 bregma 77 lambda 77 08 08 10.38 asterion 77 04 02 01 07 9.09 it is also evident from table iii; the lambdoid suture is the commonest suture for the occurrence of the wormian bones unilaterally on the left side, as well as bilaterally. percentage frequency for the occurrence of the wormian bones at lambdoid suture, lambda, asterion, sagittal suture and coronal suture are 74.2, 10.38, 9.90, 5.19 and 1.29 respectively. table iii: incidence at various sites of skull. 19 pjmsvolume 2 number 2: julydecember 2012 original article gross incidence: the percentage frequency of the wormian bones in the present study is found to be 34.22. this rate of occurrence of wormian bone in present study is significantly lower from the incidence of frequency of wormian bone noted by hooton (5). he noted 79.5 percentage incidences of wormian bones in the pecos population. this percentage frequency of wormian bones is much higher than the percentage frequency of these bones in the present study. bass(9)found that the percentage incidence of wormian bones was only about 26% in the population such as the arikara. it is also significantly different and lower than incidence rate observed in the present study. as an indication of population variability of this parameter, brothwell (1), studied and listed the percentage frequency of wormian bones in the various population groups (55.56 to 80.32). it is observed that the incidence rate of wormian bones in the present study is significantly lower. sexual dimorphism: the percentage incidence of the wormian bones in the male and female skulls in the present study is found to be 39.13 and 21.87 respectively which appears to be quiet higher in the males. hooton (5) noted 82 and 77 percentage incidence of wormian bones in male and female respectively. this percentage frequency of wormian bones is much higher than the percentage frequencies of these bones in the present study. quantitatively the present data is similar to the observations of berry (10) who noted a higher incidence of the wormian bones in male skulls especially at asterion in the different population groups including the indian punjabis. the present study shows the incidence rate of cranial sites no. of skulls incidence total no. percentage unilateral bilateral right left coronal suture 14 sagittal suture 14 lambdoid suture 14 04 06 02 12 85.71 bregma 14 lambda 14 01 01 7.14 asterion 14 01 02 01 01 7.14 shapes oval triangular irregular no. of wormian bones (total 173) 69 24 80 percentage 39.88 13.87 46.24 range of maximum length 5 mm to 25 mm range of maximum breadth 2 mm to 12 mm average maximum length 11 mm average maximum breadth 6 mm cranial sites no. of skulls incidence total no. percentage unilateral bilateral right left coronal suture 63 01 01 1.29 sagittal suture 63 04 04 5.19 lambdoid suture 63 12 19 14 45 71.42 bregma 63 lambda 63 07 07 11.11 asterion 63 03 02 01 06 9.52 table iv: incidence at various cranial sites in male skulls. the commonest site of occurrence of wormian bones is lambdoid suture (71.42%), second commonest appears to be lambda (12.69%) followed by asterion (9.52%). male skull shows the presence of 6.34% these bones in sagittal sutures and 1.58% in coronal sutures. table v: incidence at various cranial sites in female skulls. it can be observed from the table iv and v that percentage of wormian bones at lambdoid suture is higher in female (85.71) than in male skulls (71.41). table vi: shapes of wormian bones from table vi, it is evident that 173 wormian bones are observed in total 77 skulls. 80 wormian bones have irregular shape with percentage frequency of 46.24, 69 bones have oval shape with percentage frequency of 39.88 while 24 wormian bones have triangular shape with percentage frequency of 13.87%. most commonly wormian bones are of irregular shape. table vii: range and the average sizes (maximum length and maximum breadth) of wormian bones 20 pjmsvolume 2 number 2: julydecember 2012 original article occurrence of wormian bones on lambdoid suture in the female (85.71%) is higher than male (71.42%) while incidence rate of wormian bones at coronal suture, sagittal suture, lambda and asterion is higher in male as compared to the female. however earlier workers had not reported the sexual dimorphism in relation to different cranial sites. incidence rate at different sites in cranium: the percentage frequencies of the wormian bones at various sites of fontanelles and in different suture are tabulated in table iii. this shows that the most common site of wormian bones in skull vault is the lambdoid suture (74.2%). the second common site is lambda (10.38%) followed by asterion (9.09%) and the sagittal suture (5.19%). the least frequent site for the wormian bones occurrence is the coronal suture (1.29%). the wormian bones are not observed in bregma in the present study. wood (8) stated that lambdoid suture being always the most complicated suture of all the cranial sutures is by far the commonest site for the development of wormian bones. this observation is similar in the present study. berry and berry (7) mentioned the similar frequencies in the occurrence of the wormian bones at the different cranial sites of human skulls. they stated in their study in different groups of the population, wormian bones are most commonly present in lambdoid suture and second common site for wormian bones being the lambda with least incidence at the bregma. findings in the present study are closely coincides with the findings of berry and berry (7) showing higher incidence of wormian bones in lambdoid suture. shapes of wormian bones: the most common shape of wormian bones in the present study is found to be irregular with percentage incidence 46.24% followed by oval shape with percentage incidence of 39.88%. the least common shape of wormian bones is being the triangular with percentage incidence 13.87%. gray (12) mentioned that wormian bones are usually irregular in shape. this is the similar observation with most common shape observed in the present study, being irregular. size of wormian bone: in the present study, wormian bones have observed various sizes ranging from minimum 5mm x 2mm to a maximum 25mm x 20mm dimensions. wood(8) stated that wormian bones vary in size from being mere normal serrations cut off the dentate edge of one of the main bones to being considerable contributions to the cranial vault several inches in diameter. he also mentioned that it is of no true morphological significance although its size of 15mm x 8mm is fairly constant. conclusion: 1) gross incidence of wormian bones in the present study is found to be 34.22%, which is quantitatively significant. 2) incidence rate of these bones is higher in the male skulls than the female skulls. in the male skulls incidence rate is 39.13%, whereas in female it is 21.87%. 3) the most common site for the occurrence of wormian bones is the lambdoid suture. the second most common site is lambda followed by asterion and then by the sagittal suture. the least common site for the occurrence of these bones is the coronal suture. 4) wormian bones are not encountered at bregma. 5) these bones frequently occur unilaterally. 6) these bones are encountered predominantly on the left side of the skull. 7) the incidence rate of wormian bones on lambdoid suture in female is higher than that of male, while occurrence of wormian bones on remaining site is higher in male as compared to female. male skull shows presence of these bones in sagittal and coronal suture. however surprisingly in females these features are not observed. 8) variable number of wormian bones is found in skull. 9) wormian bones observed in the present study have various sizes of minimum of 5mm x 2mm to a maximum of 25mm x 20mm. 10) the most common shape of wormian bones is found to be irregular followed by oval and least common shape of wormian bones being triangular. references: 1. brothwell dr. digging up bones. london, british museum of natural history, 1963. 2. schwartz jh. skeleton keys. new york: oxford university press, 1995. 3. hess l(1946), brothwell dr(1981), schwartz (1995). ossicula wormiana. human biology; (11), 61-80, cited by bennet ka (1965). the etiology and genetics of wormian bones. american journal of physical anthropology 23, 255-260. 4. dorsey ga. wormian bones in artificially deformed kwakiuti crania. american journal of anthropology 1897; 10: 169-173. 5. hooton ea. the indian of pecos pueblo: a study of their skeletal remains yale university press, new haven, conn; 1930, cited by bennet ka (1965). 6. torgerson j. hereditary factors in sutural pattern of the skull. acta radiologica 1951; 36:374-382, cited by bennet ka (1965). 7. berry ac, berry rj. epigenetic variation in the human cranium. journal of anatomy 1967;101: 361-379. 8. wood jone's 8th edn, buchanan's manual of anatomy 1953: 226-228. 9. bass wm. the variation in physical types of the pre-historic plain indians. plains anthrop 1964; 9: 65-145. 10. berry ac. factors affecting the incidence of non-metrical skeletal variant. journal of anatomy 1975; 120: 519-535. 11. gray h. anatomy, descriptive and surgical 1860; 2nd edition: 61, philadelphia. 21 pjmsvolume 2 number 2: julydecember 2012 original article page 22 page 23 page 24 page 25 review article http://doi.org/10.18231/j.pjms.2019.011 panacea journal of medical sciences, may-august, 2019;9(2):39-42 39 sickle cell disease and folate supplementation suprava patel1*, samapika bhaumik2 1associate professor, 2mbbs student, dept. of biochemistry, all india institute of medical sciences, raipur, chhattisgarh, india *corresponding author: suprava patel email: dr_suprava@yahoo.co.in abstract sickle cell disease is an important inherited blood disorder in which anemia occurs due to short life span of the deformed rbcs. though scd is predominantly present in africa, it has been reported from other tropical regions including india. scd may also manifest as vasoocclusive crisis which occurs as a result of interplay among impaired blood rheology, increased adhesiveness of rbcs with inflammatory cells and vascular endothelium, and hemostatic activation. damage of erythrocyte membranes also increases exposure of adhesion molecules and binding motifs viz. phosphatidyl serine, basal cell adhesion molecule-1/lutheran, integrin-associated protein, and intercellular-adhesion-molecule-4. release of immature rbcs or reticulocytes with adhesion molecules and increased cellular effect of selectins pand e-, vascular-cell-adhesion-molecule-1, icam-1 and interleukin-8 on endothelial cells aggravates the crisis. increased level of circulating homocysteine causes increased cytotoxic activity on endothelial cells, elevates hydrogen peroxide levels, decreases nitric oxide synthesis, induces cytokine production to stimulate the inflammatory state, activates procoagulant factors, and dysregulation of lipid metabolism. positive role of folic acid supplementation in scd is not well supported and there are possible side effects of folate supplementation. the final biologically active form of folic acid, l-methylfolate or levomefolic acid or 5-mthf, is the best option which gets readily absorbed and exerts its action without requiring any bioconversion. keywords: sickle cell disease, vaso-occlusive crisis, 5-mthfr, folate supplementation. introduction sickle cell disease (scd) is an important inherited blood disorder. in a patient with scd, the haemoglobin s in the rbcs gets altered leading to a rigid sickle or half-moon shaped disfiguration of the rbcs which lose their plasticity and can choke the narrow blood vessels thereby hindering oxygen supply to different tissues/organs. the short life span of these rbcs gives rise to anaemia commonly known as sickle cell anaemia. lack of blood/oxygen supply to different tissues/organs in scd leads to chronic severe pain (back, chest, hands and feet), bacterial infections, damage to bone/muscles/organs, and even necrosis. scd may also lead to sickle cell crisis (or sickling crisis) namely vasoocclusive crisis, sequestration crisis, aplastic crisis and haemolytic crisis. though the signs of scd may appear in the childhood, its severity varies from one individual to another. factors such as stress, excessive exercise, dehydration, temperature variation (cold climate) and high altitude often play important role in setting in a crisis.1 epidemiology though scd is predominantly present in africa, it has been recorded in the population of other tropical regions viz. arabian peninsula, and central, southern and eastern parts of india. population migration from africa has also led to reporting of this condition from other countries as well. sub-saharan africa is believed to have about 80% of scd reported globally.2 as per a global burden of disease (gbd) report of 2015, scd affected about 4.4 million people and an additional population of 43 million had sickle cell trait.3,4 in 2015, it resulted in about 1,14,800 deaths.5 a significant prevalence of the mutation responsible for sickle cell has been reported among other ethnic groups such as those native to italy, greece, turkey, saudi arabia, india, pakistan, bangladesh, china, and cyprus.6 who has reported that the prevalence rate of scd varies between 2030% in cameroon, ghana, nigeria, republic of congo and gabon, and about 45% in some parts of uganda.7 according to the above who report, about 5% of the world population carries the trait genes of haemoglobin disorders (scd and thalassemia) and about 3,00,000 babies with severe haemoglobin disorder are born each year. in india, lehman and cutbush8 first reported sickle haemoglobin in tribal population in the nilgiris in south india in the year 1952. dunlop and mazumder9 in the same year reported similar findings in the tea garden migrant laborers from bihar and odisha in assam. a large number of subsequent screening studies have shown that the ethnic/tribal population mostly present in the states of madhya pradesh, maharashtra, odisha, gujarat, chhattisgarh and certain pockets of tamil nadu and kerala are sickle cell carriers.10 scd is commonly encountered in the ethnic population of central india who share a genetic linkage with african communities.11 in endemic areas of madhya pradesh, rajasthan and chhattisgarh, the prevalence varies between 9.4 to 22.2%.12 screening of new born babies for the presence of sickle cell disorders in the population has been initiated in the states of gujarat, maharashtra, madhya pradesh, chhattisgarh and odisha.1316 vaso-occlusive phenomenon and role of homocysteine polymerization of mutant haemoglobin s and impairment of rbc rheology occur due to a single amino acid substitution in the beta-globin chain. abnormalities in rbcs result in haemolysis and a vicious cycle of vaso-occlusive phenomenon which in turn triggers inflammation and redox instability finally leading to progressive smalland largevessel vasculopathy.17 recent studies have shown that vasosuprava patel et al. sickle cell disease and folate supplementation panacea journal of medical sciences, may-august, 2019;9(2):39-42 40 occlusion occurs as a result of interplay among impaired blood rheology, increased adhesiveness of rbcs with inflammatory cells and vascular endothelium, and haemostatic activation.18 blood rheology is guided by plasma viscosity, haematocrit and rbc deformability. increased plasma viscosity is an important factor in reduced blood flow through capillaries and venules of tissues.19 these deformable sickle cells may further get mechanically sequestered in the microcirculation leading to transient vaso-occlusion.2,20 damage of erythrocyte membranes also increases exposure of adhesion molecules and binding motifs viz. phosphatidyl serine (ps), basal cell adhesion molecule-1/lutheran (b-cam-1/l), integrin-associated protein (iap), and intercellular-adhesion-molecule-4 (icam-4).19-21 further, as a result of chronic anaemia in scd, immature rbcs or reticulocytes with adhesion molecules (vla-4 and cd 36) are released in the circulation.21 endothelial dysfunction and sterile inflammation also increase the cellular effect of selectins (p and e-), vascular-cell-adhesion-molecule-1 (vcam-1), icam-1 and chemoattractant like interleukin-8 (il-8) on endothelial cells.18,22,23 various studies have shown the role of erythrocyte-neutrophil-endothelium or plateletneutrophil-endothelium adhesions in microcirculation as a cause of systemic vaso-occlusion. further, the cellular and molecular mechanisms of vaso-occlusion are also dictated by the type of organ or vascular bed.17 enzyme methionine synthase uses 5methyletetrahydrofolate (mthf) to convert homocysteine (a sulfur containing toxic amino acid) to methionine, and hence, a deficiency of 5-mthf will lead to increased level of circulating homocysteine. homocysteine when present in high concentration in plasma, it acts as a risk factor for cardiovascular disease, stroke, venous thrombosis and arteriosclerosis.24,25 high concentration of homocysteine causes increased cytotoxic activity on endothelial cells, elevates hydrogen peroxide levels, decreases nitric oxide synthesis, induces cytokine production to stimulate the inflammatory state, activates procoagulant factors, and dysregulation of lipid metabolism. hyperhomocysteinemia is also responsible for changes in rheological properties of blood viz. decreasing antithrombin iii and tissue plasminogen activator, and increasing factor vii and cprotein.26,27 further, homocysteine also increases interaction between endothelial cells and leukocytes.28 studies have found higher plasma homocysteine concentration in scd patients in spite of higher plasma folate and vitamin b12 concentration.29 synthesized in endothelial cells, nitric oxide (no), regulates vasal vascular tone and endothelial function, and maintains blood oxygenation via hypoxic pulmonary vasoconstriction and reduced shunt physiology. no also has vaso-dilatory, antioxidative, anti-adhesion and antithrombotic properties. hence, any imbalance in the no homeostasis could adversely affect the scd pathophysiology.30 cytokine expression increases in vaso-occlusive and proinflammatory episodes. this phenomenon reflects a positive correlation to the increase in dehydration in scd.31,32 these cytokines stimulate a membrane oxidoreductase (protein disulfide isomerase), which exists in higher concentrations in sickle-rbc membranes compared with those on healthy rbcs. scd patients exhibit high levels of thrombin generation markers, reduction of natural anticoagulant proteins, thrombotic complications, and increase in platelet activation, fibrinolytic system and tissue factor expression. thus, coagulation activation is multi-factorial with contributions from ischemia-perfusion injury and inflammation, hemolysis and no deficiency, and increased rbc phosphatidylserine expression.33 folic acid supplementation because of premature destruction of the rbcs in scd patients, rbc count is always lower than normal and folate stores are often depleted because of high cell turnover. this requirement of folic acid for erythropoiesis is compensated by the dietary intake. folate acts as a coenzyme in the synthesis of nucleic acids including the conversion of homocysteine to methionine and the methylation of deoxyuridylate to thymidylate. during dna synthesis, folate is required for proper cell division, the impairment of which can lead to megaloblastic anaemia.34-36 mthf is a member of the group of compounds known as ‘folate’ and is the primary form found in serum. folate plays an important role in regulating homocysteine concentration and hence, it is indicated in cases of hyperhomocysteinemia. in the digestive system, the majority of dietary folate is converted into 5-mthf before entering the bloodstream. though folic acid supplementation treats chronic haemolytic anaemia, its positive role in scd is not well supported. folate intake leads to a decrease in symptoms of anaemia in scd and folic acid replenishes the depleted folate stores necessary for erythropoiesis. potential advantages of folate therapy in patients with scd include the prevention of hyper-homocysteinemia but that may predispose to thrombotic events.37 it is believed that folate in anaemia raises haemoglobin levels and helps provide a healthy reticulocyte response.38 in patients with scd, folate supplementation does not improve the deficiency or megaloblastic changes and folic acid supplementation did not improve the serum and erythrocyte folate levels.39 one study found no “striking effects” of folic acid supplementation in sickle cell anaemia on the hematological profile or on growth in children with scd who received this nutrient.40 folic acid supplementation @ 1mg/day for patients with sickle cell anaemia has been recommended in the guidelines for scd by the national heart, lung, and blood institute.41 literature reviews by yasin et. al. (2012)39 revealed that there are studies favouring folic acid supplementation. these studies have cited low serum and erythrocyte folate levels in scd patients and high incidence of megaloblastic anaemia, and the positive effects of supplementation included reversal of developmental delay, reduced dactylitis and reduction of homocysteine levels suprava patel et al. sickle cell disease and folate supplementation panacea journal of medical sciences, may-august, 2019;9(2):39-42 41 leading to reduced cardiovascular, stroke and venous thrombosis risk. yasin et. al39 also came across studies against folic acid supplementation which conversely found that folate is not deficient in patients, megaloblastic change is uncommon and both these parameters did not improve with supplementation. also, folic acid does not increase haemoglobin, growth characteristics, infections, splenic sequestration and dactylitis. possible side effects of folate supplementation include increased priapism and increased twin pregnancy rates in patients with scd,39 an increased risk of some neoplasms like colorectal carcinoma with high folate intake42 and a detrimental effect on cancer-protective natural killer cells.43 some research has found that folate supplementation in scd can mask cobalamin deficiency with consequent neuropsychiatric manifestations.44 unlike most folate, the majority of folic acid is not converted to the active form of vitamin b9, 5-mthf, in the digestive system. instead, it needs to be converted in the liver or other tissues.45,46 even a small dose, such as 200– 400 mcg per day, may not be completely metabolized until the next dose is taken. this is a cause for concern, since high levels of un-metabolized folic acid have been associated with several health problems including increased cancer risk. these may also speed up growth of precancerous lesions.47-49 in elderly people, high levels of folic acid may mask vitamin b12 deficiency and untreated vitamin b12 deficiency may lead to dementia and impair nerve function.50,51 some studies have found that circulating unmetabolized folic acid is linked to reduced natural killer cell activity – an important part of the innate immune system.43 various signs of folic acid accumulation in circulating blood may include nausea, decreased appetite, bloating, disturbed sleep, feeling irritable, numbness and or tingling, oral sores, skin rashes, psychological behaviour and even seizures. hence, the rationale of administering folic acid as a treatment in scd (where the patient is already deficient in 5-mthfr enzyme) is highly debatable. however, the final biologically active form of folic acid, l-methylfolate or levomefolic acid or 5-mthf, is the best option which gets readily absorbed and exerts its action without requiring any bioconversion. this is most suitable even in the scd patients who already have mthfr deficiency. lmethylfolate is the primary biologically active form of folate used at the cellular level for dna reproduction, the cysteine cycle and the regulation of homocysteine. it is also the form found in circulation and transported across membranes into tissues and across the blood-brain barrier. it is synthesized in the absorptive cells of the small intestine from polyglutamylated dietary folate. it is a methylated derivative of tetrahydrofolate. levomefolic acid is generated by mthfr from 5, 10methylenetetrahydrofolate (mthf) and used to recycle homocysteine back to methionine by methionine synthase.52 l-methylfolate is water-soluble and primarily excreted via the kidneys. in a study of 21 subjects with coronary artery disease, peak plasma levels were reached in one to three hours following oral or parenteral administration. peak concentrations were found to be more than seven times higher than folic acid.53 conclusion vaso-occlusive crisis is an important consequence of scd. homocysteine when present in high concentration in plasma, it acts as a risk factor for cardiovascular disease, stroke, venous thrombosis and arteriosclerosis. folate plays an important role in regulating homocysteine concentration and hence, it is indicated in cases of hyperhomocysteinemia. potential advantages of folate therapy in patients with scd include the prevention of hyperhomocysteinemia but that may predispose to thrombotic events. folic acid supplementation @ 1mg/day for patients with sickle cell anaemia has been recommended. however, owing to the possible side effects of folate supplementation, the final biologically active form of folic acid, lmethylfolate or levomefolic acid or 5-mthf, is preferred. it gets readily absorbed and exerts its action without requiring any bioconversion. this is most suitable even in the scd patients who already have mthfr deficiency. source of funding none. conflict of interest none. references 1. “what causes sickle cell disease?”. national heart, lung and blood institute. june 12, 2015. archived from the original on 24 march, 2016. retrieved 8 march, 2016. (sickle cell diseasewikipedia) 2. rees dc, williams tn, gladwin mt. sickle-cell disease. lancet 2010;376(9757):2018–2031. 3. global burden of disease 2015: disease and injury incidence and prevalence, collaborators. (8 october, 2016). “global, regional and national incidence, prevalence and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study 2015”. lancet 388(10053):1545-1602. (sickle cell disease-wikipedia) 4. global burden of disease 2013. collaborators (22 august, 2015). “global, regional and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the global burden of disease study 2013”. lancet. 386(9995):743-800. (sickle cell disease-wikipedia). 5. global burden of disease 2015: mortality and causes of death, collaborators. (8 october, 2016). “global, regional and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the global burden of disease study 2015”. lancet 388(10053):14591544. (sickle cell disease-wikipedia) 6. nietert pj, silverstein md, abboud mr. sickle cell anaemia: epidemiology and cost of illness. pharmacoeconomics 2002;20:357–366. 7. who regional committee for africa report no. afr/rc 60/8 dated 23.6.2010. 8. lehman h, cutbush m. sickle cell trait in southern india. br med j 1952;1:404–405. 9. dunlop kj, mazumder uk. the occurrence of sickle cell anaemia among a group of tea garden labourers in upper assam. indian med gaz 1952;87:387–91. suprava patel et al. sickle cell disease and folate supplementation panacea journal of medical sciences, may-august, 2019;9(2):39-42 42 10. roshan b colah, malay b mukherjee, snehal martin, kanjaksha ghosh. sickle cell disease in tribal populations in india. indian j med res 2015;141(5):509–15. 11. “sickle cell anaemia”. (2014). www.hematology.org. archived from the original on 25.6.2017. retrieved 1.5.2017. 12. awasthy n, aggarwal kc, goyal pc, prasad ms, saluja s, sharma m. sickle cell disease: experience of a tertiary care center in a nonendemic area. annals trop med public health 2008;1(1):1–4. (sickle cell diseasewikipedia). 13. mohanty d, das k, mishra k. newborn screening for sickle cell disease and congenital hypothyroidism in western orissa. proc 4th int conf sickle cell dis raipur. 2-10;29–30. 14. panigrahi s, patra pk, khodiar pk. neonatal screening of sickle cell anaemia: a preliminary report”. indian j pediatr 2012;79:747– 50. 15. jain dl, sarathi v, upadhye d, nadkarni ah, ghosh k, colah rb. newborn screening shows a high incidence of sickle cell anaemia in central india. haemoglobin 2012;36:316–22. 16. italia y, krishnamurti l, mehta v, raicha b, italia k, mehta p, et al. feasibility of a newborn screening and follow-up programme for sickle cell disease among south gujarat (india) tribal populations. j med screen 2015;22:1–7. 17. sundd prithu. pathophysiology of sickle cell disease. annual review of pathology: mechanisms of disease. 2015;14:263-92. 18. zhang d, xu c, manwani d, frenette ps. neutrophils, platelets, and inflammatory pathways at the nexus of sickle cell disease pathophysiology. blood 2016;127:801–9. 19. barabino ga, platt mo, kaul dk. sickle cell biomechanics. annu rev biomed eng 2010;12:345–67. 20. bunn hf. pathogenesis and treatment of sickle cell disease. n engl j med 1997;337:762–9. 21. kaul dk, finnegan e, barabino ga. sickle red cell-endothelium interactions. microcirculation 2009;16:97–111. 22. kato gj, steinberg mh, gladwin mt. intravascular haemolysis and the pathophysiology of sickle cell disease. j clin invest 2017;127:750–60. 23. gladwin mt, ofori-acquash sf. erythroid damps drive inflammation in scd. blood 2014;123:3689-90. 24. refsum h, ueland pm, nygard o, vollset se. homocysteine and cardiovascular disease. annu rev med 1998;49:31-62. 25. clarke r, daly l, robinson k, naughten e, cahalane s, fowler b, et. al. hyperhomocysteinemia: an independent risk factor for vascular disease. n eng j med 1991;334:1149-55. 26. siniscalchi a, mancuso f, gallelli l, ibbadu gf, mercuri nb, de sarro g. increase in plasma homocysteine levels induced by drug treatments in neurologic patients. pharmacol res 2005;52:367-75. 27. postuma rb, lang ae. homocysteine and levodopa: should parkinson disease patients receive preventive therapy? neurol 2004;63:886-91. 28. dudman np, temple se, guo xw, fu w, perry ma. homocysteine enhances neutrophil-endothelial interactions in both cultured human cells and rats in vivo. circ res 1999;84:409-16. 29. wendell vilas-boas, bruno antonio veloso cerqueira. association of homocysteine and inflammatory-related molecules in sickle cell anaemia. hematol 2016;21(2):126-31. 30. lori styles. nitric oxide effects in sickle cell disease. blood 2008;112:sci-48. 31. graido-gonzalez e, doherty jc. plasma endothelin-1, cytokine, prostaglandin e2 levels in sickle cell disease and vaso-occlusive sickle crisis. blood 1998;92:2551-5. 32. rybicki ac, benjamin lj. increased levels of endothelin-1 in plasma of sickle cell anaemia patients. blood 1998;92:2594-6. 33. denis noubouossie nigel s, key kenneth i. ataga. coagulation abnormalities of sickle cell disease: relationship with clinical outcomes and the effect of disease modifying therapies. blood rev 2016;030(4):245-56). https://doi.org/10.1016/j.blre.2015.12.003. 34. bailey lb, caudill ma. folate. in: erdman jr jw, macdonald ia, zeisel sh editor(s). present knowledge in nutrition. 10th edition. washington, dc: wiley blackwell. 2012;321–42. 35. carmel r. (2005). “folic acid”. in: shils m, shike m, ross a, caballero b, cousins r editor(s). modern nutrition in health and disease. 10th edition. lippincott williams & wilkins. 470–481. 36. standing committee. (1998). “standing committee on the scientific evaluation of dietary reference intakes. dietary reference intakes for thiamine, riboflavin, niacin, vitamin b6, folate, vitamin b12, pantothenic acid, biotin, and choline”. 10th edition. washington, dc: national academy press. 37. selhub j, jacques pf, bostom ag, d’agostino rb, wilson pw, belanger aj, et al. association between plasma homocysteine concentrations and extracranial carotid-artery stenosis. new eng j med 1995;332(5):286-91. 38. stuart mj, nagel rl. sickle cell disease. lancet 2004;364(9442):1343–60. 39. al-yassin a, osei a, rees d. folic acid supplementation in children with sickle cell disease. arch disease childhood 2012;97:a91–2. http://dx.doi.org/10.1136/aechdischild-2012301885.219 40. rabb lm, grandison y, mason k. a trial of folate supplementation in children with homozygous sickle cell disease. br j haematol 1983;54:589–94. 41. the management of sickle cell disease. (june2002). 4th ed revised. national institutes of health/national heart, lung, and blood institute, division of blood diseases and resources, nih pub no. 02-2117. 42. kim yi. folate: a magic bullet or a double edged sword for colorectal cancer prevention?. gut 2006;55(10):1387-9. 43. troen am, mitchell b, sorensen b, wener mh, johnston a, wood b, et al. unmetabolized folic acid in plasma is associated with reduced natural killer cell cytotoxicity among postmenopausal women. j nutr 2006;136(1):189–94. 44. dhar m, bellevue r, carmel r. pernicious anaemia with neuropsychiatric dysfunction in a patient with sickle cell anaemia treated with folate supplementation. new engl j med 2003;348(22):2204-07. 45. patanwala i, king mj, barrett da, rose j. folic acid handling by the human gut: implications for food fortification and supplementation. am j clin nutr 2014;100(2):593-9. doi: 10.3945/ajcn. 113.080507. epub 2014 june 18. 46. writ aj, dainty jr, finglas pm. folic acid metabolism in human subjects revisited: potential implications for mandatory folic acid fortification in the u.k. br j nutr 2007;98(4):667-75. epub 2007 jul 9. 47. cole bf, baron ja. folic acid for the prevention of colorectal adenomas: a randomized clinical trial. jama 2007;297(21):23519. 48. ebbing m, banaa kh. cancer incidence and mortality after treatment with folic acid and vitamin b12. jama 2009;302(19):2119-26. doi: 10.1001/jama.2009. 1622. 49. figueiredo jc, grau mv. folic acid and risk of prostate cancer: results from a randomized clinical trial. j natl cancer inst 2009;101(6):432-5. doi:10.1093/jnci/djp 019. epub 2009 mar 10. 50. reynolds eh. benefits and risks of folic acid to the nervous system. j neurl neurosurg psychiatry 2002;72(5):567-71. 51. morris ms, jacques pf, rosenberg ih, selhub j. folate and vitamin b12 status in relation to anaemia, macrocytosis and cognitive impairment in older americans in the age of folic acid supplementation. am j clin nutr 2007;85(1):193-200. 52. “5-methyltetrahydrofolate-compound summary” pubchem, ncbi, retrieved 25 september, 2012 (levomefolic acidwikipedia). 53. http://intetlab.com/site/products/cerefolin-nac_package insert% 204-26-10. pdf. (levomefolic acid-wikipedia). http://www.hematology.org/ http://dx.doi.org/10.1136/aechdischild-2012-301885.219 http://dx.doi.org/10.1136/aechdischild-2012-301885.219 panacea journal of medical sciences 2021;11(1):31–36 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article joint involvement in rheumatoid arthritis: sonographic evaluation in comparison with radiography sharanayya1, shamrendra narayan2, vandana verma3, madhu sharma3, anjana pande3, vivek jirankali1,* 1dept. of radiology, navodaya medical college hospital & research centre, raichur, karnataka, india 2dr. ram manohar lohia institute of medical sciences, lucknow, uttar pradesh, india 3sarojini naidu medical college, agra, uttar pradesh, india a r t i c l e i n f o article history: received 14-08-2020 accepted 14-10-2020 available online 29-04-2021 keywords: erosions ultrasonography radiograph synovitis a b s t r a c t background: the aim of this study was to evaluate the role of ultrasonography (including power doppler) in assessing the joint involvement in rheumatoid arthritis (ra) and its comparison to radiographic changes. materials and methods: 55 patients with ra underwent ultrasound and radiographic examination of wrist and hand with laboratory investigations. 25 subjects were taken as controls. following points were specifically looked in ultrasound – synovitis, synovial hypertrophy, effusion, cartilage thickness, swelling of tendon, osteophytes, erosions. erosion sites were compared using radiographs. ultrasonography was performed by two radiologists and inter-observer agreement was calculated. results: out of total 55 cases, 44 cases were classified as early ra and 11 cases as advanced ra. out of 25 control subjects, 3 subjects had a lesion – atypical for ra, however – all 3 had previous trauma at that site. inter-observer agreement was excellent. intra-articular erosions were seen in all cases of advanced ra and in only 26/44 cases in early ra cases. tenosynovitis was seen in 21/44 cases of early ra while only one case of advanced ra showed tenosynovitis. there was reduced cartilage thickness in all patients of advanced ra while none was observed in early ra cases. synovial hypertrophy and synovial effusion were almost similar in both early and advanced ra cases. ultrasonography detected erosions in 37/54 cases while radiography detected erosions in only 11/54 cases. conclusions: sonography can be used as a primary modality to diagnose ra especially early ra, which helps in reducing disabilities by early aggressive treatment. it is more sensitive than radiography in detecting erosions. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction wrists and hands are involved in many pathological conditions. their involvement is always associated with disability in performing regular activities on the part of the patient and difficulty in diagnosing on part of the treating clinician due to lack of specific diagnostic criteria. common causes of the chronic wrist pain include fractures, ligament tears, radioulnar subluxation, erosive * corresponding author. e-mail address: vivekjirankali@gmail.com (v. jirankali). and non-erosive arthritis, osteoarthritis, avascular necrosis of carpal bones, neoplasms, tendinopathy, neuropathy and various infections. rheumatoid arthritis (ra) is a chronic inflammatory disease of unknown aetiology marked by a symmetric, peripheral polyarthritis. the major abnormalities of ra appear in the synovial joints as soft tissue swelling caused by synovial hypertrophy, effusion, bursal and tendon sheath swelling. 1 marginal erosions are due to inflamed synovium destroying the cortex and underlying bone and they occur initially at the bare area: the margins where synovium is not https://doi.org/10.18231/j.pjms.2021.009 2249-8176/© 2021 innovative publication, all rights reserved. 31 https://doi.org/10.18231/j.pjms.2021.009 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.009&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:vivekjirankali@gmail.com https://doi.org/10.18231/j.pjms.2021.009 32 sharanayya et al. / panacea journal of medical sciences 2021;11(1):31–36 covered by cartilage. these findings can occur in unison or as an isolated entity depending upon the duration and the activity of the disease. presence of erosions in early ra is associated with bad prognosis and it may also guide in the choosing the appropriate therapy. 2 appropriate treatment of ra in its early stages helps in reduction of disabilities. 3 there is limited scope of physical examination and lab tests for early diagnosis of ra. and even radiographic changes are seen in the late course of the disease. 4 ultrasound is superior to clinical examination in detecting synovitis. 5 power doppler has been used to assess the disease activity and there is a good correlation between doppler hyperaemia and histologically detected pannus. 6 ultrasound is non-invasive, readily available, portable and inexpensive modality which can be used to examine multiple joints at a time. it can also be used to evaluate extra-articular entities such as enthesopathies and tenosynovitis. 7,8 the study has also compared the radiography and ultrasonography in detection of osteophytes and erosions. the aim of the current study was to evaluate the role of ultrasonography (including power doppler) in assessing the joint involvement in ra and its comparison to radiographic changes. 2. materials and methods 2.1. patients approval of institutional ethical committee was taken. 55 patients who were diagnosed with ra according to acr/eular criteria were included in the study. the study was conducted in a tertiary care hospital (navodaya medical college hospital and research centre, raichur) from march 2018 to january 2020. details regarding history and physical examination were collected. conventional radiograph of the affected hand was obtained in standard views. serological markers like rheumatoid factor (rf), c-reactive protein (crp) and anti-citrullinated protein antibody (anti-ccp) were estimated. 25 subjects were taken as controls who came for ultrasonography of the different part of the body (other than wrist). both the groups were age matched. radiographs were not taken for control groups as ethical committee did not grant permission. 2.2. ultrasonography ultrasonography was performed in all cases using samsung medison sa800 machine using high frequency (6-12mhz) linear array transducer. ultrasound was performed by two radiologists who were blinded to the clinical and laboratory data. scanning of wrist and hand was performed with the patient seated, with hands resting on the examination table. examinations were carried out on both sides for comparison. colour and power doppler were used as and when required to evaluate blood flow with standard settings of the machine. following points were specifically looked – synovitis, synovial hypertrophy, effusion, cartilage thickness, swelling of tendon, osteophytes, erosions etc. 2.3. statistical analysis after collecting the data, it was entered in microsoft excel. frequency and percentages were calculated for qualitative data. inter-observer agreement was calculated. data was analyzed by using “ibm spss statistics” (version 16.0). analysis was done by using student ‘t’ test and chi-square test. all statistical tests were applied at a significance level of “α=.05” (p value < 0.05). 3. results out of 25 control subjects, 3 subjects had a lesion – atypical for ra, however – all 3 had previous trauma at that site. the study subjects consisted of 55 individuals with 41 females and 14 males (females>males). majority of the patients belonged to the age group of 41-50 years. out of total 55 cases, 44 cases were classified as early ra and 11 cases as advanced ra. the sonographic findings that were observed were synovial hypertrophy, synovial effusion, intra-articular erosions, tenosynovitis and reduced cartilage thickness (tables 1 and 2). positive power doppler signals were seen in hypertrophied synovial tissues in few cases. interobserver agreement was excellent with kappa value of 0.87 (95% ci 0.77-0.93). intra-articular erosions were seen in all cases of advanced ra and in only 26/44 cases (59%) in early ra cases. tenosynovitis was seen in 21/44 cases (48%) of early ra while only one case (9%) of advanced ra showed tenosynovitis. tenosynovitis was most commonly seen in extensor group of tendons around the wrist (18/21 cases – 86%). it was seen in only 3/21 cases (14%) in flexor group of tendons. there was reduced cartilage thickness in all patients of advanced ra while none of the early ra case showed reduced cartilage thickness. synovial hypertrophy and synovial effusion were almost similar in both early and advanced ra cases. in both early and advanced ra, synovial hypertrophy and intraarticular erosions were found predominantly in wrist and inter-carpal joints. raised crp, ra factor and anti-ccp antibody was found in both early and advanced cases of ra (table 3). of the extensor group, extensor carpi ulnaris (ecu) was very commonly involved followed by extensor digitorum (ed). in the flexor compartment, flexor digitorum superficialis (fds) and flexor carpi radialis (fcr) were commonly involved. ultrasonography detected erosions in 37/54 (69%) cases while radiography detected erosions in only 11/54 (20%) of cases (table 4). ultrasonography detected osteophytes in sharanayya et al. / panacea journal of medical sciences 2021;11(1):31–36 33 8/54 (15%) cases while radiography detected osteophytes in only 3/54 (6%) of cases. table 1: sonographic findings in early ra (n=44) s.no sonographic feature no. of cases percentage 1. synovial hypertrophy (sh) 42 95.45% 2. synovial effusion (se) 04 9.09% 3. intra articular erosions (iae) 26 59.09% 4. tenosynovitis (tsyn) 21 47.72% 5. reduced cartilage thickness (rct) table 2: sonographic findings in advanced ra (n=11) s.no sonographic feature no. of cases percentage 1. synovial hypertrophy 11 100% 2. synovial effusion 00 00 3. intra articular erosions 11 100% 4. tenosynovitis 01 9.09% 5. reduced cartilage thickness 11 100% fig. 1: longitudinal ultrasound demonstrates synovial hypertrophy in mid inter-carpal joint with power doppler signal. 4. discussion early treatment and intervention of ra reduces the future possible occurrence of deformities and disabilities. 9 this led to the need of new diagnostic methods which can diagnose early ra with good accuracy. mri is one such modality, but is expensive and time consuming. thus, use of ultrasonography in early diagnosis of ra began and it showed to have good sensitivity. few previous studies have concluded that ultrasonography can be used to detect erosions in hands in ra. 10–12 only few studies among fig. 2: longitudinal ultrasound demonstrates synovial fluid effusion around the extensordigitorum tendon. fig. 3: longitudinal ultrasound demonstrates intra-articular erosions on ulnar side of inter-carpal joint withpannus. while plain radiograph of the same patient is normal. fig. 4: transverse ultrasound demonstrates tenosynovitis of extensor carpi ulnar is tendon. them have compared ultrasound with radiography for the detection of erosions. thus, aim of our study was to evaluate the role of ultrasonography in the diagnosis of ra (particularly early ra) and comparison with radiography in the detection of erosions. proliferative synovitis is the earliest pathologic change seen in rheumatoid arthritis and is usually but not exclusively bilateral and symmetric. 13 approximately 96% of our patients had this finding at presentation. it’s presence in symmetric distribution involving wrist, intercarpal, metacarpophalangeal (mcp), proximal interphalangeal (pip) joints in varying proportions increases the probability of the disease being ra. 14 this fact is even more reinforced by the chronicity of symptoms. 34 sharanayya et al. / panacea journal of medical sciences 2021;11(1):31–36 table 3: serological changes in early and advanced ra serological marker early ra percent advanced ra percent n=44 n=11 raised crp 34 77.27% 10 90.90% ra factor +nt 23 52.27% 07 63.63% anti ccp +nt n=27 48.14% n=8 62.50% table 4: x-ray and hrus (high-resolution ultrasound) comparison detecting osteophyte and erosions. modality erosions n=37 percentage osteophytes n=8 percentage x-ray 11 29.72% 3 37.5% usg 37 100% 8 100% the widely accepted method for synovial hypertrophy quantification with greyscale ultrasound is the semiquantitative scale. 15 0 indicates no intra-articular changes, and 1–3 indicates mild, moderate, and large synovial hypertrophy. we also found application of this quantification system in our group easier and effective. both dorsal and volar scans can be used to detect joint effusion and synovial hypertrophy (figures 1 and 2). backhaus et al found 86% of positivity when scanning volar side of the hand compared to dorsal one, with only 14% positivity of dorsal synovitis alone in clinically affected joints. 16 ostergaard et al found only a third of patients having synovitis on both volar and dorsal side of the fingers, in the majority of cases synovitis being limited to volar43% or dorsal27%. 17 in our study, we found it easier to demonstrate synovial hypertrophy (sh) on examining dorsal aspect of mcp, intercarpal, wrist joints and volar aspect of pip joints. the difficulty arose when there was no power doppler signal (inactive pannus). in such cases the abnormal thickened soft tissue lying in joint space was considered as sh. detection of bone erosions at the time of ra diagnosis is related to a poor long-term functional and radiographic outcome, 18 and the presence of erosions in early undifferentiated arthritis is a risk factor for developing persistent arthritis. 19 when compared with radiography, us is definitely more sensitive in identifying the presence of erosions during initial patient evaluation of ra patients. 20 the findings of our study is in agreement with findings proposed by bajaj et al. 2007. 20 out of the 37 patients, where erosions were evident on hrsg, x-ray was positive in only eleven cases. detection of erosions early in the disease is predictive of an aggressive disease course. 21 thus, us also helps in determining prognosis. intra articular erosions were greatest in the wrist followed by the metacarpophalangeal (mcp), proximal interphalangeal (pip), and distal interphalangeal (dip) joints respectively. 22 in agreement with study stated here, 18 and 17 patients had involvement of wrists and intercarpal joints (icj) respectively in our study, out of total 26 patients who had erosive early ra (figure 3). in fact, in our study, out of total 55 patients, 12 (8 in early ra and 4 in advanced ra) had only involvement of wrists and icj. mcp and pip were involved in only 4 and 2 patients respectively. and in advanced ra, wrists and icj were invariably involved (all the patients had involvement of wrists and icj). in the wrist, erosion distribution was concentrated in the radiocarpal and medial carpometacarpal complex. 22 our findings were also in agreement with the conclusions of j c buckland-wright. 22 probably least important were the pip joints when evaluation of erosions were concerned. thus, examination of wrists and icj for evaluation of ra cannot be overemphasised. it can be noted that erosions were detected more on ultrasound than radiograph as ultrasound is a three-dimensional modality while radiograph is a twodimensional one. the diagnostic accuracy of sonography in the detection of erosions could not be calculated as ultrasound detected more erosions than radiographs and radiography is the gold standard for the detection of erosions. therefore, it was just a comparison study between radiography and ultrasonography. tenosynovitis is commonly an accompanying sonographic finding in patients of early ra. various hand tendon abnormalities were described in early stages of the disease in ra: widening of the tendons sheaths, loss of normal fibrillar echostructure, irregularity of the tendon margins. 23 in our study, widening of the tendon sheath due to hypo-echoic irregular synovial thickening was the common abnormality seen as shown in figure 4 (76% of total tenosynovitis). it may or may not be associated with synovial effusion. alternatively, synovial effusion can be seen without synovial hypertrophy. least common sonographic finding was the altered tendon echotexture (seen only in 24%). although any tendon may be affected, the flexor digitorum, extensor digitorum, and extensor carpi ulnaris (ecu) were frequently involved. 24 extensor group of tendons were commonly involved in our study group (86%). one interesting observation in our study was the involvement of ecu. isolated ecu involvement without involving other tendons was seen in 6 patients (29%). and two of these patients had tenosynovitis of ecu as the sharanayya et al. / panacea journal of medical sciences 2021;11(1):31–36 35 only initial finding without any evidence of synovitis. on follow-up, these two were later diagnosed as ra. thus, we find the study conducted by siri lillegraven et al. 2011 agreeable. 25 as the disease progresses there will be cartilage destruction, there by reducing the joint space. tendon contractures which result in joint deformity are also common during this stage. however, role of sonography lies in preventing their occurrence rather than detecting them. 5. conclusions sonography can be used as a primary modality to diagnose rheumatoid arthritis, especially early rheumatoid arthritis, which helps in reducing disabilities by early aggressive treatment. it is more sensitive than radiography in detecting erosions. 6. limitations major limitation of the study is that ultrasonography is operator dependant. correlation with mri would have helped in better diagnostic outcome. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. sharma b, sharma m. ultrasonography of hands in rheumatoid arthritis. indian j rheumatol. 2009;4:102–11. 2. heide avd, remme ca, hofman dm, jacobs jw, bijlsma jw. prediction of progression of radiologic damage in newly diagnosed rheumatoid arthritis. arthritis rheum . 1995;38(10):1466–74. doi:10.1002/art.1780381013. 3. breedveld fc, dijkmans ba. differential therapy in early and late stages of rheumatoid arthritis. curr opin rheumatol. 1996;8(3):226– 9. doi:10.1097/00002281-199605000-00010. 4. heijde dm. radiographic imaging: the ’gold standard’ for assessment of disease progression in rheumatoid arthritis. rheumatology. 2000;39(1):9–16. doi:10.1093/oxfordjournals.rheumatology.a031496. 5. farrant jm, connor pj, grainger aj. advanced imaging in rheumatoid arthritis. skeletal radiol. 2007;36(4):269–79. doi:10.1007/s00256006-0219-9. 6. walther m, harms h, krenn v, radke s, trutz-peter f, gohlke f, et al. correlation of power doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis. arthritis rheum . 2001;44(2):331–8. doi:10.1002/1529-0131(200102)44:2<331::aid-anr50>3.0.co;2-0. 7. hoving jl, buchbinder r, hall s, lawler g, coombs p, mcnealy s, et al. a comparison of magnetic resonance imaging, sonography, and radiography of the hand in patients with early rheumatoid arthritis. j rheumatol. 2004;31:663–75. 8. lopez-ben r, bernreuter wk, moreland lw, alarcon gs. ultrasound detection of bone erosions in rheumatoid arthritis: a comparison to routine radiographs of the hands and feet. skeletal radiol. 2004;33(2):80–4. doi:10.1007/s00256-003-0693-2. 9. molenaar et, boers m, heijde dvd, alarcon g, bresnihan b, cardiel m, et al. imaging in rheumatoid arthritis: results of group discussions. j rheumatol. 1999;26:749–51. 10. backhaus m, kamradt t, sandrock d, loreck d, fritz j, wolf kj, et al. arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. arthritis rheum . 1999;42(6):1232–45. doi:10.1002/15290131(199906)42:6<1232::aid-anr21>3.0.co;2-3. 11. mcgonagle d, gibbon w, connor po, blythe d, wakefield r, green m. a preliminary study of ultrasound aspiration of bone erosion in early rheumatoid arthritis. rheumatology (oxford). 1999;38:329–31. 12. wakefield rj, gibbon ww, conaghan pg, o’connor p, mcgonagle d, pease c, et al. the value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. arthritis rheum . 2000;43(12):2762–70. doi:10.1002/1529-0131(200012)43:12<2762::aid-anr16>3.0.co;2-. 13. rowbotham el, grainger aj. rheumatoid arthritis: ultrasound versus mri. ajr am j roentgenol . 2011;197(3):541–6. doi:10.2214/ajr.11.6798. 14. ozgul a, yasar e, arslan n, balaban b, taskaynatan ma, tezel k, et al. the comparison of ultrasonographic and scintigraphic findings of early arthritis in revealing rheumatoid arthritis according to criteria of american college of rheumatology. rheumatol int. 2009;29(7):765– 8. doi:10.1007/s00296-008-0765-7. 15. szkudlarek m, court-payen m, jacobsen s, klarlund m, thomsen hs, østergaard m, et al. interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. arthritis rheumatism: official j am coll rheumatol. 2003;48(4):955–62. doi:10.1002/art.10877. 16. backhaus m, ohrndorf s, kellner h, strunk j, backhaus tm, hartung w, et al. evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. arthritis care res: official j am coll rheum. 2009;61(9):1194–201. doi:10.1002/art.24646. 17. østergaard m, szkudlarek m. ultrasonography: a valid method for assessing rheumatoid arthritis? arthritis rheum. 2005;52(3):681–6. doi:10.1002/art.20940. 18. heijde dmvd. joint erosions and patients with early rheumatoid arthritis. rheumatology. 1995;34:74–8. 19. visser h, cessie s, vos k, breedveld fc, hazes jmw. how to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. arthritis rheum. 2002;46(2):357–65. doi:10.1002/art.10117. 20. bajaj s, ben rl, oster r, alarcón gs. ultrasound detects rapid progression of erosive disease in early rheumatoid arthritis: a prospective longitudinal study. skeletal radiol. 2006;36(2):123–8. doi:10.1007/s00256-006-0196-z. 21. der heijde dv, riel pv, leeuwen mv, hof mv, rijswijk mv, de putte lv, et al. prognostic factors for radiographic damage and physical disability in early rheumatoid arthritis. a prospective followup study of 147 patients. rheumatology. 1992;31(8):519–25. doi:10.1093/rheumatology/31.8.519. 22. buckland-wright jc, walker sr. incidence and size of erosions in the wrist and hand of rheumatoid patients: a quantitative microfocal radiographic study. ann rheum dis . 1987;46(6):463–7. doi:10.1136/ard.46.6.463. 23. grassi w, tittarelli e, blasetti p, pirani o, cervini c. finger tendon involvement in rheumatoid arthritis. arthritis rheum: official j am coll rheum. 1995;38(6):786–94. doi:10.1002/art.1780380611. 24. boutry n, lardé a, lapègue f, solau-gervais e, flipo rm, cotten a, et al. magnetic resonance imaging appearance of the hands and feet in patients with early rheumatoid arthritis. j rheumatol. 2003;30(4):671–9. 25. lillegraven s, boyesen p, hammer hb, ostergaard m, uhlig t, sesseng s, et al. tenosynovitis of the extensor carpi ulnaris tendon predicts erosive progression in early rheumatoid arthritis. ann rheum dis. 2011;70(11):2049–50. doi:10.1136/ard.2011.151316. http://dx.doi.org/10.1002/art.1780381013 http://dx.doi.org/10.1097/00002281-199605000-00010 http://dx.doi.org/10.1093/oxfordjournals.rheumatology.a031496 http://dx.doi.org/10.1007/s00256-006-0219-9 http://dx.doi.org/10.1007/s00256-006-0219-9 http://dx.doi.org/10.1002/1529-0131(200102)44:2<331::aid-anr50>3.0.co;2-0 http://dx.doi.org/10.1007/s00256-003-0693-2 http://dx.doi.org/10.1002/1529-0131(199906)42:6<1232::aid-anr21>3.0.co;2-3 http://dx.doi.org/10.1002/1529-0131(199906)42:6<1232::aid-anr21>3.0.co;2-3 http://dx.doi.org/10.1002/1529-0131(200012)43:12<2762::aid-anr16>3.0.co;2-## http://dx.doi.org/10.2214/ajr.11.6798 http://dx.doi.org/10.1007/s00296-008-0765-7 http://dx.doi.org/10.1002/art.10877 http://dx.doi.org/10.1002/art.24646 http://dx.doi.org/10.1002/art.20940 http://dx.doi.org/10.1002/art.10117 http://dx.doi.org/10.1007/s00256-006-0196-z http://dx.doi.org/10.1093/rheumatology/31.8.519 http://dx.doi.org/10.1136/ard.46.6.463 http://dx.doi.org/10.1002/art.1780380611 http://dx.doi.org/10.1136/ard.2011.151316 36 sharanayya et al. / panacea journal of medical sciences 2021;11(1):31–36 author biography sharanayya, assistant professor shamrendra narayan, assistant professor vandana verma, professor madhu sharma, assistant professor anjana pande, assistant professor vivek jirankali, senior resident cite this article: sharanayya, narayan s, verma v, sharma m, pande a, jirankali v. joint involvement in rheumatoid arthritis: sonographic evaluation in comparison with radiography. panacea j med sci 2021;11(1):31-36. introduction materials and methods patients ultrasonography statistical analysis results discussion conclusions limitations source of funding conflict of interest original research article http://doi.org/10.18231/j.pjms.2019.016 panacea journal of medical sciences, may-august, 2019;9(2):60-65 60 autonomic manifestations in diabetes mellitus: a case control study in rural population kailash s mottera1, shiva kumar2* 1,2consultant physician, dept. of internal medicine, 1lotus hospitals, hsr layout, bangalore, karnataka, 2suryodaya healthcare, malur, karnataka, india *corresponding author: shiva kumar email: drkailash.81@gmail.com abstract autonomic dysfunction is one which is often a disabling complication of diabetes mellitus. failure to recognize the symptoms in a diabetic autonomic dysfunction may lead to a substantial morbidity and mortality, however insidious the onset may be. thus, knowing its importance, this study features the various clinical manifestations of autonomic dysfunction in diabetes, in the rural area, and by simple bedside tests. this study aims to detect cases of autonomic dysfunction and its significant correlation with diabetes. this study was carried out on 50 patients with diabetes mellitus and 50 healthy controls. autonomic function bedside tests were conducted on all study participants and the autonomic scores were calculated. electrocardiograms were taken to calculate the corrected qt-interval. glycemic profile was measured in all the subjects. comparison of these parameters were done between the diabetic and control group. significant positive autonomic scores were observed in all the tests in diabetic group when compared to the study group. impotence (36%), postural giddiness (30%) and sweating disturbances (26%) were the common symptoms noted among the diabetic group. prolonged qtc interval of value greater than >0.44 was seen in 18 subjects (36%) in the diabetic group where it is seen only in 4 subjects (4%) in the control group. among the diabetic group mean hba1c for those with negative autonomic scores was 5.98±1.41% as compared to 7.24±2.42% with positive autonomic scores. thus, there is an increased incidence of autonomic dysfunction among diabetic patients. the increased autonomic scores are suggestive of the same. keywords: autonomic function tests, diabetes mellitus, hba1c, qt interval, autonomic neuropathy. introduction india is the diabetic capital of the world. diabetes is definitely a growing menace in our society, with a growing worldwide incidence. diabetes is continued to be known to man for centuries but yet to be fully understood. the number of people with diabetes has increased alarmingly since 1985. in 1985, an estimated 30 million people world-wide had diabetes; by 2003, it was estimated that approximately 194 million people had diabetes, and this figure is expected to rise to almost 350 million by 2025.1 to beat it all, though diabetes can be easily detected and diagnosed overall, it’s actual ‘hold’ over the various systems in the form of complications are seldom fully recognized. most people link diabetes to major manifestations of the eyes or heart that they overlook its grasp on the nerves, and the dreaded neuropathic complications. all forms of diabetes are characterized by hyperglycemia, due to relative or absolute lack of insulin or the malfunctioning of insulin. this hyperglycemia progresses onto the development of diabetes-specific microvascular pathology in the retina, glomerulus, and peripheral nerves.2 autonomic dysfunction is another disabling complication in diabetics. significance of autonomic dysfunction in diabetes is huge as it has 5-year mortality of 50%, it is common cause of sudden death, has been correlated with greater complications after elective surgery and increased danger with general anesthesia.3 the significant increase in major microvascular complications makes it important to screen diabetes at a younger age of 45 years. failure to recognize the symptoms in a diabetic, as due to autonomic dysfunction and later lead to lot of unnecessary investigations and wasteful treatment. thorough understanding of diabetic autonomic dysfunction on the various systems is necessary.4 common clinical presentations with autonomic dysfunctions are postural hypotension, gastrointestinal disturbances, sweating abnormalities, bladder dysfunction, erectile dysfunction and other symptoms.5,6 among these complications, cardiac manifestation seems to more common and dreadful. autonomic nerves provide the heart with very fine control mechanism; variations in vagal tone very rapidly alter heart rate on a beat-to-beat basis while stimulation of the sympathetic tone has a more gradual accelerator effect. there are several investigations to assess the cardiac autonomic functions. heart rate variability in most widely accepted predictor of functional status of the heart. the actual measurement of heart rate variability has been achieved via multiple different modalities. it is usually calculated by analyzing the time series of beat-to beat intervals from ecg or arterial pressure tracings, i.e. standard deviation of beatto-beat intervals. it consists of time domain and frequency domain parameters. other conventional tests are generally used to measure cardiac autonomic function tests are recording the heart rate and blood pressure changes during maneuvers.7,8 the objective of the study was to observe the presenting manifestations of autonomic dysfunction in diabetes mellitus and compare it with the normal subjects. materials and methods the study was conducted in patients who presented in the opd of general medicine in the rural medical college. the institutional ethical clearance was obtained for the study. the study was conducted in november, 2008 to april, 2010. diabetic group consisted of 50 subjects who were randomly selected and consisted of 34 males and 16 females. the study also involved 50 controls, i.e. non-diabetic patients. inclusion criteria for the diabetic group are patients with fasting (of more than 8 hours) blood glucose levels of more than 126 kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 61 mg/dl and/or two-hour post-prandial blood glucose levels of more than 200 mg/dl.9-10 patients with severe anemia, congestive cardiac failure, gross nutritional deficiency, exposure to alcohol, lead, neurotoxic drugs (like inh) and drugs affecting the autonomic function, renal failure, on antihypertensive medication, chronic obstructive lung disease, central or peripheral neuropathies due to cause other than diabetes, liver diseases, cardiac arrhythmias were excluded from the study. the selected 50 diabetic patients were questioned about the presence of symptoms reported to be related to autonomic neuropathy, viz. postural giddiness, and nocturnal polyuria, disturbances of bladder sphincter, constipation, diarrhea, impotence and bouts of localized sweating. all the patients were subjected to a detailed clinical examination. glycosylated hemoglobin levels were assessed in all the subjects. the following tests were performed to assess the autonomic functions in the above patients.11-12 tests reflecting parasympathetic function and sympathetic functions are listed in the table 1 with their scoring system.13 heart rate variation during deep breathing deep breathing, at six breaths a minute, is the most convenient and reproducible technique. the patients breathe deeply at six breaths a minute (five seconds in and five seconds out) for one minute. an electrocardiogram is recorded throughout the period of deep breathing, with a marker used to indicate the onset of each inspiration & expiration. the shortest r-r interval during inspiration and longest r-r interval during expiration was measured to calculate the difference in heart rate. heart rate response to valsalva maneuver the patient is asked to blow into the sphygmomanometer tube to maintain a pressure of 40 mm of hg for 15 seconds, with continuous recording of electrocardiogram. during each maneuver, the electrocardiogram is recorded during the strain, and for 15 seconds following the release. the results are expressed as valsalva ratio, which is the ratio of longest r-r interval after the maneuver to the shortest r-r interval during the maneuver. immediate heart rate response to standing during the change of position from lying to standing a characteristic immediate rapid increase in heart rate occurs, which is maximal at about the 15th beat after standing. a relative overshoot bradycardia then occurs, maximal at about the 30th beat. this response is mediated by the vagus nerve. the test is performed with patient lying quietly on a bed, while the heart rate is recorded continuously on an electrocardiograph. the patient is asked to stand up unaided and the point, at which the patient starts to assume an erect posture, is marked on the electrocardiogram. the shortest rr interval at around the 15th beat and longest r.-r interval at around 30th beat are measured. the characteristic heart rate response is expressed by the 30.15 ratio. blood pressure response to standing the test is performed by measuring the patient's blood pressure while he is lying down quietly, and after he stands up at one minute intervals. three readings were obtained, and the average drop in the systolic blood pressure was taken. blood pressure response to sustained handgrip the patients were asked to maintain 1/3rd of maximal voluntary contraction for 5 minutes, and blood pressure is recorded in the non-exercising arm, at rest, and during oneminute interval during the grip. the result is expressed as the difference between the highest diastolic blood pressure during the handgrip, and the mean of the three diastolic blood pressure readings, before the handgrip began. a corrected qt interval (qtc interval) resting ecg is recorded in all the patients and qt interval in seconds is detected. the qtc interval (in seconds) = qt interval (in seconds)/ √r-r interval (in seconds) (13). based on the results of the above tests, the autonomic manifestations in diabetics were ascertained, and further analyzed using statistical test, student t test. results total of 100 subjects participated the study with 50 subjects each in diabetic and control group. impotence is the commonest symptom of autonomic dysfunction and polyneuropathy the commonest complication with the incidence of 36% in the diabetic group. the other common symptoms are sweating disturbances (26%), postural giddiness (30%). the occurrence of symptoms between diabetic group and control group is compared and presented in the table 2. incidence of cataract in the diabetic group was 20% and in control group was 12%. the average of participants in the study was 54.43±15.12 years and the mean duration of diabetic in the participants was 10.96±6.95 years. table 1: normal, borderline and abnormal values in tests for autonomic functions tests normal values borderline values abnormal values a. parasympathetic function tests 1. heart rate variation during deep breathing (beats/min) 15 or more 11-14 10 or less 2. immediate heart rate response to standing (30:15 ratio**) 1.04 or more 1.01-1.03 1.00 or less 3. heart rate response to valsalva maneuver (valsalva ratio*) 1.21 or more 1.11-1.20 1.10 or less b. sympathetic function tests kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 62 1. b.p response to standing (fall in systolic blood pressure) (mm of hg) 10 or less 11-29 30 or more 2. b.p response to handgrip (increase in diastolic blood pressure) (mm of hg) 16 or more 11-15 10 or less scores* 0 1 2 *of total sum of 10, if total score obtained from tests is >5, i.e 6 or above, it is considered positive autonomic score table 2: presenting complaints among the diabetic and control group presenting complaints diabetic group (n=50) control group (n=50) p value no % no % postural giddiness/syncope 15 30.0 2 4.0 0.001** constipation 10 20.0 0 0.0 0.001** diarrhea 4 8.0 5 10.0 1.000 sweating disturbances 13 26.0 0 0.0 <0.001** pupillary changes 9 18.0 0 0.0 0.003** bladder disturbances 10 20.0 0 0.0 0.001** urinary tract infections 5 10.0 1 2.0 0.204 impotence 18 36.0 0 0.0 <0.001** cholelithiasis 8 16.0 3 6.0 0.110 cataract 10 20.0 6 12.0 0.275 dermopathy 5 10.0 0 0.0 0.058+ ulcers on foot 10 20.0 0 0.0 0.001** pulmonary tuberculosis 2 4.0 2 4.0 1.000 the heart rate and bp responses in the two group in depicted in table 3. significant positive autonomic cardiovascular reflex tests among diabetic group than control group. autonomic scores were compared between the groups and there statistically more significant positive autonomic scores in diabetic group than control group. the results are depicted in fig. 1 and table 4. table 3: comparison of heart rate and bp response in two groups of patients diabetic group control group p value heart rate response to deep breathing 12.26±4.95 21.04±5.26 <0.001** heart rate response to valsalva maneuver 1.07±0.27 1.28±0.19 <0.001** immediate heart rate response to standing 1.01±0.15 1.27±0.19 0.001** b.p response to standing 14.88±7.51 10.96±9.31 0.030* b.p response to handgrip 14.40±5.57 18.24±3.95 <0.001** table 4: distribution of autonomic scores among the subjects autonomic score diabetic group control group no % no % negative (<=5.0) 22 44.0 44 88.0 positive (>5.0) 28 56.0 6 12.0 total 50 100.0 50 100.0 inference autonomic positive cases are significantly more in cases compared to controls with p<0.001** fig. 1: distribution of autonomic scores among the subjects the mean corrected qt interval (qtc) is 0.419 ± 0.05 seconds in the diabetic group and 0.394 ± 0.04 seconds in the control group. the statistically significant difference between diabetic and control group with p=0.003*. qtc interval of value greater than >0.44 was seen in 18 subjects (36%) in the diabetic group where it is seen only in 4 subjects (4%) in the control group. comparison of corrected qtc intervals by kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 63 e.c.g (in seconds) in two groups of patients is depicted in table 5. table 5: comparison of corrected qtc intervals by e.c.g (in seconds) in two groups of patients corrected qt interval diabetic group (n=50) control group (n=50) 0.35-0.40 25(50.0%) 34(68.0%) 0.41-0.45 7(14.0%) 12(24.0%) 0.46-0.50 18(36.0%) 4(16.0%) mean ± sd 0.419±0.05 0.394±0.04 inference corrected qtc interval is significantly increased in cases with p=0.003** mean glycosylated haemoglobin (hba1c) was in the diabetic group was 8.24±2.59%. mean hba1c was 7.24±2.42% in the subjects with positive autonomic scores and it was 5.98±1.41% in subjects with negative autonomic scores. discussion incidence of varied symptoms of autonomic dysfunction in diabetic group is described as follows. in this study, 46 out of the 50 diabetes patients studied, presented with symptoms suggestive of autonomic neuropathy in the form of impotence, postural giddiness, constipation, sweating disturbances, bladder disturbances and diarrhea. impotence was the most common symptom in this study. it was encountered in 18 out of the 50 patients (36%). out of this, it was encountered in 10 out of the 34 males, mainly in the form of erectile dysfunction. rundles14 found impotence in 19 patients out of 125 diabetic patients. noronha jl et al15 found impotence in 52% of their study diabetic subjects, being the commonest symptom. gupta et al16 in their study found 12 patients with impotence in 50 diabetic patients. postural giddiness was the next common symptom seen in 15 out of the 50 diabetic patients (30%). this is statistically significant. the findings in this study were similar to that of nijhawan et al17 who found an incidence of 28% (7 out of 25 patients). goel a et al18 in their observation, have made a fact that postural giddiness, is the commonest symptom (21.3%), others being impotence (9.3%), diarrhea (9.3%), abnormal sweating and dysphagia. sweating disturbances in the form of decreased sweating were seen in 26% of the patients 13 out 50 diabetics. no control had symptoms of sweating disturbances, making this a significant symptom of autonomic neuropathy. bladder disturbances, in the form of incontinence and retention of urine, were seen in 10 out of 50 patients (20%). rundles14 observed 32 out of 125 diabetics (25.6%) with bladder disturbances while gupta et al16 observed bladder disturbance in 5 out of 50 diabetics (10 %). constipation was also a common symptom seen in 10 out the 50 diabetic patients (20%). aaron i et al19 says that constipation is the most common lower g.i symptom in diabetics. diarrhea, which was nocturnal, profuse and watery, was seen in 4 out of the 50 diabetic patients (8%). rundles14 reported 21.6% patients with diarrhea 26 out of 125 patients, chowdary d et al20 in their update article on “approach to case of autonomic neuropathy”, states that diabetes mellitus is the most important cause of autonomic neuropathy. autonomic features, which involve the cardiovascular, gastrointestinal, urogenital, sudomotor and pupillomotor systems, occur in varying combinations, of which, orthostatic hypotension is often the first recognized and most disabling symptom. comparison of autonomic dysfunction in diabetic group and control group is described as follows. ewing’s autonomic test scoring system as used to evaluate if a patient had autonomic dysfunction. this system is described in the methods. it has maximum total score of 10 to a minimum of 0, a score of more than 5, i.e. 6 or more was considered as positive autonomic scores. among the 50 diabetic patients, 28 patients had positive autonomic scores (56%). only 6 among 50 controls had an autonomic score of more than 5, indicating a strong association between autonomic dysfunction and its manifestations in diabetes. the incidence of autonomic neuropathy in diabetics, ranged from 17 to 68% in other studies. pappachan m21 et al in their study, showed a prevalence of cardiovascular autonomic neuropathy in 60% of the 100 cases of diabetics studied. goel a et al18 have reported 29 out of 75 diabetic patients (39%) to have dysautonomia. similar results were seen with oluranti b. familoni et al22 have showed a prevalence of 37% of dysautonomia among the diabetics under study. duration of diabetes vs incidence of autonomic dysfunction the incidence of autonomic neuropathy increased with the increasing duration of diabetes. among those with positive autonomic scores, the average age was 54.43±15.12 years as compared to 42.91±12.59 years in those with negative scores, indicating the increased prevalence of autonomic dysfunction in diabetics among the older age groups. also we see that in those cases that had positive autonomic scores, the average duration of diabetes was 10.96±6.95 years as compared to 5.39±3.06 years in those who had negative scores. this clearly indicates the correlation between increasing duration of diabetes and the occurrence of autonomic neuropathy. roy freeman et al23 reported an incidence of 15% autonomic neuropathy in diabetics of duration up to 10 years and 62% in diabetics of more than 10 years.9 lakhotia m et al13 showed a great incidence of dysautonomia with increasing duration (up to 80% in those with duration of more than 5 years). glycemic control and autonomic dysfunction poor glycemic control is associated with diabetic complications and notably with autonomic neuropathy. the mean value of glycosylated hemoglobin in most of these patients at the time of recruitment for study was 7.24±2.42%. it was noticed that the cases with positive autonomic scores had uncontrolled blood sugars (fasting and post-prandial blood sugars) than those with negative scores. among the cases, those with positive scores had a mean value of glycosylated hemoglobin of 8.24±2.59% as against that of 5.98±1.41% in those with negative scores. the target kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 64 glycosylated haemoglobin in normal individuals is 7.0%, and for diabetics is 6.5%.21 this clearly indicates that these patients had a poor glycemic control over the previous 3 months or more, also indicating the significant correlation between poor glycemic control and prevalence of diabetic autonomic neuropathy. pappachan jm et al21 in their study, also showed that incidence of diabetic autonomic neuropathy increased with increasing duration and poor glycemic control. gupta rc et al16 studied cardiovascular reflexes after 6 months of strict metabolic control and found that 22% patients showed significant symptomatic improvement and 18% showed improved test score. sympathetic v/s parasympathetic tests in the present study, the tests used to evaluate parasympathetic system where found to be more sensitive indicators of autonomic neuropathy. more than 80% of the diabetics with positive autonomic scores had at least one parasympathetic test abnormal or borderline, and at least 60% had at least two tests abnormal or borderline. goel a et al18 observed that 50% of the diabetics with dysautonomia had both abnormal sympathetic and parasympathetic tests. noronha jl15 reported 45.5% of their diabetic subjects had inadequate heart rate response to standing. in this study, 48% cases had abnormal or borderline values for the heart rate response to standing, results almost matching with their study. corrected qt interval in e.c.g. v/s diabetic autonomic neuropathy a corrected qt interval of more than 0.44 seconds was present in diabetic autonomic dysfunction and was more prominent in cases with significant risk factors, like advanced age, longer duration and peripheral neuropathy. in this study, it was ascertained that the corrected qt interval was statistically significantly increased among diabetic cases compared to controls. oluranti b. familoni et al22 showed a prevalence of 30% of diabetic autonomic neuropathy in the cases with prolonged corrected qt interval. pappachan jm et al21 in their study, showed a significant association between can and prolonged corrected qt interval (or 5.55s). roy freeman, in his article, “autonomic peripheral neuropathy”, roy freeman 200523 says that mortality in diabetics due to cardiovascular autonomic neuropathy is 27-56% in 5-10 years period. conclusion there were increased number of abnormal parasympathetic (heart rate variability) tests as compared to sympathetic (blood pressure variability) tests. there was a statistically significant effect of duration of disease and glycemic state (based on fasting blood sugar/ post-prandial blood sugar/ hba1c) on autonomic neuropathy among the cases. there were statistically significant prolongations in corrected qtintervals in diabetics compared to controls. it is necessary to anticipate the early autonomic dysfunction in diabetic patients and accord necessary treatment. source of funding none. conflict of interest none. references 1. michael brownlee, lloyd. p. aiello, mark e. cooper, william’s textbook of endocrinology, 11th edition, chapter 32, 1418-1490. 2. tarsy daniel, freeman roy. “the nervous system and diabetes”, joslin’. diabetes mellitus, 13th edition 794-798. 3. harrison’s principles of internal medicine, autonomic neuropathy in diabetes mellitus, chapter 338, 17th edition, pg.2289-2293. 4. michael e. farkouh, elliot j. rayfield, valentin fuster: “diabetes and cardiovascular disease” hurst’s the heart, 12th edition, pp 2073-2103. 5. adams d raymond, victor morris; principles of neurology, 9th edition, pp 505-527. 6. api textbook of medicine, diagnosis of diabetes mellitus, 8th edition, vol. 2, pages 1049-1051. 7. suraj kupa, virend k. somers, “cardiovascular manifestations of autonomic disorders”, braunwald’s heart disease: a textbook of cardiovascular diseases, 8th edition, wb saunders, 2008, pp 2171-2183. 8. robertson rh, robertson d. “cardiovascular manifestations of autonomic disorders”, braunwald’s heart disease: a textbook of cardiovascular diseases, 7th edition, wb saunders, 2008, pgs 2173-2184. 9. american diabetes association standards of medical care in diabetes—2007. diabetes care 2007;30 (suppl 1):s4-s41. 10. gabir mm, hanson rl, dabela d. the 1997 american diabetic association and 1999 world health organization criteria for hyperglycemia in the diagnosis and prediction of diabetes. diabetes care 2000;23:1108-1112. 11. ewing dj, clarke bf. diagnosis and management of diabetic autonomic neuropathy. br med j 1982;285:916-8. 12. ewing dj, campbell iw, murray a, neilson jmm, clarke bf. immediate heart-rate response to standing: simple test for autonomic neuropathy in diabetes. br med j 1978;1:145-7. 13. lakhotia m, shah pkd, vyas r, jain ss, yadav a, parihar ma. clinical dysautonomia in diabetes mellitusa study with seven autonomic reflex function tests. japi 1997;45:4. 14. rundle rw. diabetic neuropathy. medicine (baltimore) 1945;24:111-60. 15. noronha jl, bhandarkar sd, shenoy pn, retnam vj. autonomic neuropathy in diabetes mellitus. j postgrad med 1981;27:1-6. 16. gupta rc, chittora md, jain a. a study of autonomic neuropathy in diabetes mellitus in relation to its metabolic control. japi 1995;43(7):1-3. 17. nijhawan s. autonomic and peripheral neuropathy in insulin dependent diabetes. joint association of physicians of india 1993;41(a):565-6. 18. goel a, ruchika agarwal, singla s, lakhani kk, sonigra dt, agarwal sb. a clinical study on autonomic nervous system manifestations in diabetes mellitus. j assoc physicians india 2005;53:999. 19. aaron i. vinik, raelene e. maser, braxton d. mitchell, roy freeman. diabetic autonomic neuropathy. diabetes care 2003;26(5):1553-79. 20. chowdary d, patel n. update article on approach to a case of autonomic peripheral neuropathy. japi 2006;54:727. 21. pappachan m, sebastian j, bino bc. cardiac autonomic neuropathy in diabetes mellitus: prevalence, risk factors and https://www.ncbi.nlm.nih.gov/pubmed/16515247 kailash s mottera et al. autonomic manifestations in diabetes mellitus: a case control study in rural population panacea journal of medical sciences, may-august, 2019;9(2):60-65 65 utility of corrected qt interval in the ecg for its diagnosis. postgrad med j 2008;84(990):205-10. 22. oluranti b. familoni, olatunde odusan, taiwo h. raimi. the relationship between qt intervals and cardiac autonomic neuropathy in nigerian patients with type 2 diabetes mellitus. nigerian med pract 2008;53(4):48-51. 23. roy freeman. autonomic peripheral neuropathy. lancet 2005;365:1259-70. https://www.ncbi.nlm.nih.gov/pubmed/18424578 panacea journal of medical sciences 2021;11(1):116–119 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original researach article a study on the role of mid trimester serum beta human chorionic gonadotropin as a predictor of hypertensive disorders of pregnancy richa rozalia gandhi1, nihar ranjan behera1,*, radha kanta panigrahi1 1dept. of obstetrics and gynaecology, scb medical college, cuttack, odisha, india a r t i c l e i n f o article history: received 17-09-2020 accepted 16-11-2020 available online 29-04-2021 keywords: hypertensive disorders of pregnancy human chorionic gonadotropin maternal mortality a b s t r a c t objective: to determine whether increase in serum beta human chorionic gonadotropin between 12 to 20 weeks of gestation is associated with increase in incidence of gestational hypertension, pre-eclampsia and eclampsia later in pregnancy. materials and method: a prospective observational study was undertaken in the department of o&g, scb medical college, cuttack for a period of one year. one hundred pregnant women were enrolled between 12 to 20 weeks of gestation for the study. their serum beta human chorionic gonadotropin was measured by enzyme linked fluorescence immuno assay and all were followed up. those who developed hypertension or pre-eclampsia or eclampsia during follow up were included in the hypertensive disorders of pregnancy group and rest were included in normal group. both the groups were compared and analyzed. results: out of the one hundred study samples 14% women developed hypertensive disorders later in pregnancy and the rest 86% remained normotensive. the beta human chorionic gonadotropin levels of the women in the hypertensive group was found to significantly higher than women in normal group. conclusion: quantitative estimation of serum beta human chorionic gonadotropin in mid trimester is a very useful screening tool for the prediction of hypertensive disorders of pregnancy. it should be adopted in the routine antenatal care so that there can be a drastic reduction in the maternal mortality and morbidity. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction hypertensive disorders of pregnancy (hdp) is a major cause of maternal mortality and morbidity world wide. 1 it comprises of gestational hypertension, pre-eclampsia and eclampsia. 2 affecting 7 to 10 % of all pregnancies it forms a deadly triangle with hemorrhage and sepsis so far as maternal deaths in developing countries is considered. 3 complications that follows this dangerous condition are many which includes acute problems like abruptio placentae, hellp syndrome, dic, renal failure, cva, hepatic failure, pulmonary edema and long term effects like metabolic syndrome and diabetes mellitus. 4 the peculiarity of this disease is that the pathogenesis starts as early as 12 weeks of pregnancy and the disease progresses * corresponding author. e-mail address: nihar_behera18.5@rediffmail.com (n. r. behera). silently without any clinical manifestations. by the time diagnosis is made end organ damage and complications are already advanced. hence the best way to defeat this menace is to develop a good predictive test and take preventive steps before the onset of complications. although the exact etiology remains unclear despite extensive clinical and basic researches it is quite well known that placenta plays a major role in the pathogenesis. 5 hence there has been a constant effort to study the relationship between placental products like beta hcg, alpha feto protein (afp), pregnancy associated plasma protein-a (papp-a), and subsequent development of hdp. 6 with this background in mind the present study is an endeavor to know whether there is any relationship between the level of serum beta hcg a major product from placental trophoblastic cells and the future development of hypertensive disorders of pregnancies. answer to this question will help in deciding whether it can https://doi.org/10.18231/j.pjms.2021.025 2249-8176/© 2021 innovative publication, all rights reserved. 116 https://doi.org/10.18231/j.pjms.2021.025 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.025&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:nihar\protect _behera18.5@rediffmail.com https://doi.org/10.18231/j.pjms.2021.025 gandhi, behera and panigrahi / panacea journal of medical sciences 2021;11(1):116–119 117 be a useful predictive test that can be utilized to catch the disease at an early stage so that interventions will ultimately prevent complications and bring down the mortality and morbidity. 2. aim and objective the aim of our study was to determine whether increase in serum level of beta human chorionic gonadotropin between 12 to 20 weeks of pregnancy is associated with increase in incidence of hypertension, pre-eclampsia and eclampsia later in pregnancy. objective was to compare the mid trimester serum beta hcg level of women developing hypertensive disorders of pregnancy with that of normal pregnant women and to estimate whether there is any significant difference. 3. materials and methods the study was a prospective observational study conducted in the department of obstetrics and gynaecology, scb medical college and hospital, cuttack which is a tertiary care center in the state of odisha. the study period was one year from august 2018 to august 2019. study sample was selected from pregnant women attending antenatal clinic of the opd. a total of one hundred women were enrolled for the study after considering the inclusion and exclusion criteria. inclusion criteria all pregnant women attending antenatal opd with gestational age between 12 and 20 weeks as estimated by their last menstrual period or first trimester ultrasound scan. exclusion criteria -women with chronic hypertension, diabetes mellitus, multiple pregnancy, molar pregnancy, anomalous fetus, chronic renal diseases, collagen vascular diseases like sle. proper informed written consent was obtained from all selected samples at the beginning. to start with all enrolled women were subjected to detailed history taking, examination and routine antenatal investigations including obstetric ultrasonography. blood pressure was measured using mercury spygnomanometer in right arm sitting position taking the appearance and disappearance of korotkoff sounds as systolic and diastolic pressures respectively. 5 ml venous blood was collected for estimation of serum beta hcg by enzyme linked fluorescence immunoassay. urine was examined for albumin by dipstick method. these were repeated at every antenatal visit and results recorded. all were followed up till delivery and 6 weeks postpartum. those women who developed gestational hypertension defined as systolic blood pressure greater than or equal to 140 mm of mercury or diastolic pressure of more than or equal to 90 mm mercury or pre-eclampsia defined as hypertension with proteinuria more than 2+ dipstick or eclampsia defined as convulsions associated with hypertension were included in the hdp group (hypertensive disorders of pregnancy group). rest of the women who did not develop features of hdp till delivery or postpartum were placed in the normal group. the two groups were compared with regard to their initial beta hcg levels and obstetric outcomes. management of all cases was done as per the protocol of the department. the collected data was analyzed according to the type of variables. continuous variables were analyzed in terms of mean and interpreted by students test. discontinuous variables were described in terms of percentage and interpreted by chisquare test. pvalues less than equal to 0.05 was considered as statistically significant. 4. results our observation revealed that during the follow up period 14 women developed hypertensive disorders of pregnancy and 86 women remained normal till the end of the study. table 1 the 14 women who developed hdp had raised beta hcg between 12 to 20 weeks gestation. the mean serum beta hcg of the hdp mothers was 54298 ± 22302 miu/ml compared to normal mothers whose mean level was 27015 ± 11250 miu/ml. the difference was statistically highly significant. table 2 the hdp mothers had a significantly higher rise in their systolic and diastolic blood pressures compared to the normal mothers suggesting that when initial beta hcg is high rise in blood pressure later in pregnancy is also high. table 3 the above table shows that more than 90 % of hdp mothers who had initial high beta hcg also went on to have positive urine albumin later in pregnancy which is a hallmark of pre-eclampsia. table 4 both the groups were matched with regard to their status at the time of booking. the above table states that the hdp mothers and normal mothers were similar with respect to their mean age at enrollment, socioeconomic status, parity and their blood pressure at the beginning of the study as the calculated differences were not statistically significant. 5. discussion it is known that hcg is a glycoprotein secreted by placental trophoblastic cells. the serum concentration of its beta subunit is a reflection of trophoblastic activity. it is postulated that in hdp there is hypoxia induced by impaired angiogenesis and insufficiency of placental spiral arteries and this leads to hyperplasia of trophoblastic cells and hypersecretion of hcg. this relationship has been studied in as early 1992 by aquilina j and ellips p et al. 7 they had concluded from their cross sectional study with 200 women that 70% mothers with elevated beta hcg in early second trimester developed hypertension later in pregnancy. the largest study was however by yaro et al in 1994 who studied 118 gandhi, behera and panigrahi / panacea journal of medical sciences 2021;11(1):116–119 table 1: comparison of beta hcg between hdp and normal group. hdp normal difference “t” df p mean sd mean sd 54298 22302 27015 11250 27283 7.13 96 < 0.005 table 2: comparison of increase in blood pressure between hdp and normal mothers blood pressure hdp normal diff b/w means “t” df p mean sd mean sd sbp 41 15 5 12 36 10.3 96 < 0.001 dbp 24 8 3 9 21 8.1 96 < 0.001 table 3: comparison of urine albumin detection between hdp and normal mothers mothers urine albumin urine albumin x 2 significancepresent absent no % no % hdp 13 92.8 1 7.2 82.9 p < 0.001 normal 2 2.3 84 97.7 table 4: comparison of hdp and normal mothers at the beginning of the study variables normal mothers hdp mothers x2 / t p value age (mean ± sd ) 26.2 ± 4.5 26.1 ± 2.3 t = 0.93 p > 0.05 socioeconomic status lower mid 17 (24.6%) lower mid 4(28.5%) x2= 1.072 p > 0.05 lower 69 (75.4%) lower 10(71.5%) parity primi 44 (51.2%) primi 8 (57.1%) x2= 0.287 p > 0.05 multi 42 (48.8%) multi 6 (42.9%) systolic bp mean sd mean sd t = 1.563 p > 0.05 112 9.1 107.9 9.7 diastolic bp mean sd mean sd t = 0.618 p > 0.05 72 7.4 70.0 6.2 more than 60,000 patients and found a similar result. they concluded that beta hcg can be used as a predictive test for hdp. 8 several recent indian studies have also shown similar results as that of our study. 9,10 nevertheless we agree that our study was not conducted for a long duration with a possibility of including a larger sample. hence we suggest that more number of larger studies should be done on this subject to make the evidence stronger enough to be accepted by all. 6. conclusion from the results of our study and analysis of other similar studies we can firmly conclude that there is a strong relationship between mid trimester beta hcg level and risk of hypertensive disorders of pregnancy. we found that there was a significant rise in the serum beta hcg between 12 to 20 weeks gestation in those women who subsequently developed hypertension, pre-eclampsia and eclampsia. hence this simple biochemical test can be utilized as a test to predict the occurrence of the most dreadful disease in pregnancy. if the predictive test comes positive effective and timely interventions can be initiated. the outcome will be a prevention of severe complications and reduction of mortality and morbidity . this will go a long way in achieving the who sustainable development goal of bringing down the mmr to 70 by 2030. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. say l, chou d, gemmill a, tunçalp ö, moller ab, daniels j, et al. global causes of maternal death: a who systematic analysis. lancet global health. 2014;2(6):e323–33. doi:10.1016/s2214109x(14)70227-x. 2. brown ma, magee la, kenny lc, karumanchi sa, carthy fpm, saitos, et al. hypertensive disorders of pregnancy:isshp classification,diagnosis and management recommendations for international practice. hypertension. 2018;72(1):24–43. 3. khan ks, wojdyla d, say l, gülmezoglu am, look pv. who analysis of causes of maternal death: a systematic review. lancet. 2006;367(9516):1066–74. doi:10.1016/s0140-6736(06)68397-9. 4. wang k, tsai j, chen pc, liang cc, chiz-tzung, che-yi c, et al. am j med. 2011;17:251–6. http://dx.doi.org/10.1016/s2214-109x(14)70227-x http://dx.doi.org/10.1016/s2214-109x(14)70227-x http://dx.doi.org/10.1016/s0140-6736(06)68397-9 gandhi, behera and panigrahi / panacea journal of medical sciences 2021;11(1):116–119 119 5. linheimer md, taylor rn, roberts jm, cunningham fg. chesley,s hypertensive disorders in pregnancy. in: and others, editor. 4th edn. amsterdam academic press; 2014. 6. lorenzo gd, ceccarello m, cecotti v, ronfani l, monasta l, brumatti lv, et al. first trimester maternal serum pigf, free βhcg, papp-a, pp-13, uterine artery doppler and maternal history for the prediction of preeclampsia. placenta. 2012;33(6):2495–501. doi:10.1016/j.placenta.2012.03.003. 7. aquilina j, maplethorpe r, ellis p, harrington k. correlation between second trimester maternal serum inhibin-a and human chorionic gonadotrophin for the prediction of pre-eclampsia. placenta. 2000;21(5-6):487–92. doi:10.1053/plac.2000.0540. 8. yaron y, cherry m, kramer rl. second trimester maternal serum marker :maternal serum alpha protein,beta human gonadotropin and their various combinations as a predictor of pregnancy outcome. am j obstet gynecol. 1999;181:968–74. 9. paul t, phukan jk, bhattacharya k. a comparative study of serum beta hcg in pih & normotensive women in third trimester pregnancy. ijar. 2016;6(4):331–3. 10. dubey p, pande k, agarwal s, jain s, singh n, gupti s. effects of raised mid trimester serum beta hcg on pregnancy outcome. indian j clin pract. 2013;. author biography richa rozalia gandhi, senior resident nihar ranjan behera, associate professor radha kanta panigrahi, assistant professor cite this article: gandhi rr, behera nr, panigrahi rk. a study on the role of mid trimester serum beta human chorionic gonadotropin as a predictor of hypertensive disorders of pregnancy. panacea j med sci 2021;11(1):116-119. http://dx.doi.org/10.1016/j.placenta.2012.03.003 http://dx.doi.org/10.1053/plac.2000.0540 introduction aim and objective materials and methods results discussion conclusion source of funding conflict of interest backup_of_final panacea jan to jun 2013 for pdf clinical profile and etiology of ocular trauma in a rural based hospital 1 2 3 3 khandelwal rekha r , shah ketaki j , gautam arjun , bisen rupal ocular trauma is one of the major causes of irreversible visual loss and blindness in developing countries. our study is aimed at determining various etiological factors responsible for ocular trauma and outline protective measures for population at risk. a hospital based case control study was done in a tertiary care rural based hospital. patients of all age groups and either sex were included. prospective information on trauma related to location, activity during injury and causative agent was recorded after face-to-face interviews. all interviewed subjects underwent a comprehensive ocular examination, including vision estimations, slit-lamp biomicroscopy and dilated posterior segment examinations. we reported 299 cases of ocular trauma, out of which 104 (34.8%) patients were in the age group of 3045 years. we found that males were 4.8 times more prone to injuries than females. 101 (33.8%) patients were affected while working in industrial area followed by 83 (27.8%) patients of household injury. road traffic accidents accounted for 61(20.4%) patients out of all injuries. 33(9%) patients had agricultural injuries. sports related injuries affecting younger age groups were seen in 15(18.7%) cases. the impact of ocular trauma in terms of need for medical care, loss of income and cost of rehabilitation services clearly points towards enormous economical burden on society as it affects mainly younger age group. hence public awareness regarding use of protective measures and potential risk factors causing injury should be done on priority basis. keywords: awareness, blindness, epidemiology, ocular trauma, rural. 1 2 professor and head, senior resident, 3 junior resident department of ophthalmology nkp sims&rc, digdoh hills, hingna road, nagpur -40019. rekha.khandelwal@gmail.com abstract: ocular trauma is a major cause of preventable monocular blindness and visual impairment throughout the world (1, 2). despite having major socioeconomic impact, very less data on magnitude and risk factors is available especially in developing countries like india (3, 4). a review suggested that at least half a million people are monocularly blind from ocular trauma worldwide (5). in india, national program for prevention of visual impairment and control of blindness reported 1.2% blindness due to injury (6). the outcome is generally not good in patients who have grossly reduced visual acuity on presentation. both anterior and posterior segment injuries are common in presentation but anterior portion bears direct impact of mechanical injuries.although it affects all age groups, previous studies have indicated that young males are most affected by ocular trauma with majority below the age of 30 years (7). protective measures would certainly reduce its incidence to a great extent. road traffic accidents (rtas) are increasing nowadays while household injuries are under reported. agricultural injuries leading to rapid corneal ulceration and vision loss is very common in developing countries. according to a study by gupta et al (8) it was observed that 1.16% of total blindness was due to ocular trauma while as per dada et al (9) study in 1984, 5.55% people were totally blind due to ocular trauma. the impact of ocular trauma in terms of need for medical care, loss of income and cost of rehabilitation ser vices clearly points towards the introduction : strengthening of preventive measures worthwhile. mass awareness regarding potential risk factors and agents causing injury can prevent number of ocular hazards. previous studies on the profile and prognostic factors in ocular trauma have been carried out in more developed countries where modern facilities for managing ocular trauma are widely available but there is paucity of such studies from the less developed countries. we conducted this study to determine causative agents and risk factors for ocular injuries and outline protective measures for patients a tertiary care rural based hospital in nagpur, india. material and methods : we studied 299 patients of ocular trauma from 1st december 2007 to 31st july 2009 in a tertiary care rural hospital. the ethics review board approval was taken from institutional ethics committee. it was hospital based case series of all ocular trauma patients attending eye out patient department and casualty. we also included referred cases from other departments who had ocular injury. patients of both sexes and all ages were included in our data after written informed consent. detailed history regarding location, activity during injury, nature and cause of injury, previous treatment and other co-existing medical or ocular conditions were recorded after face to face interview with the patient or parents in cases of childhood ocular trauma. pjmsvolume 3 number 1: january-june 2013 original article 15 results : in our study of 299 cases, 104 (34.78%) cases were in 3045 years of age group followed by 93 (31.10%) cases in 18-29 age group (table i). it is observed that men were affected 4.8 times more as compared to females in overall study. the most common location of ocular injury was observed to be industrial area, found in 101(33.78%) cases, followed next by 83 (27.76%) cases in household settings. males (99 cases, 40%) were more commonly involved in work place related ocular trauma while household injuries were common in females, 32 ( 61.5%). we studied the activity being done by the injured at the time of injury and found that maximum number of injuries occurred in work related places, and industrial work is the most common cause in 102 (34.11%) patients. sports related ocular trauma was seen in 56 (18.7%) cases and was the second most common cause and it was seen in males younger than 16 years of age. playing in an unsupervised environment led to serious ocular morbidity in these cases (table ii). it is seen from table that potentially earning age group i.e. 17 to 44 years were more affected by trauma. the association between activity done during injury and these age categories was found to be statistically significant. (chi square = 166.7, df =10, p<0.001). in our series, 98 (32.78%) cases had ocular injury with blunt objects like cricket ball, stone etc which had a major share leading to severe degree of ocular trauma. this was followed by sharp agents like gilli danda, metal wires, pen/pencils in 39 (13.04%) patients. agricultural agents like vegetable matter including jowar plants, wooden sticks had caused ocular morbidity in 21 (7.02%) patients. iron particles or small wooden and dust particles were included in projectile objects and it accounted for 31 (10.0%) cases of all ocular injuries. chemical injuries either due to industrial acids or alkalies or household phenyl etc. led to burns in and around eye in 20 (6.69%) cases. in 24 (8.03%) cases, causative agent could not be elicited (table iii). a significant proportion of subjects in our study, 38 (17.73%) cases had ocular trauma due to fall or road traffic accidents. it was observed that only two (5.26%) patients had used helmets or seatbelts while driving and remaining 36 (94.74%) patients gave no history of using such safety measures. four (10%) cases were found driving under the influence of alcohol and in rest of the cases alcohol history was found to be unreliable (table iv). it was seen that out of 102 industrial workers only four (1.34%) patients used protective eyewear. discussion : epidemiological profile of ocular trauma varies in d e ve l o p i n g a n d d e ve l o p e d co u nt r i e s . eco n o m i ca l backgrounds, public awareness and availability of resources are responsible for this difference. in our study out of 299 cases, we reported that cases between 30-45 years of age group were most commonly affected by ocular injuries. this feature is of great importance as this is the most economically productive age group and has important consequences on finances of household and society (10, 11). mean age of participants in study of urban slum population by vats s et al (12) was 24.21 years. one population based study in singapore found bimodal peak of age distribution in younger age group and in elderly (13). consistent with other studies (14-16), our study observed 4.8% male dominance of ocular trauma than females. a study by wong et al (13) found that male population has 4 times higher risk than females. an epidemiological study by mccarty et al (3) reported 34% overall rate of ocular trauma in male population. this male preponderance is explained on the basis that men are more commonly involved in industrial work and in outdoor activities. children below 12 years of age are more susceptible to uniocular injuries while playing and thus are at high risk of amblyopia. in our study 22.4% of cases were below 16 years of age while a study by saxena et al (16) in 2002 reported 65.2% boys with ocular trauma. vats s et al (12) also observed that all injuries in children below 16 years were unsupervised leading to greater ocular damage. the most common site for ocular trauma in our study was work place (33.8%) which was similar to data found in indian urban slum population study (12) with higher prevalence of ocular trauma in laborers. household injuries were more common in females and it was the second common site for ocular trauma as stated by mccarty et al (3) study. study by nirmalan et al (14) reported that 26.7% of all ocular trauma occurred in a domestic settings. playgrounds or recreational centers accounted for 15% eye injuries in our study. most of these were seen in younger age groups due to non usage of eye protection. vats s et al (12) reported 14.7% sport related injuries while singh dv et al (17) observed 7.6% injuries at recreational venue. road traffic accidents can cause serious injuries in and around the eye. we had 17.73% (38 cases) of vehicular accidents out of which only 5.2% cases were using helmets or seatbelts. vats s et al (12) reported 3.7% cases of rta while khatri s et al (15) reported 13.7% cases of visual acuity (snellen's) was recorded and anterior segment was evaluated with slit-lamp (haag streit). posterior segment was evaluated using direct and indirect ophthalmoscope (heine) with +20 d lens. intraocular pressure was measured with goldman applanation tonometer (gat), or noted digitally. radiological investigations like x-ray orbit, ct scan, mri scan or b-scan were done as indicated. all the findings were recorded in case record form taking into consideration the proforma of ocular trauma society of india (otsi) and american society of ocular trauma. the data collected were suitably coded and entered into pre-designed microsoft access software. data analysis was done with spss 11.0 package. pjmsvolume 3 number 1: january-june 2013 original article 16 table iv: safety measures and road traffic accident cases road traffic accident alcohol consumed number (%) seatbelts or helmet used number (%) yes 04 (10.53) 02 (5.26) no 34 (89.47) 36 (94.74) total 38 (100) 38 (100) table iii: distribution of cases based on causative agents and its relation with gender causative agent blunt object sharp object projectile objects vegetable matter industrial chemicals household chemicals finger /fist/body parts animal body parts sports equipment fireworks others unknown total male 86 32 31 14 08 05 10 02 09 07 15 23 247 female 12 07 00 07 01 06 10 01 01 01 05 01 52 total number (%) 98 (32.78) 39 (13.04) 31 (10.37) 21 (7.02) 09 (3.01) 11 (3.68) 20 (6.69) 03 (1.00) 10 (3.34) 08 (2.68) 20 (8.37) 24 (8.03) 299(100) (chi square = 166.7, df =10, p<0.001) table ii: distribution of ocular trauma cases by activity and its correlation with different age groups activity -industrial work -playing or sports related -slip / fall -farming -bystander & other -total 0-16 years 03 45 09 00 10 67 17-44 years 93 10 35 18 41 197 45 & above 06 01 09 11 08 35 total (n=299) 102 56 53 29 59 299 percentage 34.11 18.73 17.73 9.07 19.73 100 table i: age and sex correlation in ocular injuries age groups (years) 0 6 6 12 13 17 18 29 30 45 46 64 >65 yrs total male number (%) 09 (3.64) 29 (11.74) 16 (6.48) 79 (31.98) 86 (34.82) 23 (9.31) 05 (2.02) 247 female number (%) 06 (11.54) 03 (5.77) 04 (7.69) 14 (26.92) 18 (34.62) 06 (11.54) 01 (1.92) 52 total number (%) 15 (5.02) 32 (10.70) 20 (6.69) 93 (31.10) 104 (34.78) 29 (9.70) 06 (2.01) 299 (100) vehicular accidents. most of the ocular injuries at workplace can be prevented by eye protection. we observed that people sustaining ocular trauma at industrial area did not use any eye protection. krishnadas s et al (18) in 2006 reported 97.8% cases did not wear protective eye wear while working in industry. this is the target population for emphasizing recommendations for safety measures. various agents like cricket ball, gilli danda, wooden sticks, vegetable matter etc can cause mild to grave ocular injury. in our study blunt objects were the most common agent found in 32.8% of cases. nirmalan pk et al (14) also observed that blunt objects were the most common agent causing ocular trauma in 54.9% of his study cases. abraham et al (19) reported wooden stick as an offending agent for ocular injury in 21% cases. we found that rural children playing with gilli danda were more prone for perforating injuries. we had 13.04% of cases caused by sharp objects while vats s et al (12) reported 2.5% of injuries with sharp objects. in our study we found that agricultural agents like vegetable matter led to ocular trauma in 7.02% of cases. a study by khatry sk et al (15) reported that 25.8% cases were due to agricultural agents in nepal. household and industrial chemicals can lead to bilateral injuries. we had 6.69% of chemical injuries while khatry s et al (15) reported 1.3% of chemical burns. singh dv et al (17) reported 5 % cases of chemical injury while 12% cases were reported by raymond s et al (20) his study. activity is also significantly associated with ocular injury. we reported 34% of cases of industrial work related ocular trauma. in our study association between activities being done and ocular trauma is found to be significant. (chi square = 166.7, df =10, p<0.001).we reported 9% cases of farm related ocular injury while khatri s et al (15) reported 25.9% cases of agricultural work related trauma in nepal. we reported 15.5% sports related ocular trauma which was similar to urban slum population study (12) in 2007 which reported it to be 22.7%. occupational hazards remain the most common cause of ocular injuries in rural population of developing countries. the patients who sustained ocular trauma at their workplace did not use any protective gear. a joint effort by the industry and agriculture experts with health professionals is the need of the hour to determine region and work specific eye protection gears. awareness regarding the use of ocular protection and possible benefits for eyes from using such protection must be highlighted. apart from general health concerns our focus should be on the young males who are vulnerable to ocular injuries and lead to great economical loss. pjmsvolume 3 number 1: january-june 2013 original article 17 references : 1. katz j, tielsch jm. lifetime prevalence of ocular injuries from baltimore eye survey. arch ophthalmology 1993; 111:15648. 2. schein od, hibberd p , shingleton bj , kunzweiler t , frambach da , seddon jm, et al. the spectrum and burden of ocular injury. ophthalm 1998; 95:300-5. 3. mc carty ca, fu cl, taylor hr. epidemiology of ocular trauma in australia. ophthalm 1999; 106:1847-52. 4. wong ty, klein be, klein r. the prevalence and 5 year incidence of ocular trauma. the beaver dam eye study. ophthalm 2000; 107:2196-202. 5. thylefors b. epidemiological patterns of ocular trauma. aust n z j ophthalmol 1992; 20:958. 6. ahmed e. quoted from the report of working group on control of blindness. ministry of health goi 1993; 3. 7. tielsch jm, parvel l, shankar b. time trends in the incidence of hospitalized ocular trauma. arch ophthalmol 1989; 107:519–523. 8. gupta ak, moraos o. ocular injuries due to accidental explosion of carbonated beverage bottles. indian j ophthalmol 1982; 30:47-50. 9. dada vk, kalra vk, angra sk. changing pattern of blindness in blind school residents in india. indian j ophthalmol 1984; 32: 161-163. 10. babar tf, khan mt, marwat mz, shah sa, murad y, khan md. patterns of ocular trauma. jcpsp 2007; 17(3):148-153. 11. may dr, kuhn fp, morris re, witherspoon cd, danis rp, matthews gp, et al. the epidemiology of serious eye injuries from the united states eye injury registry. graefes arch clin exp ophthalmology 2000; 238:153-157. 12. vats s, murthy gvs, chandra m, gupta sk, vashist p. epidemiological study of ocular trauma in an urban slum population in delhi, india. indian j ophthalmol 2007; 56(4):313-6. 13. wong ty, tielsch jm. a population based study on the incidence of severe ocular trauma in singapore. am j ophthalmol 1999; 128:345351. 14. nirmalan pk, katz j, tielsch jm, robin al, thulasiraj rd, krishnadas r, et al. ocular trauma in a rural south indian population: aravind comprehensive eye survey. ophthalmol 2004; 111:1778–1781. 15. khatry sk, lewis ae, schein od. the epidemiology of ocular trauma in rural nepal. br j ophthalmol 2004; 88: 456-460. 16. saxena r, sinha r, purohit a, dada t, vajpayee rb, azad rv. pattern of pediatric ocular trauma in india. indian j pediatrics 2002; 69 (10): 863-67. 17. singh dv, sharma yr, azad rv, talwar d, rajpal. profile of ocular trauma at tertiary eye centre. jk science 2005; 7:1-6. 18. krishnadas s , nirmalan pk , shamanna br , srinivas m, gn rao, thomas r. ocular trauma in rural population of southern india. american journal of ophthalmology 2006; 113: 1159-1164. 19. abraham di, vitale si, west si, isseme i. epidemiology of eye injuries in rural tanzania. ophthalmic epidemiology 1999; 6(2):85-94. 20. raymond s, favilla i, nguyen a, jenkins m, mason g. eye injuries in rural victoria, australia. clin experiment ophthalmol 2009; 37(7):698-702. pjmsvolume 3 number 1: january-june 2013 original article 18 page 19 page 20 page 21 page 22 julydecember 2012 pdf for website aptitude evaluation for medical profession in first and final year m.b.b.s. students 1 2 salpekar radhika , mujawar nilofer abstract aptitude is the competency to do a certain kind of work at a certain level. the medical profession remains one of the most popular choices of the indian youth. four factors are necessary for becoming a good doctor: empathy, fortitude, aptitude and a sense of responsibility. studies suggest that aptitude evaluation before entering a profession has many advantages. yet it is not undertaken before joining the medical colleges. the differential aptitude test battery (datb) is a tool for evaluation of aptitude and evaluates a person's verbal reasoning, abstract reasoning, numerical ability space relations and language usage. a study was undertaken to evaluate the aptitude of first and final year students for the medical profession, to compare the aptitude for medical profession between male and female students and to determine a correlation between knowledge of english language and their reasoning powers. keywords: aptitude, dabt, medical profession introduction: the medical professional's job is not easy. to have the right attitude: hard work, sleepless nights, preparedness for a kaleidoscope of emotions, service over economics, willingness to look death in the eyes – the medical professional has to have the right aptitude. studies suggest that aptitude evaluation before entering a profession provides the advantages of increased professional thinking, enhanced communication skills, better problem solving, decision making and increased learner motivation (1). aptitude career tests which are specially designed and developed by expert psychologists help candidates to know what role they will fit into in future. the test analyses the aptitude and skill sets of candidates like logical thinking skills, analytical skills, leadership capabilities, power of comprehension, communication skills, etc, along with capabilities that can be improved. hidden potential or talents can be assessed. the choice of occupation of young adolescents has become an area of interest to educational planners and educational psychologists (2). this is a result of the awareness by stakeholders of the inherent dangers and frustrations suffered by the students, who find themselves in unsatisfactory professions. consequently, educational authorities have realized the need for institutions to have career guidance counsellors who would help the adolescents select an appropriate career in line with their capabilities. the choice of a particular career is influenced by certain factors, among which are peer group influence and parental influence. family influence is an important force in preparing youth for their roles as workers (3). young people develop many attitudes about work and career as a result of interactions with their family. family background provides the basis from which their career plans and decision making evolve. however, within each family, the level of involvement can vary, offering both positive and negative influences. a paper by penick and jepsen stated that parental influence surpasses that of peer influence (4). but, this is a variable factor pertaining to the student's rapport with their parents and peers. a study by csinady and molnar found that altruistic motivations were the most significant career choice reasons among medical undergraduates (5). the medical profession faces a changing gender composition with more and more females opting for medicine as their career. a study in the united kingdom showed an increase in feminisation of the medical profession (6). aims and objectives: we did this study to investigate the relative importance of aptitude in choosing a career and to find out if parental and peer group have some bearing on the choice of career among the undergraduates. we also aim to explore if there is difference in aptitude for the medical profession between girls and boys. 1. to determine the proportion of students with medical aptitude. 2. to compare the aptitude for medical profession between male and female students. 3. to determine a correlation between knowledge of english language and their reasoning powers. materials and methods: study design and participants: this is a crosssectional study that was conducted during may and june 2012. it aimed at assessing the aptitude for medical profession among undergraduates. therefore, the population of this study comprised of students of first and final year m.b.b.s. attending nkp salve institute of medical sciences and research centre, nagpur. 250 students were included in the 41 1 2 mbbs student, professor, department of paediatrics, nkpsims & rc, digdoh hills, hingna road, nagpur -440019. nilofer.mujawar@gmail.com pjmsvolume 2 number 2: julydecember 2012 educational research study. of these, 100 students completed the test all the way through. 64 students did not attend the test and 58 completed the test only partially. the results of 28 more had to be excluded because of misconduct. data collection tools: we used differential aptitude test battery (datb) which is a well validated, time tested, objective based questionnaire in english. it included 330 questions under 5 sections as follows: 1. verbal reasoning. 2. abstract reasoning. 3. numerical ability. 4. space relations. 5. language usage. this questionnaire was used to provide an integrated, well-standardized procedure for measuring the abilities of the students. all the questions were based on basic knowledge and comprehension. contents: verbal reasoning – the verbal reasoning test, as the name implies, is a measure of ability to understand concepts framed in words. it is aimed at the evaluation of the student's ability to abstract or generalize and to think constructively and logically. the analogies from this test are peculiarly appropriate for the measurement of reasoning ability. this skill is important for work involving communicating ideas or understanding written material. sample careers: law, journalism, social work, arts, european studies, media, public relations, advertising, education, etc. sample subjects: english, history, languages, etc. abstract reasoning – the abstract reasoning test is intended as a nonverbal measure of the student's intellectual ability. the series presented in each problem requires the perception of an operating principle in the changing diagrams. in each instance, the student must discover the principle governing the change of figures and give evidence of his understanding by designating the diagram which logically should follow. sample careers: engineer, doctor, scientist, musician, software design, teacher, computer programmer, mechanic, management, etc. sample subjects: physics, chemistry, biology, music, history, art, etc. numerical ability – the numerical ability items are designed to test understanding of numerical relationships and facility in handling numerical concepts. the problems are framed in item type ordinarily called “arithmetic reasoning”. sample careers: finance, science, architecture, engineering, sales, etc. sample subjects: maths, physics, accounting, economics, etc. space relations – the capacity to imagine a constructed object from a picture of a pattern has been used in this test. it measures the ability to visualise a three-dimensional object from a two-dimensional pattern and to visualise how this object would look if rotated in space. sample careers: art, design, architecture, engineering, carpentry, dentistry, photography, fashion design, etc. sample subjects: art, home economics, technical graphics, etc. language usage – measures ability to spell common english words. this is a basic skill necessary in many academic and vocational pursuits, especially in courses requiring written reports. it also measures the ability to detect errors in grammar, punctuation and capitalization. sample careers: writing, teaching and almost all university courses, etc. sample subjects: all subjects and all exams. the students were asked to solve the questionnaire in a stipulated time of 2 hours, each section getting a specific time allotment, as follows: verbal reasoning – 20 minutes abstract reasoning – 20 minutes numerical ability – 20 minutes space relations – 30 minutes language usage – 30 minutes based on the above sections, another skill is measured, which is the “educational aptitude”. it is measured by combining the score of verbal reasoning and numerical ability. this score provides the best general measure of educational aptitude or the ability to learn from books and teachers and to perform well in academic subjects i.e. to learn from a traditional teaching environment such as a school, a college or a university. the participants were also asked to answer questions about their family background and also what prompted them to opt for medicine as their career. ethical considerations: a written informed consent was obtained from each participant. the study objectives were explained to the students. also, the participants were assured confidentiality of the collected information and that they were free to decline participation in the study. the study protocol and data collection instrument were reviewed and approved by the institutional ethics committee. permission to administer the questionnaire was obtained from the teachers concerned. 42 pjmsvolume 2 number 2: julydecember 2012 educational research statistical analysis: the questionnaires were corrected manually using a validated ohp answer mat. data were entered in ms excel and the raw score was converted into percentile score using a validated conversion table (figure 1) this was done to . standardize the scores. data were analysed using percentage analysis. this was done manually by simple percentage method after which we graded the students into various categories ranging from low to very high. accordingly, two of the best scores/grades were selected and suitable career options suggested. both, regular batch and repeater batch students of first and final year were included. variables such as schooling and medium of school education were not included in the outcome. results: of the total 250 students approached, the result of 100 students was analysed. there were 62 males and 38 female students. 38% of the students possessed the aptitude required for medical profession. the other career options suggested included major fields such as engineering, architecture, journalism, law, finance, etc. other fields included were dentistry, fashion designing, software designing, teaching, etc (figure 2). these results suggest that 38% of the students have the required aptitude for medical profession. this means, they had a high score in abstract reasoning. some students showed good grades in other sections as well. this suggests that students also possess a good aptitude for more than one field. apart from the 38%, the rest of the students also possessed the aptitude for becoming a doctor, but in a slightly lower grade. similarly, students who showed the aptitude for medical profession also showed some diverse range of aptitude in the other fields. the results can thus be interpreted variably. 5.2% of the lot showed high to very high aptitude in all the fields, broadening their area of career options. out of the 53 first year students, 26.6% have the aptitude to become doctors. of the 47 final year students, 51.3% showed high grades. gendered results were seen in this study. 31.5% of 62 males and 41.7% of 38 females gave a good result. there is a significant difference in the percentage of aptitude possessed by males and females (7). 14% of the undergraduates have high english language skills. this was based on their ability to spell common english words and correct grammatical and punctuation mistakes. 42 out of 100 students have average english language skills. this result suggests the students' command over english language (figure 3). figure 1: analysis graph for aptitude test. the percentile scores have been entered according to the respective fields. two of the highest percentile scores are selected i.e. abstract reasoning and numerical ability, and suitable career options are suggested. figure 2: percentage of students possessing the aptitude for various fields figure 3: comparison between the percentages of students showing various grades of skills in the english language 43 pjmsvolume 2 number 2: julydecember 2012 educational research high educational aptitude was seen in 38% of the students, suggesting their ability to learn from books and teachers. 16 students have low educational aptitude. as expected, 87.8% of the students said that, the decision to opt for medicine as their career was their own. altruism and a sense of helping mankind seemed to be the common factor among many such students (8). 9.7% said that their parents and family members prompted them to become doctors. a mere 2% said that their peer group influenced their choice. discussion: presently, there is no structured program for youngsters to assess themselves and to make an informed choice when it comes to choosing a profession.our data reveals that only a third of the medical undergraduates have aptitudes for the medical profession. the rest of the students showed an aptitude corresponding to a variety of other fields like architecture, engineering, law, journalism, computer designing, fashion designing, etc. our findings therefore suggest that these 38% students have a better potential in the field of medicine. students that are suited for other fields can also become good doctors. this can be achieved by the persons' innate or inherent aptitude, interest and dedication for their jobs. hence, four factors are truly necessary for becoming a good doctor: empathy, fortitude, aptitude and a sense of responsibility. aptitude is the competency to do a certain kind of work at a certain level. the aptitude measures the inclination, the tendency, readiness to learn and personal strengths and weaknesses. these career tests focus on a candidate's analytical and abstract reasoning skills with regard to their numerical, verbal and spatial capabilities. a candidate may have the adequate educational qualification and work experience. but an aptitude test will determine how they are going to apply the acquired knowledge and skills in a specific domain or situation. a varying degree of results were seen in first and final year students. more than half of the final year students showed the aptitude required for medicine. the innate nature of aptitude is in contrast to achievement, which represents knowledge or ability that is gained. this means that the students who actually reached the final year probably possessed an inherent aptitude for medicine as opposed to the freshmen that contained a very diverse group of aptitudes. students cross the obstacles of medical school on the basis of their judgement skills. maturity is attained over a period of these years at medical colleges. thus, the discrepancy that is seen in these results may well be because of the sheer innateness of aptitude that students of final year possess. about 41% of the female students have the medical aptitude as opposed to 31% of the male students. our findings are consistent with those of other studies (6) that gender discrimination and segregation is still prevalent in the medical profession. but there are significant differences in perceptions between the genders (9). a number of females are breaking barriers and choosing a career that satisfies their conscience and works best with their abilities. aptitude and ability seem to be words that sound alike. however, there is an ocean of a difference between aptitude and ability. through work experience, a candidate may acquire the 'ability' to perform a role or fulfil a task. on the other hand, aptitude refers to possessing an innate potential or natural talent to complete a specific task, even if this talent has not developed to the fullest. this aptitude test was conducted to find out if there is any correlation between the aptitude of a person and their choice of career. the fact that a person shows a high aptitude in a particular field refers to the persons' ability to excel in that particular field. measuring the aptitude of students before choosing a career is now rapidly becoming popular. the choice of profession should be a decision that has been thought through and through with the guidance of parents and teachers (10). of paramount importance is the fact that students should not succumb to parental and peer pressures. thus undergoing an aptitude test prior to entering any profession can help students immensely. aptitude test can be used to narrow down the career options and also to give a head start to their careers (11). students are entering the medical profession while possessing an aptitude for other careers. parental counseling is equally important to sensitize parents about the fact that the aptitude of a child holds an important stand in deciding the career. girls perhaps because of their maternal instincts have a greater aptitude foe practicing medicine then the boys. as the time spent in the medical college increased the aptitude for the medical profession also increased. a good proportion of students become doctors despite having a below average command over the english language. peer group hardly influences the choice to choose the medical profession. impact: the study would make the students aware of their strengths and weaknesses. though aptitude for english language is lacking it poses no difficulty for the students but it would help the students if the teachers simplified the matters for them. teachers could assess the abilities of individual students and accordingly help them in the/those fields in which they have a weakness. and also encourage those fields in which they have a strong aptitude. 44 pjmsvolume 2 number 2: julydecember 2012 educational research acknowledgement: we thank the medical research unit of nkp salve institute of medical sciences for sponsoring this research. references: 1. bennett gk, seashore hg, wesman ag. the differential aptitude tests: an overview. the personnel and guidance j 1956; 35: 81-91. 2. middleton eb, loughead ta. parental influence on career development: an integrative framework for adolescent career counselling. journal of career development 1992; 3:161-173. 3. deridder l. the impact of parents and parenting on career development. comprehensive career development project 1990: 325. 4. penick n, jepsen d. family functioning and adolescent career development. career development quarterly 1992; 4: 208222. 5. csinady a, molnar r, hazag a. career choice motivations of medical students and some characteristics of the decision process in hungary. central european journal of medicine 2008; 3(4):494. 6. miller ds, slocombe te. preparing students for the new reality. college student journal 2012; 46(1): 18. 7. kaplan b, uner s. desirability of medicine as a profession in developing countries: the case of turkey. cah social demogr med 2010; 50(4): 517-28. 8. riska e. gender and medical careers. maturitas 2011; 68(3): 264-7. 9. eisenberg rl, yablon cm. career development for residents and beyond: filling the gaps. ajr 2011; 196(1): 6-7. 10. aptitude test may be fairer way of selecting medical school candidates. bmj 2012; newspaper article: 21. 11. clark d, miller k. “knife before wife”: an exploratory study of gender and the uk medical profession. journal of health organization and management 2008; 22(3): 238. 45 pjmsvolume 2 number 2: julydecember 2012 educational research page 45 page 46 page 47 page 48 page 49 panacea journal of medical sciences 2020;10(2):162–166 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article correlation between vitamin-d and calcium levels with severity of nail involvement in psoriasis: an observational study from northern india shikha khare1,*, tamal trivedi2 1dept. of dermatology, ndmc medical college & hindu rao hospital, new delhi, india 2dept. of medicine, pentamed hospital, new delhi, india a r t i c l e i n f o article history: received 16-07-2020 accepted 25-07-2020 available online 26-08-2020 keywords: calcium vitamin d nail psoriasis napsi a b s t r a c t introduction: psoriasis is a common chronic autoimmune inflammatory multisystem disease mainly involving skin, nails and joints. several studies have reported lower levels of vitamin d and calcium in psoriasis. but there is paucity of literature regarding levels of vitamin d and calcium in nail psoriasis. objective: to study the level of vitamin d and calcium in psoriasis patients with nail involvement and to correlate their levels with nail severity using nail psoriasis severity index (napsi). materials and methods: a total of 60 psoriasis patients with nail changes were recruited for the study. the severity of nail changes was calculated using nail psoriasis severity index (napsi). all non-specific nail changes which were present in the psoriasis patients were noted as well. apart from routine investigations, blood calcium level and serum vitamin d levels were also sent for investigation. results: majority of the participants were male with male: female ratio of 2.75:1. the mean age at of onset of nail involvement was 42.87 ± 17.19 years. about three-fourth of the patients were hypocalcaemic and vitamin d deficient or insufficient. there was a moderate negative correlation between napsi and blood calcium (mg/dl), and it was statistically significant (rho = -0.33, p = 0.011). there was a weak positive correlation between napsi and s. vitamin-d (ng/ml), and this correlation was not statistically significant (rho = 0.11, p = 0.402). however, on multivariate regression analysis of napsi, significant association was found between nail psoriasis severity index (napsi) with blood calcium level and serum vitamin d levels (p=0.01). conclusion: blood calcium and serum vitamin d levels were found low in patients of nail psoriasis. hence, oral vitamin d and calcium supplementation may aid in the earlier response to standard nail psoriasis treatment and further studies are required to prove the therapeutic effect of calcium and vitamin d in nail psoriasis. © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction psoriasis is a common chronic autoimmune inflammatory multisystem disease mainly involving skin, nails and joints. complex fine tuning and intricate interaction between cells of adaptive immune system (t helper lymphocytes that is th1, th17 and th22) and innate immune system (macrophages, dendritic cells) contribute to keratinocyte hyperproliferation and epidermal hyperplasia, skin inflammation and infiltration of t cells, dendritic cells, * corresponding author. e-mail address: drshikhakhare@gmail.com (s. khare). macrophages and neutrophils and also leads to dendritic cell maturation, acquired immune response amplification and t regulation inhibition. 1,2 the role of vitamin d in various autoimmune diseases (like systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, diabetes melitus, primary biliary cirrhosis) blaming the vitamin d receptor polymorphism in the pathogenesis of these autoimmune diseases has been suggested. 3 vitamin d receptors are also present in cells of immune lineages such as t lymphocytes, b lymphocytes, antigen presenting cells and synthesize active metabolite of vitamin d. vitamin d modulates innate and https://doi.org/10.18231/j.pjms.2020.034 2249-8176/© 2020 innovative publication, all rights reserved. 162 https://doi.org/10.18231/j.pjms.2020.034 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto:drshikhakhare@gmail.com https://doi.org/10.18231/j.pjms.2020.034 khare and trivedi / panacea journal of medical sciences 2020;10(2):162–166 163 adaptive immune response in an autocrine manner in local immunological environment. vitamin d inhibits b cell proliferation, t cell proliferation (leading to shift in th1 to th2 phenotype) and decreases the inflammatory th17 phenotype. besides, vitamin d also inhibits production of inflammatory cytokines by monocytes and also inhibits dendritic cells differentiation and maturation. 4 in innate immunity, vitamin d acts by triggering tolllike receptors on macrophages leading to induction of antimicrobial peptide cathelicidin. calcium and vitamin d have a very important role in growth, differentiation and metabolism of nail unit. in autoimmune diseases, apart from modulating immune responsive cells, vitamin d supplementations also aids in calcium homeostasis and absorption for growth and development of nails and bones. nail involvement is very common in psoriasis and can present in up to 92% patients. 5–12 specific nail changes in psoriasis includes nail bed signs (subungual hyperkeratosis, onycholysis, oil drop dyschromia and splinter haemorrhage) and nail matrix signs (pitting, crumbling, leuconychia and red spots in lunula). several studies have reported lower levels of vitamin d and calcium in psoriasis. 13–16 calcium and vitamin d have role in proper growth and differentiation of nail unit. but there is paucity of literature regarding levels of vitamin d and calcium in nail psoriasis. 2. objective to study the level of vitamin d and calcium in psoriasis patients with nail involvement and to correlate their levels with severity using nail psoriasis severity index (napsi). 3. materials and methods this cross-sectional study was conducted in 60 psoriasis patients with nail changes who were aged more than 18 years attending the outpatient department of dermatology. the duration of study was 3 months from 16th september 2019 to 15th december 2020. detail history was taken and all the 20 nails were thoroughly examined and photographed. the severity of nail changes was calculated using nail psoriasis severity index (napsi) where each nail is divided into 4 quadrants and scoring is done on the basis of presence of nail bed or nail matrix signs in each quadrant of the nail. so, the total score is 8 for 1 nail, 80 for all fingernails and 160 for both finger as well as toe nails. two different persons agreed on the napsi scoring of the patients. apart from nail signs which are specific for psoriasis and included in napsi scoring, all non-specific nail changes which were present in the psoriasis patients were also included and their frequency was noted. besides routine investigations, blood calcium level and serum vitamin d levels were sent as well. patients who were already on oral calcium and vitamin d supplementation, pregnant and lactating females or patients suffering from any other chronic disease which could affect calcium and vitamin d levels were excluded from our study. written and informed consent were obtained from all patients. patients were categorised as having normal calcium (blood calcium level ≥8.2 mg/dl) or having hypocalcaemia (blood calcium level <8.2 mg/dl). on the basis of serum vitamin d levels, they were categorised as vitamin d deficient (<20 ng/ml), insufficient (20–30 ng/ml) and having normal vitamin d (>30–100 ng/ml). after completion of the study the data was compiled and double checked in the statistical package for social sciences (spss 11.5, spss inc., chicago, il, u.s.a.). chi square test, student’s t-test and wilcoxon mann whitney u test were used to analyse the data. statistical significance was considered at p<0.05. 4. results we collected data of 60 psoriasis patients with nail changes. of these, majority that is 44 (77.3%) were males and 16 (22.7%) were females with male: female ratio of 2.75:1. the age of patients ranged from 18 to 85 years with mean age of 44.67 ± 16.81 years. the age at of onset of nail involvement in psoriasis ranged from 15 to 85 years with a mean of 42.87 ± 17.19 years. amongst specific nail signs included in napsi, the most frequent nail sign observed was subungual hyperkeratosis present in 44 (73.3%) patients, followed by onycholysis in 22 (36.6%), pitting in 32(53.3%), crumbling in 31 (51.6%), oil drop dyschromia in 16 (26.6%), splinter haemorrhage in 15 (25%), leuconychia in 5 (8.3%) patients. red spots in lunula was not present in any of the patients. apart from these, various non-specific signs were also prevalent, most common being longitudinal ridging found in 32 (53.3%) patients, followed by beau’s line in 13 (21.6%), clubbing in 4 (6.6%), onychodystrophy in 3 (5%), pterygium in 3 (5%), longitudinal melanonychia in 2 (3.3%) and koilonychia in 2 (3.3%) patients. the mean napsi was 38.03 ± 27.05 with range from 0 (in patients with nail signs not involved in napsi) to 99. of these, only 8 (13.3%) of the patients had napsi ≤10, while majority that is 52 (86.7%) patients had severe nail involvement having napsi >10. the blood calcium level ranged from 7.1 to 10.9 mg/dl with a mean of 9.26 ± 1.12 mg/dl. of these 16 (26.7%) were having normal calcium (≥8.2 mg/dl) while majority that is 44 (73.3%) were having hypocalcaemia (<8.2 mg/dl). the serum vitamin d levels of the patients ranged from 3.8 to 72 ng/ml with a mean of 24.65 ± 13.72 ng/ml. of these, 24 (40%) were vitamin d deficient (<20 ng/ml), 22 (36.7%) were vitamin d insufficient (20–30 ng/ml) and 14 (22.3%) were having normal vitamin d (>30–100 ng/ml). 164 khare and trivedi / panacea journal of medical sciences 2020;10(2):162–166 table 1: association between napsi ≤10 and >10 with calcium and vitamin d parameters napsi category p value ≤10(n = 8) >10(n = 52) blood calcium (mg/dl) 9.80 ± 0.87 9.18 ± 1.14 0.0691 blood calcium 0.0952 <8.2 mg/dl 0 (0.0%) 16 (30.8%) ≥8.2 mg/dl 8 (100.0%) 36 (69.2%) serum vitamin-d (ng/ml) 18.23 ± 8.73 25.63 ± 14.13 0.1671 serum vitamin-d 0.2722 <20 ng/ml 4 (50.0%) 20 (38.5%) 20-30 ng/ml 4 (50.0%) 18 (34.6%) >30 ng/ml 0 (0.0%) 14 (26.9%) ***significant at p<0.05, 1: wilcoxon-mann-whitney u test, 2: fisher’s exact test 4.1. association between napsi ≤10 and >10 with calcium and vitamin d (table 1) the mean blood calcium level in patients with napsi ≤10 was 9.80 ± 0.87 mg/dl and napsi>10 was 9.18 ± 1.14 mg/dl and it was not significant (w = 292.000, p = 0.069).). in patients with napsi ≤10, (100%) had blood calcium level <8.2 mg/dl while in patients with napsi>10, 16 (30.8%) patients had blood calcium <8.2 mg/dl while 36 (69.2%) patients had blood calcium ≥8.2 mg/dl and it was not significant (χ 2=3.357, p=0.095). the mean serum vitamin d level in patients with napsi ≤10 was 18.23 ± 8.73 mg/dl and napsi>10 was 25.63 ± 14.13 mg/dl and it was not significant ((w = 144.000, p = 0.167).). in patients with napsi ≤10, 4 (50%) patients were vitamin d deficient, 4 (40%) patients were vitamin d insufficient and none had normal vitamin d while in patients with napsi>10, 20 (38.5%) patients were vitamin d deficient, 18 (34.6%) patients were vitamin d insufficient and 14(26.9%) had normal vitamin d levels and it was not significant (χ 2=0.832, p=0.272). 4.2. correlation between napsi and blood calcium there was a moderate negative correlation between napsi and blood calcium (mg/dl), and this correlation was statistically significant (rho = -0.33, p = 0.011). for every 1-unit increase in napsi, the blood calcium (mg/dl) decreases by 0.01 units. 4.3. comparison of calcium <8.2 mg/dl and ≥8.2 mg/dl in terms of napsi the mean napsi in the s. calcium: <8.2 mg/dl group was 47.38 ± 23.80 and in the serum calcium: ≥8.2 mg/dl group was 34.64 ± 27.60. there was a significant difference between the 2 groups in terms of napsi (w = 472.000, p = 0.045). 4.4. comparison of vitamin d deficiency/insufficiency in terms of napsi the mean napsi in the vitamin d deficient group was 37.08 ± 23.36, in the vitamin d insufficient group was 29.36 ± 23.06 and in patients having normal vitamin d was 53.29 ± 33.40 and it was not significant (p=0.086). 4.5. correlation between napsi and serum vitamin-d (ng/ml) there was a weak positive correlation between napsi and s. vitamin-d (ng/ml), and this correlation was not statistically significant (rho = 0.11, p = 0.402). 4.6. correlation between s. calcium (mg/dl) and s. vitamin-d (ng/ml) there was a weak positive correlation between s. calcium (mg/dl) and s. vitamin-d (ng/ml), and this correlation was statistically significant (rho = 0.29, p = 0.023). for every 1-unit increase in s. calcium (mg/dl), the s. vitamin-d (ng/ml) increases by 3.96 units. 4.7. napsi univariate and multivariate regression on univariate analysis, no correlation was found between napsi and age of psoriasis patients, age of onset of nail involvement and blood calcium levels. positive correlation was found between napsi and male gender, serum vitamin d levels (p<0.05) (table 2). on multivariate regression analysis of napsi with only selected variables in model, there was significant association between napsi and male gender, blood calcium level and serum vitamin d levels (p<0.05) (table 3). 5. discussion since ages we have utilised the beneficial effect of vitamin d production in skin by sunlight in psoriasis treatment. there is a possible bidirectional relationship between lower levels of vitamin d and psoriasis. 14 various vitamin d khare and trivedi / panacea journal of medical sciences 2020;10(2):162–166 165 table 2: univariate analysis of napsi dependent: napsi unit value total p age (years) [18.0,85.0] mean (sd) 38.0 (27.0) 60 (100.0) 0.299 gender male mean (sd) 32.5 (22.9) 44 (73.3) 0.007 female mean (sd) 53.4 (32.0) 16 (26.7) age of onset (years) [8.0,83.0] mean (sd) 38.0 (27.0) 60 (100.0) 0.885 blood calcium (mg/dl) [7.1,10.9] mean (sd) 38.0 (27.0) 60 (100.0) 0.119 serum vitamin d (ng/ml) [3.8,72.0] mean (sd) 38.0 (27.0) 60 (100.0) 0.009 table 3: regression of napsi with selected variables in model dependent: napsi unit value coefficient (univariable) coefficient (multivariable) age (years) [18.0,85.0] mean (sd) 38.0 (27.0) 0.22 (-0.20 to 0.64, p=0.299) gender male mean (sd) 32.5 (22.9) female mean (sd) 53.4 (32.0) 20.92 (5.96 to 35.88, p=0.007) 22.76 (9.03 to 36.50, p=0.002) age of onset (years) [8.0,83.0] mean (sd) 38.0 (27.0) 0.03 (-0.43 to 0.49, p=0.885) blood calcium (mg/dl) [7.1,10.9] mean (sd) 38.0 (27.0) -4.90 (-11.09 to 1.30, p=0.119) -10.36 (-15.99 to -4.72, p=0.001) serum vitamin d (ng/ml) [3.8,72.0] mean (sd) 38.0 (27.0) 0.66 (0.17 to 1.14, p=0.009) 0.77 (0.32 to 1.23, p=0.001) model fit: f (3,56) = 9.94, p = <0.001 number in dataframe = 60, number in model = 60, missing = 0, log-likelihood = -269.68aic = 549.4, r-squared = 0.35, adjusted r-squared = 0.31 receptor polymorphism have been shown to affect the skin barrier and development of psoriatic lesions. 15 there is also decreased expression of vitamin d receptor in psoriatic skin. 17 vitamin d analogues have been used very frequently as first line modality in the treatment of psoriasis. many studies have depicted lower levels of vitamin d in psoriasis. 18–20 in our study also, vitamin d levels were found low with mean of 24.65 ± 13.72 ng/ml in psoriasis patients with nail involvement with more than three-fourth of the patients being either vitamin d insufficient or vitamin d deficient. vitamin d levels also significantly correlated with severity of nail psoriasis measured via napsi on multivariate analysis (p=0.001). hypocalcaemia is known risk factor for severe psoriasis, pustular psoriasis and erythrodermic psoriasis. in our study, the mean blood calcium was 9.26 ± 1.12 mg/dl and around three-fourth of the patients were hypocalcaemic. there was a moderate negative correlation between napsi and blood calcium (mg/dl), and this correlation was statistically significant (rho = -0.33, p = 0.011). several other studies have also shown calcium levels to be low in patients of psoriasis. 21,22 to the best of our knowledge, no study has been done regarding levels of vitamin d and calcium in nail psoriasis. this study highlights the deficiency of vitamin d and calcium in nail psoriasis and how this deficiency correlates with the severity of nail involvement in psoriasis. 6. conclusion blood calcium and serum vitamin d levels were found low in patients of psoriasis. hence, oral vitamin d and calcium supplementation may aid in the earlier response to standard nail psoriasis treatment and further studies are required to prove the therapeutic effect of calcium and vitamin d in nail psoriasis. 7. source of funding none. 8. conflict of interest none. references 1. cai y, fleming c, yan j. new insights of t cells in the pathogenesis of psoriasis. cell mol immunol. 2012;9:302–9. 2. schon mp. adaptive and innate immunity in psoriasis and other inflammatory disorders. front immunol. 2019;10:1764. 3. agmon-levin n, theodor e, segal rm, shoenfeld y. vitamin d in systemic and organ-specific autoimmune diseases. clin rev allergy immunol. 2013;45(2):256–66. 4. aranow c. vitamin d and the immune system. j investig med. 2011;59(6):881–6. 166 khare and trivedi / panacea journal of medical sciences 2020;10(2):162–166 5. lewin k, wit sd, ferrington ra. pathology of the fingernail in psoriasis. br j dermatol. 1972;86(6):555–63. 6. de jong emgj, seegers bampa, gulinck mk, boezeman jbm, van de kerkhof pcm. psoriasis of the nails associated with disability in a large number of patients: results of a recent interview with 1,728 patients. dermatol. 1996;193(4):300–3. 7. feldman sr, koo jym, menter a, bagel j. decision points for the initiation of systemic treatment for psoriasis. j am acad dermatol. 2005;53(1):101–7. 8. agrawal s, garg vk, agarwalla a, shyangwa pm. psoriasis in eastern nepal: clinical profile and patient’s beliefs about the disease. indian j dermatol. 2003;48:78–82. 9. jiaravuthisan mm, sasseville d, vender rb, murphy f, muhn cy. psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. j am acad dermatol . 2007;57(1):1–27. 10. augustin m, reich k, blome c, schäfer i, laass a, radtke ma. nail psoriasis in germany: epidemiology and burden of disease. br j dermatol. 2010;163(3):580–5. 11. brazzelli v, carugno a, alborghetti a, grasso v, cananzi r, fornara l, et al. prevalence, severity and clinical features of psoriasis in fingernails and toenails in adult patients: italian experience. j eur acad dermatol venereol. 2012;26(11):1354–9. 12. shrestha dp, gurung d. psoriasis: clinical and epidemiological features in a hospital based study. nepal j dermatol, venereol leprol. 2012;10(1):41–5. 13. cubillos s, norgauer j. low vitamin d-modulated calcium-regulating proteins in psoriasis vulgaris plaques: s100a7 overexpression depends on joint involvement. int j mol med. 2016;38(4):1083–92. 14. barrea l, savanelli mc, somma cd, napolitano m, megna m, colao a, et al. vitamin d and its role in psoriasis: an overview of the dermatologist and nutritionist. rev endocr metab disord. 2017;18(2):195–205. 15. richetta ag, silvestri v, giancristoforo s, rizzolo p, d’epiro s, graziano v, et al. a-1012g promoter polymorphism of vitamin d receptor gene is associated with psoriasis risk and lower allelespecific expression. dna cell biol. 2014;33(2):102–9. 16. soleymani t, hung t, soung j. the role of vitamin d in psoriasis: a review. int j dermatol. 2015;54(4):383–92. 17. visconti b, paolino g, carotti s, pendolino al, morini s, richetta ag, et al. immunohistochemical expression of vdr is associated with reduced integrity of tight junction complex in psoriatic skin. j eur acad dermatol venereol. 2015;29(10):2038–42. 18. gisondi p, rossini m, cesare ad, idolazzi l, farina s, beltrami g, et al. vitamin d status in patients with chronic plaque psoriasis. br j dermatol. 2012;166(3):505–10. 19. orgaz-molina j, buendía-eisman a, arrabal-polo ma, ruiz jc, arias-santiago s. deficiency of serum concentration of 25hydroxyvitamin d in psoriatic patients: a case-control study. j am acad dermatol. 2012;67(5):931–8. 20. zaher haem, el-komy mhm, hegazy ra, khashab hame, ahmed hh. assessment of interleukin-17 and vitamin d serum levels in psoriatic patients. j am acad dermatol. 2013;69(5):840–2. 21. chaudhari s, rathi s. correlation of serum calcium levels with severity of psoriasis. int j res dermatol. 2018;4(4):591–4. 22. morimoto s, yoshikawa k, fukuo k, shiraishi t, koh e, imanaka s, et al. inverse relation between severity of psoriasis and serum 1,25dihydroxyvitamin d level. j dermatol sci. 1990;1(4):277–82. author biography shikha khare senior resident tamal trivedi consultant cite this article: khare s, trivedi t. correlation between vitamin-d and calcium levels with severity of nail involvement in psoriasis: an observational study from northern india. panacea j med sci 2020;10(2):162-166. introduction objective materials and methods results association between napsi 10 and >10 with calcium and vitamin d (table 1) correlation between napsi and blood calcium comparison of calcium <8.2 mg/dl and 8.2 mg/dl in terms of napsi comparison of vitamin d deficiency/insufficiency in terms of napsi correlation between napsi and serum vitamin-d (ng/ml) correlation between s. calcium (mg/dl) and s. vitamin-d (ng/ml) napsi univariate and multivariate regression discussion conclusion source of funding conflict of interest 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2020;10(3):194–196 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article effect of ltot on pasp in patients with pulmonary hypertension due to chronic lung disease karthikeyan g1,*, chinnusamy k2, kavin mani salai1 1dept. of respiratory medicine, kmch institute of health sciences and research, coimbatore, tamil nadu, india 2dept. of general medicine, kmch institute of health sciences and research, coimbatore, tamil nadu, india a r t i c l e i n f o article history: received 07-07-2020 accepted 10-08-2020 available online 29-12-2020 keywords: ltot pasp. a b s t r a c t aims and objectives: to study the response to ltot in patients with pulmonary hypertension due to chronic lung disease. materials and methods: this retrospective study was carried out in a tertiary health care centre. patients with copd, post tb oad and ild who were on ltot were included in the study. records of these patients were reviewed and was analysed. results: retrospective study of 41 patients who were on ltot was done. out of 41 patients 18 were post tb oad, 12 were copd and 11 were ild. average duration of ltot/day was 16hrs and the average drop in pasp was 3.2mm hg/yr. the average duration of ltot/day in post tb oad, copd, ild patients were 16.2,14.8,16.8hrs and average drop in pasp in mm hg/yr was 3.5,2.5 and 3.4 respectively. discussion: response to ltot is better seen in post tb oad and ild than copd, leading to hope of quality of life improvement. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction patients with chronic lung disease with hypoxemia have poor prognosis in spite of treatment regimens that are aimed at improving lung function. because of this, such patients are often treated with supplemental oxygen on outpatient basis. but there is lack of knowledge to the response to supplemental oxygen therapy. hence this study was undertaken in a tertiary health care centre to assess the response of ltot on pasp in patients with pulmonary hypertension due to chronic lung disease. 2. materials and methods this retrospective study was carried out in a tertiary health care centre. patients with copd, post tb oad and ild who were on ltot were included in the study. records of patients with copd, post tb oad and ild who were * corresponding author. e-mail address: karthikeyan.g10@gmail.com (karthikeyan g). on ltot were reviewed. details of 2d echo findings 1yr apart, l/min of ltot and duration of ltot/day were obtained from the records and was analysed. 3. results retrospective study of 41 patients who were on ltot was done in whom 2d echo was done 1 year apart. out of 41 patients 18 were post tb oad,12 were copd and 11 were ild. among 41 patients, 5 were taking ltot < 14 hrs/day, 9 were taking 14-16 hrs/day, 23 were taking 16-18 hrs/day, 4 were taking for 18-20 hrs/day.27 patients were using ltot for > 17 hrs/day. the average drop in pasp in post tb oad, copd, ild patients were 3.5,2.5 and 3.4mm hg/yr respectively. drop in pasp by 5 mm hg/yr was noted in patients who have used ltot for 18-20hrs/day followed by 4.1 and 3.2mm hg/yr who have used ltot for 16-18hrs and 1416hrs/day respectively. patients who were using ltot for < https://doi.org/10.18231/j.pjms.2020.042 2249-8176/© 2020 innovative publication, all rights reserved. 194 https://doi.org/10.18231/j.pjms.2020.042 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:karthikeyan.g10@gmail.com https://doi.org/10.18231/j.pjms.2020.042 karthikeyan g, chinnusamy k and salai / panacea journal of medical sciences 2020;10(3):194–196 195 fig. 1: post tb, oad and copd fig. 2: duration of ltot/day fig. 3: 14hrs/day did not show a significant drop in pasp. 4. discussion retrospective data of 41 patients who were on ltot were reviewed and analysed. among 41 patients, 27 patients were using ltot for > 17 hrs/day (fig-ii). the nott(nocturnal oxygen therapy trial) and mrc(medical research council) trial showed considerable survival benefits and drop in pulmonary artery pressures by 4 mm hg in patients who fig. 4: took ltot for more than 16 hrs/day. 1,2 in our study the average duration of ltot/day was 16hrs and the average drop in pasp was 3.2mm hg/yr. in a study by emmanuel et al, ltot reverse the progression of pulmonary hypertension in patients with copd. 3 in a similar study by omar et al, ltot improves pulmonary hypertension which in turn improves quality of life in copd patients. 4 the average duration of ltot/day in post tb oad, copd, ild patients were 16.2,14.8,16.8hrs and average drop in pasp in mm hg/yr was 3.5,2.5 and 3.4 respectively (fig-iii). drop in pasp by 5mm hg/yr was noted in patients who have used ltot for 18-20hrs/day followed by 4.1 and 3.2mm hg/yr who have used ltot for 16-18hrs and 1416hrs/day respectively. patients who were using ltot for < 14hrs/day did not show a significant drop in pasp (figiv). greater the duration of hours of ltot/day, more is the drop in pasp.2response to ltot is better seen in post tb oad and ild than copd. in this study the duration of ltot(14.8hr/day) in copd patients are less when compared to post tb oad and ild, hence further studies are needed for proper assessment of response to ltot in copd patients. 5. conclusion there is a definite drop in pasp of 3.2mm hg/yr with ltot usage of 16hrs/day. the average drop in pasp in post tb oad, copd and ild were 3.5, 2.5 and 3.4mm hg/yr respectively. patients who were using ltot for < 14hrs/day did not show a significant drop in pasp. greater the duration of hours of ltot/day, more is the drop in pasp. 6. abbreviations 1. ltot-long term oxygen therapy 2. pasp-pulmonary artery systolic pressure 3. posttb oad-post tb obstructive airway disease 4. copd-chronic obstructive pulmonary disease 5. ild-interstitial lung disease. 196 karthikeyan g, chinnusamy k and salai / panacea journal of medical sciences 2020;10(3):194–196 7. source of funding none. 8. conflict of interest the authors declare they have no conflict of interest. references 1. medical research council working party. long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: report of the medical research council working party. lancet. 1981;1:681–6. 2. continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung diseases:a clinical trial. ann intern med. 1980;93:391– 8. 3. weitzenblum e, sautegeau a, ehrhart m. long-term oxygen therapy can reverse the progression of pulmonary hypertension in patients with chronic obstructive pulmonary disease; 2005. 4. minai oa, chaouat a, adnot s. pulmonary hypertension in copd: epidemiology, significance, and management: pulmonary vascular disease: the global perspective; 2010. author biography karthikeyan g, assistant professor chinnusamy k, associate professor kavin mani salai, senior resident cite this article: karthikeyan g, chinnusamy k, salai km. effect of ltot on pasp in patients with pulmonary hypertension due to chronic lung disease. panacea j med sci 2020;10(3):194-196. introduction materials and methods results discussion conclusion abbreviations source of funding conflict of interest julydecember 2012 pdf for website comparative study of morphology and histology of human and buffalo tongue 1 2 3 fulse anant , dehankar r , ksheersagar d abstract: the present study was carried out to assess the comparative gross morphology and histology of mammalian tongues with buffalo tongue with special reference to the distribution of papillae.10 cadaveric tongues of human and 10 from buffalo (with tissue from anti 2/3, sulcus terminalis, lateral area, post. 1/3 pharyngeal & at the root areas of the tongue were taken for histological studies. all the samples were fixed in bouin's fluid. after paraffin-embedding, 5-7 micron thick were cut and mounted serially & stained with h & e stain. in buffalo, the anterior part of the tongue was longer. intermolar eminence was present in the tongue of buffalo. the dorsum of human tongue was divided into an anterior (oral) part and a posterior (pharyngeal) part. the length of oral part was double than the pharyngeal part. the various papillae were noted in human and buffalo. all of the circumvallate, foliate papillae and most of the fungiform papillae bore taste buds. keywords: human tongue, papillae, intermolar eminence, sulcus terminalis, bouin's fluid. introduction: the tongues of mammals share certain important characteristics, but there are also important differences. it varies in form and size and demonstrates morphological diversity that is greatly influenced by feeding habits (1). the dorsal surface of the oral part shows four types of papillae: filiform, fungiform, circumvallate and foliate papillae. filiform, lenticular and conical papillae possess a protective and mechanical function. the fungiform, foliate and vallate papillae are related to taste perception. in man foliate papillae are rudimentary, but in many animals they are the site of localization of the main aggregation of taste receptor (2, 3). the taste buds are ellipsoid clusters of specialized epithelial cells embedded in the stratified squamous epithelium of fungiform, circumvallate and foliate papillae of tongue. glands of the tongue can be divided into three main groups according to their structure and location (4). aims & objectives: to study the comparative gross morphology, characteristic features and the histological pattern of mammalian tongue, with special reference to the distribution of papillae. materials & method: after institutional ethical committee approval, tongues of mammals were obtained from nagpur veterinary college while human cadaveric tongues were obtained from donated cadavers to department of anatomy, nkpsims&rc, nagpur. all the specimens were collected within 2 to 6 hours after death of the animals.10 cadaveric tongues of human and buffaloes were obtained. tissue from anterior 2/3, sulcus terminalis, lateral area, posterior 1/3 pharyngeal & at the root areas of the tongue were taken for histological studies. all the samples were fixed in bouin's fluid. after paraffin-embedding, 5-7 micron thick sections were cut and mounted serially & stained with h & e stain. observations: buffalo tongue: anterior oral part found to be four times longer than the posterior pharyngeal part. filiform & fungiform papillae were observed anterior to torus linguae (fig. 1) .giant conical papillae on the torus linguae and simple conical papillae were on the sides of the giant conical papillae whereas circumvallate papillae found on the posterior limit of the torus linguae, 13-20 on either sides (fig.2). buffalo tongue showed mucous acini in pharyngeal part (fig. 3). dorsum of the pharyngeal part was smooth and unpapillated. ventral surface was unpapillated & showed frenulum linguae. human tongue: the dorsum of the tongue found to be divided into anterior (oral) part and a posterior (pharyngeal) part by a v-shaped sulcus terminalis. the length of oral part was two times the pharyngeal part. the dorsum of the oral part was covered by different types of lingual papillae. these included filiform, fungiform and circumvallate and foliate papillae (fig. 4). filiform & fungiform papillae were present in anterior oral part and circumvallate papillae were observed on sulcus terminalis where as two foliate papillae found in front of the palatoglossal fold (fig. 5). human tongue showing mucous glands in pharyngeal part and apical lingual glands (glands of nuhn) in anterior part (fig. 6). discussion: division of the tongue into anterior and posterior parts seems to vary from one species to another. according to labh and mitra (5) the anterior (oral) part is longer than the posterior (pharyngeal) part in various species of mammals. in 15 1 2 assistant professor, associate 3 professor, professor, department of anatomy nkpsims & rc, digdoh hills, hingna road, nagpur -440019. anantfulse@gmail.com pjmsvolume 2 number 2: julydecember 2012 original article fig 1dorsal surface of buffalo tongue fig 2. photomicrographs of buffalo tongue showing lingual papilla (h&e stain) . (a) papilla filiformis (b) fungiform (c) circumvallate papilla (d) simple conical (e) giant conical (f) circumvallate papilla trench mucous acini fig 3. photomicrograph of buffalo tongue showing mucous acini in pharyngeal part. x10 (h&e) fig 4dorsal surface of human tongue fig 5photomicrographs of human tongue showing lingual papilla x10 (h &e) (a) filiform papilla (b) fungiform papilla (c) circumvallate papilla fig 6. photomicrographs of human tongue showing lingual glands x10 (h & e) (a) mucous glands in pharyngeal part (b) apical lingual glands (glands of nuhn) buffalo it is 4:1. the same is observed here. the larger proportion of the oral part in the animal series might be due to greater mobility required for grasping of food (5, 6). in human being this ratio is 2: 1, which is similar with the other workers' studies (7-10).in all the samples of human tongue, the sulcus terminalis is well defined forming a vshaped line, arms of which are directed antero-laterally as described by bloom and fawcett. in buffalo, it was not found in any of the samples, which is similar to the findings of labh and mitra (5). intermolar eminence was found on the posterior aspect of the oral part of tongue in buffalo described that the oral part of the dorsum is marked posteriorly by a raised intermolar eminence or torus linguae (11).kutuzov and sicher (12) and labh and mitra (5) believed that this specialized prominence probably compensates for the deficient masticatory mechanism caused by incomplete dental formula (12, 5). thus it may help to rub the food against hard palate. human do not possess this eminence. in human samples the dorsum of the oral part is densely beset with the thread like narrow, conical filiform papillae. these findings are similar with the gray (10). filiform papillae have been classified in three subtypes by differing structure and distribution on the 16 pjmsvolume 2 number 2: julydecember 2012 original article dorsum. these are simple conical, giant conical and true filiform papillae. prakash et al (11) described them in buffalo tongue as lenticular papillae on the torus linguae. the fungiform papillae are scattered on the dorsum of the tongue, but are found to be aggregated at the tip and cranial margins of buffalo tongue. prakash et al (11) described them in buffalo tongue that they are more numerous around the tip and on the lateral cranial margin. they also scattered on the rest of the dorsum including torus linguae. the fungiform papillae in human tongue are scattered among the filiform papillae, which are more numerous at the tip and margins (7,8,10). in this study similar findings are obtained as mentioned by these workers. the number of circumvallate papillae varies from species to species. in buffalo, we observed 13-22 circumvallate papillae on each side and are arranged in a v-shaped pattern on the caudo-lateral part of torus linguae with the apices of the v directed towards the root of the tongue. the numbers of circumvallate papillae in human tongue are variable. they are about 7 to 12; 6 to 12; 8 to 12 and form a v-shaped row immediately in front of the sulcus terminalis (7, 9 &10). in the present study, the circumvallate papillae show great variations in their number and distribution. in human 8 to 10 circumvallate papillae are arranged in v-shaped pattern with the apex directed posteriorly. conclusion: from the given observation we can conclude that the anterior part of the tongue is longer than posterior, in buffalo it is found to be 4:1 and in human it is 2:1. intermolar eminence is present in the tongue of buffalo while it is absent in human. three subtypes of filiform papillae have been noted in buffalo tongue. these are simple conical, giant conical and true filiform papillae. circumvallate papillae in buffalo tongue form row on the posterolateral part of the intermolar eminence. foliate papillae are rudimentary in human, absent in buffalo tongue. all of the circumvallate, foliate papillae (except humans) and fungiform papillae bear taste buds. serous glands are present in the oral part of the tongue, while mucous glands are present in the pharyngeal part. apical lingual gland is present in human tongue. references: 1. hiiemae km, crompton aw. mastication, food transport and swallowing in functional vertebrate morphology. harvard university press 1985; 262–290. 2. guimaraes gc, miglino ma. anatomic study & distribution of the vallate papillae in domestic cats. brezj vetres anim sci 2007;44: 82-88. 3. sonntage cf. the comparative anatomy of the tongue of the mammalian x rodentia. proc zool soc 1924; 2:725-743. 4. jung hs, akita p. spacing patterns on tongue surface –gustatory papilla. int j dev biol 2004; 48:157-161. 5. labh pn, mitra nl. a comparative histological study of mammalian tongue. j anat soc of india 1967; 16:106-116. th 6. sisson sbs. in anatomy of the domestic animals, 4 edition london: w.b. saunders and co. 1965: 501. th 7. ham aw. histology, 6 edition, jb. lippincott company, philadelphia and toronto 1969: 654-655. th 8. bloom w, fawcett d. a textbook of histology, 10 edition, saunders company, philadelphia london 1975: 601. th 9. padykula ha. histology 4 edition, by leon weiss and roy o. greep, mc graw hill book company 1977: 644-651. 10. gray h. gray's anatomy, 37th edition 1993; churchill livingstone 1993: 1319-1322. 11. prakash p, rao gs. anatomical and neurohistological studies on the tongue of the indian buffalo (bubalus bubalis). acta anat 1980; 107: 373-383. 12. kutuzov h, sicher h. anatomy and functions of the palate in white rat . anat rec 1993; 114: 67-84. 17 pjmsvolume 2 number 2: julydecember 2012 original article page 19 page 20 page 21 backup_of_final panacea jan to jun 2013 for pdf the anthropometric study of mandible in maharashtra 1 2 3 chimurkar v ,nikamp , chimurkar l the anthropometric study of mandible is important for individual identity like age, sex, stature, race etc. the knowledge of different measurements on mandible is also important to the dental surgeons in maxillofacial surgeries, reconstructive surgery of mandible and plastic surgery of face. in the present study, 280 cadaver mandibles including 200 male and 80 female mandibles were studied. we have measured the mandibular body height at second molar, height of the left ramus, mandibular ramus height up to incisura mandibularis with the help of spreading calliper (vernier). the observed values of males were compared with female mandibles for sexual dimorphism on the basis of percentage beyond demarking point; these parameters were found to be very useful in sex determination. keywords : anthropometry, mandible, ramus. 1 2 associate professor, associate professor, 3 assistant professor, dept. of anatomy jawaharlal nehru medical college, sawangi (meghe), wardha. drchimurkarvk@rediffmail.com abstract: anthropometry is an advanced branch in research field where the study of human skeleton is carried out to establish individual identity like sex, age, stature, race, etc (1-3). anthropometry helps us to know the developmental and functional changes in the human body. anthropometric study also helps us to know the morphological variations and the asymmetry of bone. traditionally the skull is a single most bone studied in physical anthropology. the main objective of human as well as primate skulls is studied by means of exact measurement(4,5). for sexing of mandibles, the dimensional methods are better than the descriptive features with anatomical basis. the human mandible has always been a difficult bone to determine sex confidently by nearly looking at the usual morphological features(6). variability in the technique and landmarks used by previous workers necessitated the detail study on mandible. the knowledge of different measurements on mandible is also important to the dental surgeons in maxillofacial surgeries, reconstructive surgery of mandible and plastic surgery of face(7). with the above aim in the present study, we tried to minimize errors by repeating the observations on two separate occasions. introduction : after obtaining institutional ethics committee approval, 280 cadaver mandibles of maharashtra zone were studied, out of that 200 were males and 80 females. the mandibles and instruments required for this research were used from the dissection hall. all mandibles used for the study were of adults above 20 years of age. the fractured, fragmented bones were discarded and only the complete intact mandibles were used for the measurements. material and method : technique of taking mandibular measurements : technique of taking mandibular measurements and landmarks on the bone was taken from books on practical anthropometry by various authors (8-10) and the figure 1: vernier callipers for mandibular measurement measurements were taken with the help of spreading vernier calliper (fig. 1). the bony points were first localized and then the measurements repeated twice on the two separate occasions and the mean was taken to get accurate results and then recorded. a straight distance between two bony points was measured (fig. 2). as per method, the demarking points were obtained by calculated range which was worked out by adding and subtracting ±3 sd to the mean value of each parameter. figure 2: various mandibular measurements pjmsvolume 3 number 1: january-june 2013 original article 24 table i: statistical analysis of mandibular body height at m2 detailed measurements male female no. of bones 200 80 range (mm) 19-30 16-26 mean (mm) 24.93 21.12 s.d. 2.36 1.95 i.p. 26 19 % of identified bones 28% 7.5% calculated range (mm ) 17.85 15.27 mean ± 3 s.d.(mm) 32.01 26.97 d.p. 26.97 17.85 % beyond d.p. 28% 2.5% it is seen from the table i that the mean mandibular height at m2 of male mandibles was 24.93mm and that of females was 21.12mm. there is quite an overlap between male and female values, the calculated range for male (±3 sd) being 17.85mm32.01mm and for female 15.27mm 26.97mm. on the basis of demarking point, 28% male and 2.5% female mandibles could be accurately sexed. so this parameter is of some value for sexual dimorphism of human skeleton. table ii: statistical analysis of height of the left ramus of mandible detailed measurements male female no. of bones 200 80 range (mm) 48-70 45-62 mean (mm) 62.49 51.78 s.d. 4.82 3.58 i.p. 61 50 % of identified bones 55% 20% calculated range 48.03 41.31 mean ±3 s.d.(mm) 76.95 62.52 d.p. 60.71 49.15 % beyond d.p. 64% 20% it is seen from the table ii that the mean height of the left ramus of male mandibles was 62.49mm and that of females 51.78mm. there is quite an overlap between male and female values, the calculated range for male (±3 sd) being 48.03-76.95mm and for female 41.31-62.52mm. on the basis of demarking point, 64% male and 20% female mandibles could be accurately sexed. so this parameter is of some value for sexual dimorphism of human skeleton. table iii: statistical analysis of mandibular ramus height upto incisura mandibularis detailed measurements male female no. of bones 200 80 range (mm) 36-57 34-48 mean (mm) 49.53 39.58 s.d. 4.04 3.52 i.p. 48 36 % of identified bones 66% 12.5% calculated range (mm) 37.41 29.02 mean ±3 s.d.(mm) 61.65 50.14 d.p. 50.14 37.41 % beyond d.p. 46% 27.5% it is seen from the table iii that the mean mandibular ramus height up to incisura mandibularis in males was 49.53mm and that of females 39.58mm. there is quite an overlap between male and female values, the calculated range for male (±3 sd) being 37.41mm61.65mm and for female 29.02mm50.14mm. on the basis of demarking point, 46% male and 27.5% female mandibles could be accurately sexed. so this parameter is of some value for sexual dimorphism of human skeleton. discussion : for sexing of skulls dimensional methods are better than the descriptive features with anatomical basis. sex identification of skeletal material is of prime importance in anthropometry and is of vital concern in medicolegal cases. the statistical analysis of 3 measurements of adult 280 unknown mandibles were differentiated on the basis of the appearance of muscular marking, size of mandible, evertion and inversion of gonial angles and presence and absence of ramal flexture on the posterior border of ramus at occlusal plain (7). as per hardlicka (8), the muscular markings are prominent in males than in females and size of mandible is larger in males than in females. for medicolegal purpose, in determination of sex, 100% accuracy is required. maximum and minimum limits of parameter values determined on the basis of mean ±3 sd which is named demarking point (d.p). there is considerable overlap between male and female values of a particular measurement, so difficulty arises in discriminating them on that measurement basis. the maximum and minimum measurements in this overlapping zone have been named as identification points (i.p.) (5,11). the calculated range for 100% accuracy is measured by mean ± 3 sd. on the basis of dp, 28% male and 2.5% female mandibles could be sexed with 100% accuracy (table i), 64% male and 20% female mandibles could be sexed with 100% accuracy (table ii), and 46% male and 27.5% female mandibles could be sexed with 100% accuracy (table iii). hardlicka a claimed to be pjmsvolume 3 number 1: january-june 2013 original article 25 references : 1) atasever n, enacar a, basar r, uzel i. the study of the relationship between the face type and condyle morphology. turk ortodontiderg1990; 3(1): 24-31. 2) harneja nk. metrical features of mandible rajasthan zone. journal of the anatomical society of india 1977: 68-69. 3) caldwell jb, letterman gs. vertical osteotomy in the mandibular rami for correlation of prognathism. j oral surg 1954; 12(3): 185-202. 4) anagnostopoulou s, veneiratos d. quantitative method for classification of human mandibular condyles. acta anat 1986; 127(3):201-204. 5) ashley mf. a study of man embracing errors. technology able to make correct sex identification in 80% cases, this increased to 90% when the lower jaw is present (8). variability in the techniques and landmarks used by previous workers necessitated the detailed study of mandible. review 1947; l49(6):345-362. 6) hill ca. technical note: evaluating mandibular ramus flexure as a morphological indicator of sex. am jour of phys anthropo 2000; 111:573-577. 7) alling cc. mandibular prognathism. oral surg 1961;14 ( suppl.1): 3-22. 8) hardlicka a. practical anthropometry, wister institute philadelphia, 2nded (3rd ed.) by t.d. steward: 1947. 9) morant gm. a biometric study of human mandible. biometrica 1936; 28:84-112. 10) usta a, kuran i, yuceyaltirik a, ozcan h. the measurements of some anthropometric landmarks of the mandible. okajimas folia anat jpn. 1996 aug;73(2-3):151-4. 11) furuta y, sakurada m, fukuda k, koizumi a. morphological studies on indian mandibles: exterior of the mandibular ramus and interior of the mandibular ramus.shiqaku1983; 70(6):1255-67. pjmsvolume 3 number 1: january-june 2013 original article 26 page 28 page 29 page 30 panacea journal of medical sciences 2020;10(2):135–138 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article study of pre analytical errors in clinical biochemistry laboratory in rural area of punjab saloni1,*, neha mittal2 1dept. of biochemistry, pgimer satellite centre, sangrur, punjab, india 2dept. of microbiology, pgimer satellite centre, sangrur, punjab, india a r t i c l e i n f o article history: received 10-06-2020 accepted 22-06-2020 available online 26-08-2020 keywords: pre-analytical errors clinical biochemistry laboratory quality management a b s t r a c t introduction: the pre analytical phase is an important component of laboratory medicine. it includes the time from the order of test by the clinician until the sample is ready for analysis – it can account up to 70% of errors during the total diagnostic process. the major 5 key components for the establishment of quality and reliability in the laboratory diagnostics include (a) quality laboratory process (qlps), (b) quality control(qc), (c) quality assurance/assessment (qa), (d) quality improvement (qi) and (e) quality policy(qp). objectives: 1. to stratify the pre-analytical errors documented during pre analytical testing process; 2. to formulate the possible corrective measures to be taken to minimise such errors. materials and methods: a prospective study was done for a period of 6 months from 1st august 2019 to 31st jan 2020 in clinical biochemistry laboratory of pgimer satellite centre, sangrur. all types of pre-analytical errors were recorded. in our study, total blood specimens received during aug 2019 to jan 2020 were 2980. out of which 284 specimens were sorted with pre analytical errors. results: these 284 specimens were categorised as follows: improper request form (n= 24); improper labelling (n=39); improper tube collection (n=51); insufficient sample n=48); in-vitro haemolysis (n=66), sample not received(snr) (n=56). conclusion: pre-analytical errors are not inevitable and can be avoided with a diligent application of proper quality control, proper education of phlebotomist about the errors and effective collection systems to improve the total quality management of laboratory so as to ensure total quality patient care. © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction the pre analytical phase is an important component of laboratory medicine. it includes the time from the order of test by the clinician until the sample is ready for analysis – it can account up to 70% of errors during the total diagnostic process. 1 the major 5 key components for the establishment of quality and reliability in the laboratory include (a) quality laboratory process (qlps), (b) quality control(qc), (c) quality assurance/assessment (qa), (d) quality improvement (qi) and (e) quality policy(qp). 2 * corresponding author. e-mail address: drsaloni7388@gmail.com (saloni). 2. objectives 1. to stratify the pre-analytical errors documented during pre analytical testing process. 2. to formulate the possible corrective measures to be taken to minimise such errors. 3. materials and methods a prospective study was done for a period of 6 months from 1st august 2019 to 31st jan 2020 in clinical laboratory of pgimer satellite centre, sangrur. all types of preanalytical errors were recorded systematically under the following categories: https://doi.org/10.18231/j.pjms.2020.029 2249-8176/© 2020 innovative publication, all rights reserved. 135 https://doi.org/10.18231/j.pjms.2020.029 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto:drsaloni7388@gmail.com https://doi.org/10.18231/j.pjms.2020.029 136 saloni and mittal / panacea journal of medical sciences 2020;10(2):135–138 fig. 1: 1. improper request forms (sample requisition). 2. incorrect identification/improper labelling. 3. insufficient volume (quantity of sample collected. 4. in-vitro haemolysis. 5. improper tube (usage for sample collection). 6. specimen handling. the analysis of such errors was done by calculating the percentage and of each category. 4. observation & result types of pre analytical errors: table 1. 5. discussion pre-analytical errors have been the focus of research in past decades. previous studies have focused on the analytical phase of diagnostic tests, and many quality control programs were initiated at diagnostic labs to monitor analytical phase errors. however, postand pre-analytical errors were neglected worldwide, and currently many studies are focusing on the importance of the pre-analytical phase to obtain accurate lab results. an american pathologist program conducted a study enrolling 660 laboratories and showed that preanalytical errors were 4.8%. 3 the college of american pathologists, including 120 labs, concluded that misidentification is a common laboratory error. 4 a danish study on laboratory errors showed that 81% of lab errors were pre-analytical, while only 10% of lab errors were analytical. moreover, 82.6% human errors and 4.3% technical errors were observed saloni and mittal / panacea journal of medical sciences 2020;10(2):135–138 137 fig. 2: table 1: pre analytical errors month improper request improper labelling insufficient sample improper tube collection hemolysis sample not received errors total opd august 5 (1.02) 7( 1.42) 7(1.42 ) 7(1.42 ) 13( 2.65) 10(2.04 ) 49(10 ) 490 sept 5 (0.92 ) 6( 1.11) 8(1.48 ) 8( 1.48) 12(2.22 ) 9( 1.66) 48( 8.88) 540 oct 4 (0.71 ) 8(1.42) 10(1.78) 12(2.14) 8(1.42) 10(1.78) 52(9.28) 560 nov 3(0.6 ) 7(1.4) 12 (2.4) 10(2) 10(2) 8(1.6) 50(10) 499 dec 4( 0.83) 5 (1.04) 5(1.04) 6(1.25) 14(2.91) 11(2.29) 45(9.37) 480 jan 3(0.72 ) 6 (1.45) 6 (1.45) 8( 1.94) 9 (2.18) 8 (1.94) 40(9.73) 411 total 24(0.8 ) 39 (1.3) 48(1.6) 51(1.71) 66(2.2) 56 (1.87) 284(9.53) 2980 there has been varied information on the error rate within the whole lab testing procedure (0.1% to 9.3%). plebani and carraro observed in their paper that the great majority of errors result from problems in the preanalytical or post-analytical phases. 5 in a study by jay and colleagues, the majority of hemolyzed samples (>95%) could be attributed to in vitro processes resulting from incorrect sampling procedure or transportation. 6 he rate of hemolysis in the present study (2.2%) comparable with study conducted by salvagno gl et al 2012 where they observed 4% in whole blood sample. 7 hemolysis leads to the extravasation of intracellular contents into the plasma, leading to false high values of potassium and intracellular enzymes such as sgot and ldh. it also leads to a prolongated turnaround time (tat) due to the need for fresh samples for processing the request. another factor leading to rejection of blood samples in our study was insufficient blood volume. every analytical process requires a fixed volume of serum/plasma for analysis. the main reasons behind this anomaly are ignorance of the phlebotomists, difficult sampling as in pediatric patients, patients with chronic, debilitating diseases, and patients on chemotherapy whose thin veins are difficult to localize. insufficient sample volume constituted the most frequent cause of test rejection in the samples collected in the opd (0.37%). binita goswami et al. collected data for 67438 routine venous blood specimens and found 77.1% pre analytical errors followed by post analytical15% and analytical 7.9%, respectively. 8 it is clear from the above discussion that incorrect phlebotomy practices are the main reason behind preanalytical errors. the reason for incorrect phlebotomy practice includes lack of awareness or possibly a heavy 138 saloni and mittal / panacea journal of medical sciences 2020;10(2):135–138 workload. this is the reason phlebotomy has been considered a separate area of improvement for medical technician. 9 to overcome pre analytical errors, the following corrective measures have been recommended: (lippi g et al, sciacovellia l et al, jo gile t). 1. skilled staff: skilled and adequate staff to maintain collection standards, which give an extra verge of expertise. 10 2. phlebotomists: with proper knowledge pertaining to phlebotomy (trained personnel) 3. regular educational competency assessments should be encouraged to allow (new and old personal) an opportunity to recognize and manage errors. 4. vacutainers: proper knowledge regarding use of evacuated tube system to the lab personal pertaining to sample volume and use of anticoagulants. 11 5. transport: laboratory personnel guided regarding importance of transport the specimens promptly to the laboratory at the earliest after collection to avoid errors related to delay. 6. advanced technology: usefulness of barcode scanners system for individual sample recognition. 6. conclusion now a day, pre-eminent advances in laboratory automation, sample collection, transport, and report dispatch leads to an utmost improvement in laboratories performance. but still there is long path to pace before we achieve 100% accuracy and precision. pre-analytical errors are not unavoidable, but we can minimize or eliminate it by improving laboratory testing. promoting quality control and systemic monitoring, will help to improve test reliability and thus enable physicians to have optimal clinical management for patient care. laboratory experts should implement continuous internal programs not only for detection of analytical errors but for overall quality management & improvement in laboratories. proper exhaustive program should be silhouette for laboratory personnel like orientation program regarding total quality management to attain better laboratory testing, monitoring, reporting and performance in terms of accuracy, precision and will eventually assists physicians to have favourable insights in patients care. 7. source of funding none. 8. conflict of interest none. references 1. sareen r, kapil m, gupta gn. preanalytical variables: influence on laboratory results and patient care. int j clinicopathol correl. 2017;1:31–4. 2. munilakshmi u, shashidhar kn, susanna ty. preanalytical variables and its impact on total quality management of clinical biochemistry laboratorya tertiary referral rural hospital study. int j clin biochem res. 2018;5(3):467–72. 3. szecsi pb, ødum l. error tracking in a clinical biochemistry laboratory. clin chem lab med. 2009;47(10):1253–7. 4. valenstein p, meier f. outpatient order accuracy. a college of american pathologists q-probes study of requisition order entry accuracy in 660 institutions. arch pathol lab med;123(12):1145–50. 5. bonini p, plebani m, ceriotti f, rubboli f. errors in laboratory medicine. clin chem. 2002;48(5):691–8. 6. jay dw, provasek d. characterization and mathematical correction of hemolysis interference in selected hitachi 717 assays. clin chem. 1993;39(9):1804–10. 7. salvagno gl, lippi g, gelati m, guidi gc. hemolysis, lipaemia and icterus in specimens for arterial blood gas analysis. clin biochem. 2012;45(4-5):372–3. 8. goswami b, singh b, chawla r, mallika v. evaluation of errors in a clinical laboratory: a one-year experience. clin chem lab med. 2010;48(1):63–6. 9. fidler jr. task analysis revisited:refining the phlebotomy technician scope of practice and assessing longitudinal change in competencies. eval health prof. 2007;30:150–69. 10. lippi g, salvagno gl, montagnana m, franchini m, guidi gc. phlebotomy issues and quality improvement in results of laboratory testing. clin lab. 2006;52:217–30. 11. sciacovellia l, plebani m. the ifcc working group on laboratory errors and patient safety. clinica chimica acta. 2009;404:79–85. author biography saloni assistant professor neha mittal assistant professor cite this article: saloni , mittal n. study of pre analytical errors in clinical biochemistry laboratory in rural area of punjab. panacea j med sci 2020;10(2):135-138. introduction objectives materials and methods observation & result discussion conclusion source of funding conflict of interest 429 too many requests you have sent too many requests in a given amount of time. 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2020;10(2):171–173 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com case report amulet in penile tracta case study sudhir singh1,* 1dept. of plastic surgery, getwell hospital, varanasi, uttar pradesh, india a r t i c l e i n f o article history: received 06-05-2020 accepted 08-06-2020 available online 26-08-2020 keywords: amulet foreign body self inserted in penile urethra psychiatric selferotism a b s t r a c t we do get strange cases of self insertion of foreign bodies in the penile urethra. it is very difficult to know the reason for inserting variety of objects. here this case needs discussion due to extreme rarity and strangeness of getting a metal amulet with the attached hanging thread inserted inside the penile urethra. © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction the insertion of extraneous objects into penile tract or lower genital tract looks unusual but has been found well documented practice in medical literature. 1–3 it occurs during pathological masturbation, intoxication, or as a result of psychiatric disturbance. the foreign body may disappear into the urethra or remain visible at the meatus. some times its removal becomes difficult even in those having portion of foreign body visible at the meatus. 4 there is varied clinical presentation of urethral foreign body. if the object has disappeared into the urethra then increased urinary frequency, dysuria, poor stream, haematuria, and urinary retention are the usual symptoms. 5 the possibility of a retained urethral foreign body can be answered by getting plain radiography of the genitourinary tract done. 6 i present a rare case of a metal amulet which is worn on the waist by thread was self inserted in penile urethra 2. case study a forty-years-old man presented with haematuria, dysuria and now with retention with full urinary bladder and pain. * corresponding author. e-mail address: s.sulekha@gmail.com (s. singh). because of his habit of attaining autoerotic stimulation, he had self inserted into his penile urethra about 3 cm size metal amulet with hanging long thread which is used for wearing on the waist. there no history of psychiatric disorders. however the metal amulet was not visible but could be palpated within the penile urethra and hanging thread attached to amulet was seen hanging outside the meatus of glans penis. under local anaesthesia traction was tried but hinderance was there. so meatotomy was done and more xylocaine jelly was infused and with minimum effort the foreign body was extracted. foley’s catheter was passed for few days and meatotomy site was repaired with 4/0 vicryl. since the patient was in agony we avoided x-ray and did the case in emergency couch as opd procedure under local anaesthesia and later other routine tests were done. there was no need for cystourethroscopy as patient was alright after the foley’s catheter removal and never reported back for any problems or symptoms of stricture occurrence. however patient supported by his attendants refused to go for psychiatric evaluation for fear of social stigma. 3. discussion insertions of foreign bodies in lower genital tract is very unusual and different types of foreign materials have https://doi.org/10.18231/j.pjms.2020.036 2249-8176/© 2020 innovative publication, all rights reserved. 171 https://doi.org/10.18231/j.pjms.2020.036 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto: s.sulekha@gmail.com https://doi.org/10.18231/j.pjms.2020.036 172 singh / panacea journal of medical sciences 2020;10(2):171–173 fig. 1: pre operative foreign body metal amulet attached to thread is self inserted inside the penile urethra fig. 2: post op. removal of amulet is done by meatotomy and with controlled traction been detected. it has been seen that these patients run under psychological disturbances and develop habit of pathological masturbation and are often involved in drug abuse and intoxication for having erotic spell even by inserting foreign body inside the lower genital tract. 7 selferotic stimulation with the help of self-inserted urethral foreign bodies has been there since time immemorial and have presented an unusual but known presentation to emergency surgeons. 7,8 often the presentation is delayed owing to embarrassment. of those who seek treatment suffer from haematuria, dysuria, urinary frequency, strangury and urinary retention as common presenting signs and symptoms. it has been seen that even fulminant sepsis and death can occur if treatment is delayed. 7 if the foreign body remains protruding from the urethral meatus then the diagnosis is obvious but the management is less straightforward than it would initially appear. 4 long, flexible foreign bodies tend to knot in the bladder, and this bar to removal may be visible on plain radiography. it is very tempting to attempt removal by traction in these type of cases but should take care in finding what is concealed to prevent urethral trauma on removal. although variety of objects, mechanism of insertion, and the time that the object remained in the genitourinary tract affect the presentation. many objects as electrical wire, aaa battery, bullets, bones, plastic cup, beads and intrauterine devices have been reported as foreign bodies or extraneous bodies in lower genitourinary system in literature. 9–11 so varieties of foreign bodies in genitourinary tract has been seen. urethral self-insertion can be found in both sexes, and variety of objects can be introduced to the bladder through the urethral opening. 9 the major causes of self-insertion of objects are psychiatric disorders and autoerotic stimulation. physical examination is of great help in diagnosis. these foreign bodies are readily palpable distal to the urogenital diaphragm and a x-ray of pelvis and computerised tomography of the abdomen and/or pelvis can aid in knowing the foreign body’s where abouts in relation to surrounding visceral structures. self insertion of metal amulet is very rare or not heard of and so there is not much information to compare different modalities of treatment. its removal depends on its physical dimensions and its nature of hardness. most important is to prevent urinary tract trauma and not adversely affect the erectile function. it is of no doubt that foreign bodies located distal to the urogenital diaphragm can often be successfully removed by endoscopic methods. 12,13 after removal, cystourethoscopy is very important to see for any urothelial injuries and to be sure of complete removal of foreign bodies. antibiotic cover is advised. 14 some times in some cases invasive foreign body removal procedures are required like external urethrotomy (for pendulous urethral foreign bodies), suprapubic cystotomy (for posterior urethral foreign bodies), or meatotomy. 12,15,16 complications following these procedures are rare but can result in infection, fistula, urethral stricture, diverticulum, and incontinence. 12,13,16,17 however urethral strictures occur in 5% of cases as common delayed complication. 12 thus, appropriate follow-up is a must. 4. conclusion here the very rare foreign body metal amulet with hanging thread outside the meatus extraction was done easily by controlled traction guided by its morphology and position by clinical examination. under local anaesthesia, only a small meatotomy was done to felicitate removal of the amulet. we need a comprehensive management of patient for preventing lower genital tract injury while removing the foreign body and preventing infection and following the patient for monitoring of development of any late complications like strictures. thorough evaluation of cause of unnatural motivation and if there is any psychosocial issues it should be properly addressed with help of psychiatrists to prevent future episodes. 5. source of funding none. singh / panacea journal of medical sciences 2020;10(2):171–173 173 6. conflict of interest none. references 1. wenderoth u, jonas u. curiosity in urology? masturbation injuries. eur urol. 1980;6:312–3. 2. granados ea, riley g, rios gj, salvador j, vicente j. self introduction of urethrovesical foreign bodies. eur urol. 1991;19(3):259–61. 3. costa g, tonno fd, capodieci s, laurini l, casagrande r, lavelli d. self-introduction of foreign bodies into the urethra: a multidisciplinary problem. int urol nephrol. 1993;25(1):77–81. 4. quin g, mccarthy g. self insertion of foreign bodies. emerg med j. 2000;17(3):229–32. 5. aliabadi h, cass as, gleich p, johnson cf. self-inflicted foreign bodies involving lower urinary tract and male genitals. urol. 1985;26:12–6. 6. eckford sd, persad ra, brewste sf, gingell jc. intravesical foreign bodies: five-year review. br j urol. 1992;69(1):41–5. 7. bedi n, el-husseiny t, buchholz n, masood j. ‘putting lead in your pencil’: self-insertion of an unusual urethral foreign body for sexual gratification. j r soc med short rep. 2010;1(2):1–5. 8. rieder j, brusky j, tran v, stern k, aboseif s. review of intentionally self-inflicted, accidental and iatrogetic foreign objects in the genitourinary tract. urol int. 2010;84(4):471–5. 9. mannan a, anwar s, qayyum a, tasneem ra. foreign bodies in the urinary bladder and their management : a pakistani experience. singap med j. 2011;52:24–8. 10. rahman nu, elliott sp, mcaninch jw. self-inflicted male urethral foreign body insertion : endoscopic management and complications. bju int. 2004;94(7):1051–3. 11. sinopidis x, alexopoulos v, panagidis a, ziova a, varvarigou a, georgiou g. internet impact on the insertion of genitourinary tract foreign bodies in childhood. 2012;doi:10.1155/2012/102156. 12. mannan a, anwar s, qayyum a, tasneem ra. foreign bodies in the urinary bladder and their management: a pakistani experience. singapore med j. 2011;52(1):24–8. 13. bedi n, el-husseiny t, buchholz n, masood j. ‘putting lead in your pencil’: self-insertion of an unusual urethral foreign body for sexual gratification. j r soc med short rep. 2010;1(2):1–5. 14. rieder j, brusky j, tran v, stern k, aboseif s. review of intentionally self-inflicted, accidental and iatrogetic foreign objects in the genitourinary tract. urol int. 2010;84(4):471–5. 15. mitterberger m, peschel r, frauscher f, pinggera gm. allen key completely in male urethra: a case report. cases j. 2009;2(1):7408. 16. poole-wilson ds. discussion on urethral injuries. proc r soc med. 1956;49:685–96. 17. moon sj, kim dh, chung jh. unusual foreign bodies in the urinary bladder and urethra due to autoerotism. int neurourol j. 2010;14:186– 9. author biography sudhir singh hon. ima professor & sr. consultant cite this article: singh s. amulet in penile tracta case study. panacea j med sci 2020;10(2):171-173. http://dx.doi.org/10.1155/2012/102156 introduction case study discussion conclusion source of funding conflict of interest panacea journal of medical sciences 2021;11(1):72–76 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a study of various biochemical parameters in patients with scrub typhus ashwini manish jantikar1,* 1dept. of biochemistry, american international institute of medical sciences, udaipur, rajasthan, india a r t i c l e i n f o article history: received 29-07-2020 accepted 29-09-2020 available online 29-04-2021 keywords: scrub typhus data mining acute undifferentiated fever thrombocytopenia a b s t r a c t background: scrub typhus is an infectious disease spreads by a bacterium called orientiatsutsugamushi. the who has dubbed scrub typhus one of the world’s most under-diagnosed/underreported diseases. it’s so also in rajasthan (india). since antigen detection tests have low sensitivity/specificity and require biopsy specimens, in the clinical setting, serological assays are the mainstay of diagnosis. objectives: to study various biochemical parameters in scrub typhus positive patients and to compare of the same with the control group (negative suspects) to elicit some specific diagnostic parameters through data mining. materials and methods: this retrospective observational cohort study included fever of unknown origin (fuo) cases classified into patients with (group 1; n = 35) or without (group 2; n= 65) scrub typhus. various biochemical parameters were correlated and compared through data mining and analyzed on apache hive. we used welch test to estimate normality of data, fligner killeen test to estimate the homogeneity of variance and mann whitney u test for comparing the two data sets. results: both the groups were comparable with respect to age and sex. platelet count, sgot, sgpt and random blood sugar were significantly different in both the groups. (p<0.05) other laboratory parameters viz. hemoglobin, wbc counts, rbc counts, bilirubin, urea and creatinine were not different significantly among group 1 and group 2. (p>0.05) conclusion s: thrombocytopenia and deranged sgot-sgpt were found to be prime clinico-pathological indicator of the scrub typhus. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction: scrub typhus (also known as bush typhus) is an infectious disease spreads by a bacterium called orientiatsutsugamushi (japanese name of the species tsutsugamushi comprises tsutsuga i.e. illness and mushi i.e. insect) belonging to order rickettsiales, family rickettsiaceae (phylum proteobacteria, class alpha proteobacteria). it is a natural obligate intracellular gram negative bacterial parasite in mites of trombiculidae family. 1 this rickettsial infection is a zoonotic acute febrile illness spread by the chigger mite (leptotrombidiumdeliense). 2 * corresponding author. e-mail address: ashwinimj@gmail.com (a. m. jantikar). orientiatsutsugamushi is the most commonly reported rickettsial infection in indian subcontinent. the mortality of untreated epidemic can range from 30% to 60%. 3,4 in untreated cases, fatality can rise to 70% as reported in a article. 5 the disease is currently estimated to impact 1 billion populations globally with 1 million casualties. 6 scrub typhus is grossly under diagnosed in india because of their nonspecific presentations, less awareness in patients as well as in clinicians (esp. that serologic testing is not useful acutely) and lack of facilities for diagnosis and treatment in periphery (like pcr based diagnosis). 7 the world health organization has dubbed scrub typhus one of the world’s most under-diagnosed/underreported diseases that often requires hospitalization. 8 currently, there is a widespread re-emergence of scrub typhus in india, https://doi.org/10.18231/j.pjms.2021.017 2249-8176/© 2021 innovative publication, all rights reserved. 72 https://doi.org/10.18231/j.pjms.2021.017 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.017&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:ashwinimj@gmail.com https://doi.org/10.18231/j.pjms.2021.017 jantikar / panacea journal of medical sciences 2021;11(1):72–76 73 micronesia, and the maldives. reports are there which say that this expansion of geographies in india is more likely to be due to increased awareness and heightened level of suspicion rather than change in agent, host or environment. 9 moreover, o. tsutsugamushi serotype distribution varies from region to region and strain types are identified by sequencing the 56 kda gene. in india, based on a 56 kd a analysis, strains similar to kato and karp are common. eschar, as widely accepted cornerstone of clinical diagnosis, is not universal too, scrub typhus without the eschar is a febrile illness without any evidence of localization, and is hence termed “acute undifferentiated fever”. 10 this illness is thus clinically indistinguishable from malaria, dengue fever, other rickettsioses, leptospirosis, and enteric fever, which are common causes of acute undifferentiated fever. 10 timely diagnosis of the disease can aid the clinician in instituting proper treatment in patients suspected of suffering from scrub typhus and may help to reduce the morbidity and mortality of this disease. 11 due to lack of awareness, a low index of suspicion among clinicians, paucity of confirmatory diagnostic facilities and clinical symptoms mimicking other more prevalent diseases such as dengue, malaria and leptospirosis, scrub typhus is under-diagnosed in india, especially in rajasthan. 12 since antigen detection tests have low sensitivity/specificity and require biopsy specimens, in the clinical setting, serological assays are the mainstay of diagnosis. 13 the cheapest and most easily available serological test is the weil-felix (wf) test which has a high specificity but a low sensitivity. 14 thus serologic testing alone is insufficient because of substantial background seropositivity in regions where it is endemic and because of the delay during a primary infection before antibodies are produced. 15 this study aims to explore some correlation of ‘laboratory parameters (through data mining)’ to the finally diagnosed cases for increasing the diagnostic efficacy. instead of an already done prospective observational study, 12 this retrospective study could be much more time/ resource efficient. this retrospective study was based on a secondary data through which we have tried to elicit a pattern – but no pre-hypothesized pattern was rigged to reach the required p-value. here lies the difference between our statistically valid data mining and malicious data dredging. contextually, the unbiased methodology of data mining (also called information harvesting or knowledge discovery) is different from data dredging (or data fishing) which juggles with data and hunt for a pattern till a correlation frame emerges (and thus the latter is derogatorily called phacking, data snooping or even data butchering). 16 to the contrary, here the dark data (unused data that is otherwise discarded) is revisited (for cluster analysis, pattern hunt and anomaly location) to see if anything unexpected is left overlooked. 17,18 in 1995, the first international conference on data mining and knowledge discovery (kdd-95) was started in montreal under aaai sponsorship. 16 starting from bayes’ theorem (1700s) and regression analysis (1800s); data mining has evolved through neural networks, cluster analysis, genetic algorithms (1950s), decision trees and decision rules (1960s), and support vector machines (1990s). currently data mining involves the 6 steps of anomaly detection, association rule learning (dependency modeling), clustering, classification, regression and summarization. 19 so, the present was planned to study various biochemical parameters in scrub typhus positive patients and to compare of the same with the control group (negative suspects) to elicit some specific diagnostic parameters through data mining. 2. materials and methods this observational study was conducted after approval from institutional ethics committee. in this retrospective observational cohort study (typhus versus non-typhus cohorts), already existing laboratory data of all scrub typhus suspect cases from out patients and in-patients departments of tertiary care teaching hospital of udaipur, rajasthan between july to december 2019 was collected. fever of unknown origin (fuo) is said when the body temperature increases to 38.3◦c (101◦f) or more several times a day lasting longer than 3 weeks or failure to reach a diagnosis despite 1 week of inpatient evaluation. 20 patients admitted with a provisional diagnosis of this fuo were selected for this study, and based on case records, bifurcated finally into scrub typhus cohort (group 1, cases) versus non typhus cohorts (group 2, controls). various biochemical tests were correlated and compared through data mining and analyzed on apache hive (technique used by facebook and netflix). from the hospital database, we retrieved relevant data series and their correlations through the apache hivetm data warehouse software which facilitates reading, writing, and managing large datasets residing in distributed storage and queried using sql syntax. 21 there is not a single "hive format" in which data must be stored. hive comes with built in connectors for comma and tab-separated values (csv/tsv) text files, apache parquettm, apache orctm, and other formats. we could extend hive with connectors for other formats. 21 usually a schema is applied to a table in traditional databases. in such traditional databases, the table typically enforces the schema when the data is loaded into the table. this enables the database to make sure that the data entered follows the representation of the table as specified by the table definition. in comparison, our software apache hive does not verify the data against the table schema on write. instead, it subsequently does run time checks when the data is read. this model is called ‘schema on read’ against other 74 jantikar / panacea journal of medical sciences 2021;11(1):72–76 ‘schema on write’ algorithms. 19 laboratory parameters viz. hemoglobin level, wbc count, rbc count, platelet count, total bilirubin, sgot (=ast) and sgpt (=alt), serum urea, serum creatinine and random blood sugar were noted down from existing laboratory data of both cases and control group. we used welch test to estimate normality of data, fligner killeen test to estimate the homogeneity of variance and mann whitney u test for comparing the two data sets. p value < 0.05 was considered significant. 3. results both the groups were comparable with respect to age and sex. platelet count, sgot, sgpt and random blood sugar were significantly different in both the groups. (p<0.05) other laboratory parameters viz. hemoglobin, wbc counts, rbc counts, bilirubin, urea and creatinine were not different significantly among group 1 and group 2. (p>0.05) platelet count was found significantly diminished in case group as compared to control. (figure 1 and table 1) deranged liver profile (sgot, sgpt) was also significantly high in case group as compare to controls. (figures 2 and 3 and table 1) serum creatinine and blood urea rise was found more in case group but that was non-significant. significantly high random blood sugar was found in case group. (figure 4 and table 1) seeing wide standard deviation, median (which is the basis of comparative box whisker plot) was preferred over mean based comparator. fig. 1: comparativeplatelet count (x103/ dl) of patients (group 1) versus control (group 2) 4. discussion although scrub typhus is a neglected disease in india, but in recent years there are reports from maharashtra, tamil nadu, karnataka, kerala, jammu and kashmir, uttaranchal, himachal pradesh, rajasthan, assam and west bengal indicating the resurgence. 20 there was a retrospective study in rajasthan in 2013 over an 8-month period from may to december 2013. all patients with a clinical presentation and/or serological confirmation of scrub typhus who tested negative for malaria, enteric fever, dengue, leptospirosis and urinary tract fig. 2: comparative sgot level (units/ l) of patients (group 1) versus control (group 2) fig. 3: comparative sgpt level (units/ l) of patients (group 1) versus control (group 2) fig. 4: comparative rbs level (mg/dl) of patients (group 1) versus control (group 2) infection (uti) were included exactly like us. but they had only 30 cases (without any control) and tried to compare different laboratory diagnostic methods. moreover, they didn’t use apache hive data retrieval system for data mining. instead it was a preliminary retrospective research. 22 thrombocytopenia is the single most common hematological abnormality; severe thrombocytopenia with platelet count less than 50x103 /µl is seen in up to half of patients. 23 lowering of platelet count (thrombocytopenia)> 60% is also on record. 20,24,25 in our study it was 65% jantikar / panacea journal of medical sciences 2021;11(1):72–76 75 table 1: comparison ofdemographic and biochemical parameters in both the groups group 1 (case)(n= 35) mean± sd group 2 (control)(n= 65) mean± sd p value age (years) 38.11 ± 15.66 39 ± 7.79 0.741 male/female ratio 13/22 26/39 0.949 hb (mg/ dl) 10.28 ± 2.68 11.4 ± 2.09 0.339 wbc (x103/ dl) 7.11 ± 2.73 7.06 ± 3.92 0.397 rbc(x 106/µl) 3.9 ± 0.992 4.2±0.64 0.128 platelet (x103/ dl) 133.26 ± 132.27 168.38 ± 114.45 0.023∗ bilirubin(mg/dl) 1.21 ± 1.44 1.098 ± 1.32 0.051 sgot(units/ l) 139.4 ± 132.26 103.88 ± 140.73 0.039∗ sgpt(units/ l) 105.89 ± 153.3 82.14 ± 108.03 0.032∗ urea (mg/dl) 49.743 ± 41.82 39.88 ± 38.14 0.054 creatinine(mg/dl) 1.121 ± 0.564 1.054 ± 0.4255 0.053 rbs(mg/dl) 122.49 ± 58.31 103.5 ± 21.053 0.048* *significant p value (12/35) in case group against 49% (32/65) in the control group. here exclusion of differential diagnosis of dengue is warranted. it was also reported that scrub typhus is the most common cause of febrile jaundice in a tertiary care hospital. 26 hepatomegaly is reported in up to 70% cases while sgot/ sgpt is increased in 49% cases. 27 another study reported rise in sgot/sgpt in 68.75% cases while 30% incidence of hepato-spleno-megaly 25 yet another study reported around 90% cases of scrub typhus having higher sgot/sgpt as well as bilirubin. 28 in our study sgot/ sgpt and bilirubin rise were parameters of the significant differences between case and control. like our significantly different serum creatinine in patient group, serum creatinine is reported raised in >40% cases. 28 but in contrast, leucocytosis (which is highly nonspecific and might be similarly increased in the suspects due to other unhygienic pathologies) was not significantly different in our study. significantly higher incidence of high random blood sugar in case group was unique in this study which was epidemiologically less tested or established. similar rise in random blood sugar was seen in some other researches 29,30 (114 mg/dl and 165 mg/dl respectively) but no causation or correlation was reported. other parameters were not different significantly. for example gender propensity was favoring males or females in different studies 12 while in our study, the difference was statistically insignificant. in contrast to this prospective study, 12 as our study was retrospective, instead of incidence confirmation, we focused on comparator validation. acute undifferentiated febrile illness of three days or more with or without organ involvement during typical tropical rainy season should be suspected as a case of scrub typhus. presence of eschar is pathognomonic and is a useful diagnostic clue. 23 however, at acute care settings, several other tropical infections such as dengue, malaria, typhoid, leptospirosis and severe bacterial sepsis may present with overlapping clinical features and may be confused with scrub typhus. the challenge lies in distinguishing them at the time of presentation. 23 both dengue and scrub typhus present with thrombocytopenia, signs of capillary leak and circulatory abnormalities, subtle laboratory features like presence of hemoconcentration or leucopenia may help in discriminating dengue to a certain extent. 23 dengue and malaria can be diagnosed at admission using point of care rapid diagnostic tests. however, if a definitive diagnosis is not possible at the outset, it is recommended to treat children empirically for scrub typhus till serological confirmation is available. 23 5. limitations there is a limitation of this data mining method too. conventional tests of statistical significance are based on the probability that a particular result would arise if chance alone were at work, and necessarily accept some risk of mistaken conclusions of a certain type (mistaken rejections of the null hypothesis). this level of risk is called the significance. 25 though we have taken precaution to avoid over-fitting, a conventional null hypothesis method is necessary to be replicated on a newer larger data set before these results are clinically generalized. 6. conclusion in our study, low platelet count (thrombocytopenia) and deranged liver profile (increased sgot-sgpt) were found to be prime clinico-pathological indicator of the scrub typhus. random blood sugar was significantly different in scrub typhus patients; relevance of which could be as precipitating or prognostic factor (as diabetic profile has not been correlated directly to scrub typhus anyhow). 76 jantikar / panacea journal of medical sciences 2021;11(1):72–76 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. petri wa. scrub typhus; 2020. available from: https: //www.msdmanuals.com/professional/infectious-diseases/rickettsiaeand-related-organisms/scrub-typhus(accessedon. 2. blanton ls, walker dh. the rickettsiaceae, anaplasmataceae, and coxiellaceae. in: manual of molecular and clinical laboratory immunology. 8th edn.. vol. 11; 2016. p. 461–72. 3. rathi n, rathi a. rickettsial infections: indian perspective. indian pediatr . 2010;47(2):157–64. doi:10.1007/s13312-010-0024-3. 4. groves mg, harrington ks. handbook of zoonoses. section a: bacterial, rickettsial, chlamydial, and mycoticzoonoses. in: 2nd edn. boca raton, fl: crc press; 1994. p. 463–74. 5. taylor aj, paris dh, newton pn. a systematic review of mortality from untreated scrub typhus (orientia tsutsugamushi). plos negl trop dis . 2015;9(8):1–13. doi:10.1371/journal.pntd.0003971. 6. tilak r, kunte r. scrub typhus strikes back: are we ready? med j armed forces india. 2019;75(1):8–17. doi:10.1016/j.mjafi.2018.12.018. 7. saraswati k, day npj, mukaka m, blacksell sd. scrub typhus point-of-care testing: a systematic review and metaanalysis. plos neglected trop dis. 2018;12(3):e0006330. doi:10.1371/journal.pntd.0006330. 8. luce-fedrow a, lehman m, kelly d, mullins k, maina a, stewart r, et al. a review of scrub typhus (orientia tsutsugamushi and related organisms): then, now, and tomorrow. trop med infect dis. 2018;3(1):8. doi:10.3390/tropicalmed3010008. 9. kumar cm, sharma p, patwari ak. scrub typhus in india: whether increased reporting or expanding geographies. indian j child health. 2016;3(3):263–5. doi:10.32677/ijch.2016.v03.i03.022. 10. prakash ja. scrub typhus: risks, diagnostic issues, and management challenges. res rep trop med. 2017;8:73. 11. farhana a, bali n, kanth f, farooq r, haq iu, shah p, et al. serological evidence of scrub typhus among cases of puo in the kashmir valley-a hospital based study. j clin diagn res. 2016;10(5):24. 12. takhar rp, bunkar ml, arya s, mirdha n, mohd a. scrub typhus: a prospective, observational study during an outbreak in rajasthan, india. natl med j india. 2017;30(2):69. 13. peter jv, sudarsan ti, prakash jaj, varghese gm. severe scrub typhus infection: clinical features, diagnostic challenges and management. world j crit care med. 2015;4(3):244. doi:10.5492/wjccm.v4.i3.244. 14. chakraborty s, sarma n. scrub typhus: an emerging threat. indian j dermatol. 2017;62(5):478. 15. walker dh. scrub typhus-scientific neglect, ever-widening impact. n engl j med. 2016;375(10):913–5. 16. tan pn, steinbach m, kumar v. introduction to data mining. pearson education india. 2016;. 17. mulder ds, spicer j. registry-based medical research: data dredging or value building to quality of care? ann thorac surg. 2019;108(1):274–82. doi:10.1016/j.athoracsur.2018.12.060. 18. arkin jm, kowey pr. does atrial fibrillation pattern affect stroke risk? data dredging to help the clinician. eur heart j. 2015;36(5):265–6. doi:10.1093/eurheartj/ehu420. 19. dutt a, ismail ma, herawan t. a systematic review on educational data mining. ieee access. 2017;5:15991–16005. doi:10.1109/access.2017.2654247. 20. munilakshmi p, krishna mv, john ms, deepa t, avinash g, reddy ps, et al. fuo cases showing prevalence of scrub typhus: a comparative study by elisa and rapid test in a tertiary care hospital in andhra pradesh, india. int j curr microbiol appl sci. 2015;4(2):632– 40. 21. apache hive; 2020. available from: https://cwiki.apache.org/ confluence/display/hive/home(accessedon. 22. masand r, yadav r, purohit a, tomar bs. scrub typhus in rural rajasthan and a review of other indian studies. paediatr int child health. 2016;36(2):148–53. doi:10.1179/2046905515y.0000000004. 23. bihari s. a study on socio-demographic, clinical and laboratory profile of scrub typhus in hadoti region kota rajasthan. paripexindian j res. 2019;5(8). 24. saluja m, vimlani h, chittora s, sen p, suman c, galav v, et al. scrub typhus: epidemiology, clinical presentation, diagnostic approach, and outcomes. j indian acad clin med. 2019;20(1):15–22. 25. mokta j, yadav r, mokta k, panda p, ranjan a. scrub typhus-the most common cause of febrile jaundice in a tertiary care hospital of himalayan state. j assoc physicians india. 2017;65(8):47–50. 26. narayanasamy dk, arunagirinathan ak, kumar rk, raghavendran vd. clinico-laboratory profile of scrub typhus — an emerging rickettsiosis in india. indian j pediatri. 2016;83(12-13):1392–7. doi:10.1007/s12098-016-2171-6. 27. huidrom s, singh lk. clinical and laboratory manifestations of scrub typhus: a study from a tertiary care hospital in manipur. cough. 2017;22:91–6. 28. gopalakrisna mv, suryaprakash h, kumar gsv, kumar kj, murthy ds. clinical features, laboratory findings and complications of scrub typhus in south indian children. j nepal paediatr soc. 2017;37(1):21–4. doi:10.3126/jnps.v37i1.16202. 29. mahajan sk, kumar s, garg m, kaushik m, sharma s, r r, et al. scrub typhus with longitudinally extensive transverse myelitis. j vector borne dis. 2016;53(1):84. 30. koraluru m, bairy i, singh r, varma m, stenos j. molecular confirmation of scrub typhus infection and characterization of orientia tsutsugamushi genotype from karnataka, india. j vector borne dis. 2016;53(2):185. author biography ashwini manish jantikar, associate professor cite this article: jantikar am. a study of various biochemical parameters in patients with scrub typhus. panacea j med sci 2021;11(1):72-76. https://www.msdmanuals.com/professional/infectious-diseases/rickettsiae-and-related-organisms/scrub-typhus(accessedon https://www.msdmanuals.com/professional/infectious-diseases/rickettsiae-and-related-organisms/scrub-typhus(accessedon https://www.msdmanuals.com/professional/infectious-diseases/rickettsiae-and-related-organisms/scrub-typhus(accessedon http://dx.doi.org/10.1007/s13312-010-0024-3 http://dx.doi.org/10.1371/journal.pntd.0003971 http://dx.doi.org/10.1016/j.mjafi.2018.12.018 http://dx.doi.org/10.1371/journal.pntd.0006330 http://dx.doi.org/10.3390/tropicalmed3010008 http://dx.doi.org/10.32677/ijch.2016.v03.i03.022 http://dx.doi.org/10.5492/wjccm.v4.i3.244 http://dx.doi.org/10.1016/j.athoracsur.2018.12.060 http://dx.doi.org/10.1093/eurheartj/ehu420 http://dx.doi.org/10.1109/access.2017.2654247 https://cwiki.apache.org/confluence/display/hive/home(accessedon https://cwiki.apache.org/confluence/display/hive/home(accessedon http://dx.doi.org/10.1179/2046905515y.0000000004 http://dx.doi.org/10.1007/s12098-016-2171-6 http://dx.doi.org/10.3126/jnps.v37i1.16202 introduction: materials and methods results discussion limitations conclusion source of funding conflict of interest panacea journal of medical sciences 2020;10(2):79–82 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article effect of surgery on the relief of pain in patients of degenerative lumbar spine disease bhavuk kapoor1, mayank kapoor2, parul vaid3,*, bharat b kapoor4, sharda kapoor5 1dept. of neurosurgery, government medical college and hospital, jammu, jammu and kashmir, india 2dept. of medicine, all india institute of medical sciences, rishikesh, uttrakhand, india 3dept. of obstetrics and gynaecology, smgs hospital gmc, jammu, jammu and kashmir, india 4dept. of anaesthesia and icu, government medical college and hospital, jammu, jammu and kashmir, india 5rbsk jammu division, jammu and kashmir, india a r t i c l e i n f o article history: received 29-06-2020 accepted 26-07-2020 available online 26-08-2020 keywords: degenerative lumbar spine disease pain relief numeric pain rating scale outcome measure a b s t r a c t background: lumbar degenerative spine conditions cause mobility dysfunction and can result in alterations in physical functioning and variable levels of pain. the best measurement of treatment quality in these diseases should be the patient’s opinion of the results using patient-reported outcome instruments. aims: to do comparative evaluation of pain intensity in lumbar degenerative spine patients in preoperative and postoperative period. settings and design: pain intensity of all selected patients was measured at admission and postoperatively using numeric pain rating scale (nprs). materials and methods: effect of surgery on pain relief in 60 patients of degenerative lumbar spine disease was studied. statistical analysis used: paired ‘t’ test was performed to find out the differences in the variables between pre-operative and post-operative stages among the study population. results: preoperative nprs values (mean=7.88) improved at discharge (mean=4.8) and throughout the follow up period at 1month (mean=3.46), at 6 months (mean=2) and 1 year (mean=1.11). conclusions: all the patients showed improvement in their nprs scores throughout the follow up period. the use of nprs outcome instrument gives us a platform to predict a positive and accurate outcome after surgery in the long term. © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction low back pain is a highly prevalent health condition globally. the mean global one-year point prevalence of low back pain is estimated to be 38.0% (±19.4). 1 lumbar degenerative spine disease encompasses degenerative disc disease, spinal stenosis, degenerative spondylolisthesis, degeneration of facet joints and degenerative scoliosis. 2 these conditions can lead to mobility dysfunction and variable levels of pain. surgical treatment is indicated for patients who do not respond to clinical therapy. * corresponding author. e-mail address: kapoorbhavuk14@gmail.com (p. vaid). in the past, surgical outcomes were commonly assessed based on surgeon’s subjective views. however, surgeon’s perspectives frequently do not correlate with patient satisfaction. 3 the patient-reported outcome measures provide a powerful, quantifiable and standardised research tool against which the effectiveness of healthcare interventions can be judged. 4 we did a study to analyse the effect of surgery on pain relief in patients of degenerative lumbar spine disease https://doi.org/10.18231/j.pjms.2020.020 2249-8176/© 2020 innovative publication, all rights reserved. 79 https://doi.org/10.18231/j.pjms.2020.020 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto:kapoorbhavuk14@gmail.com https://doi.org/10.18231/j.pjms.2020.020 80 kapoor et al. / panacea journal of medical sciences 2020;10(2):79–82 2. materials and methods this study was done on sixty patients of lumbar degenerative spine disease. 2.1. inclusion criteria patients of lumbar degenerative spine disease having symptoms of low back pain, neurogenic claudication, difficulty in walking not responding to conservative treatment and willing to undergo surgical treatment. patient aged more than 45 years. 2.2. exclusion criteria patients having spine pathology due to infection, malignancy or trauma. patients undergoing repeat surgery for lumbar degenerative spine disease. 3. methodology patients having symptoms of lumbar degenerative spine disease were admitted in neurosurgery department. a detailed history and clinical examination was done and diagnosis of lumbar degenerative spine disease by various radiological tests like x-ray, mri and ct scan if required was done. after doing routine and specific investigations and after taking informed consent, patients were posted for surgery. ethical clearance was taken. the intensity of pain was assessed in the pre-operative period and post-operatively at the time of discharge, at 1 month, 6 months and 1year interval by making use of the numeric pain rating scale (nprs). 3.1. numeric pain rating scale (nprs) it is used to assess degree of back pain. the nprs is a 0-10 point scale in which 0 is considered no pain and 10 is the worst pain possible. the nprs can be administered verbally (therefore also by telephone) or graphically for self-completion. 3.2. stastistical evaluation descriptive analysis was carried out. parametric data was expressed as mean ± standard deviation. paired ‘t’ test was performed to find out the differences in the variables between pre-operative and post-operative stages among the study population. statistical significance was assumed at a value of p <0.05. findings were statistically analyzed by using statistical package for social sciences (spss) software for windows. 4. results in our study most of the patients were in the age group of 58-70 (56.6%) and total males patients in the study were 32(53.3%) & total females patients in the study were 28(46.7%). most of the patients (58.3%) had duration of symptoms between 1-5 years [table 1]. table 1: duration of symptoms duration of symptoms no of cases percentage (%) < 1 year 17 28.3 1-5years 35 58.3 > 5 years 8 13.3 most of the patients were having preoperative nprs value of 8(40%) [figure 1 ] fig. 1: preoperative nprs values on comparison of mean preoperative nprs value with postoperative values at discharge, 1 month, 6 months & 1 year, there was statistically significant improvement in the postoperative nprs values as compared to the preoperative values [table 2]. 5. discussion persons affected by lumbar degenerative spine conditions are at risk for physical functioning limitations, pain, disability and possible neurologic deficit. we assessed the intensity of pain in patients in the preoperative period and following surgical treatment by using numeric pain rating scale (nprs). the mean age was 59 years in our study. jansson ka et al noted that mean age of patients was 66 years in their study. 5 with an increase in number of elderly population, it is kapoor et al. / panacea journal of medical sciences 2020;10(2):79–82 81 table 2: comparison of preoperative nprs values with postoperative values comparison of different groups mean number of cases standard deviation standard error mean p-value group 1 preoperative-nprs 7.88 60 0.865 0.111 <0.001 discharge-nprs 4.8 60 0.776 0.100 group 2 preoperative-nprs 7.88 60 0.865 0.111 <0.001 1month-nprs 3.46 60 0.832 0.107 group 3 preoperative-nprs 7.88 60 0.865 0.111 <0.001 6months-nprs 2 60 0.552 0.071 group 4 preoperative-nprs 7.88 60 0.865 0.111 <0.001 1year-nprs 1.11 60 0.323 0.041 expected that there will be an increased incidence of patients with degenerative spine disease (miyamoto h, 2008). 6 hence, it is important to know whether surgical treatment is as useful for elderly people as for younger. in our study, there was no statistically significant effect of age on the outcome following surgery. some studies have found that increasing age is associated with less favourable outcome (yamashita k, 2006). 7 other studies have found that increasing age had no effect on the outcome (sigmundsson et aland arinzon et al). 8,9 in our study, there was no statistically significant effect of gender on the outcome following surgery. these findings are in accordance with the findings of thornes e et al, 2011. 10 sigmundsson et alin their study of 109 patients with central spinal stenosis also found that there were no statistically significant differences in outcome parameters between males and females. 8 but several studies have shown that female gender has less satisfaction with the procedure (mariconda m et al , 2000 & shabat s et al , 2005). 11,12 total males in our study were 32(53.3%) & total females in the study were 28(46.7%). in a study of 109 patients with central spinal stenosis in the swedish spine register by sigmundsson et al, there were 56(51.3%) males & 53(48.6%) females. 8 in our study, 58.3% of patients have duration of symptoms between 1-5 years, indicating the chronic nature of the lumbar degenerative spine conditions. there was no statistically significant effect of duration of symptoms on outcome in our analysis. amundsen t et al (2000) also did not find that duration of symptoms had any influence on outcome after a 10-year follow-up. 13 two meta-analyses exploring prognostic factors in spinal stenosis surgery also found that duration of symptoms was not a significant factor influencing the outcome (aalto tj et al. 2006). 14 most (40%) of patients in our study were having preoperative nprs value of 8. so, most of the patients were having severe pain at presentation. mean nprs value in the preoperative assessment in our study was 7.88 (sd = 0.865). in a prospective study of 326 patients who underwent lumbar spine surgery for degenerative disorders by solberg t et al, mean nprs value was 6 in the preoperative period. 15 mean postoperative nprs value at the time of discharge in our study was 4.8 (sd =0.776). comparing preoperative nprs value in our study with postoperative follow up value at discharge, the difference was found to be statistically significant (p < 0.001). mean postoperative nprs value at the time of one month follow up in our study was 3.46 (sd =0.832) and the difference on comparing with the preoperative value was found to be statistically significant (p < 0.001). mean postoperative nprs value at the time of six months follow up in our study was 2 (sd =0.552) and the difference on comparing with the preoperative value was found to be statistically significant (p < 0.001). mean postoperative nprs value at the time of one year follow up in our study was 1.11 (sd =0.323) and the difference on comparing with the preoperative value was found to be statistically significant (p < 0.001). this indicates the reduction of the pain throughout the follow up period and the benefit and success of surgery. our findings are in accordance with the findings in the prospective study of 326 patients who underwent lumbar spine surgery for degenerative disorders by solberg t et alin which they described the criteria for success for nprs by defining the optimal cut off point and they found that the cut off value for success for the mean change score was 2.5. 15 werner dat et al did a study with an aim to identify dichotomous cut offs for failure and worsening. they described "failure" after 12 months for nprs, as an insufficient improvement from baseline, with nprs final raw score > 5.5. in our study mean nprs value was 1.11at one year follow up, hence there was no “failure”. 16 in our study we found that there was large improvement in pain intensity postoperatively. this indicates the benefit of surgical intervention in patients suffering from lumbar degenerative spine disease. 6. conclusions preoperative nprs values (mean=7.88) improved at discharge (mean=4.8) and throughout the follow up period at 1month (mean=3.46), at 6 months (mean=2) and 1 year 82 kapoor et al. / panacea journal of medical sciences 2020;10(2):79–82 (mean=1.11). so, all the patients showed improvement in their nprs values throughout the follow up period, indicating the benefit of surgical intervention. this study confirms that nprs is an important tool to assess the intensity of pain in patients with lumbar degenerative spine disease undergoing surgical treatment. the use of this index helps to predict the outcome after surgery in the long term. the results obtained after using this outcome instrument will be useful as more accurate information could be provided to the patients in future. this indicator could also be used by the surgeon to self audit his work. 7. source of funding none. 8. conflict of interest none. 9. acknowledgement the authors acknowledge the support of their family members. the authors would like to thank all the patients as well. references 1. hoy d, bain c, williams g, march l, brooks p, blyth f. a systematic review of the global prevalence of low back pain. arthritis rheum. 2012;64(6):2028–37. 2. sasiadek mj, bladowska j. imaging of degenerative spine disease-the state of the art. adv clin exp med. 2012;21(2):133–42. 3. haefeli m, elfering a, aebi m, freeman bjc, fritzell p, consciencia jg, et al. what comprises a good outcome in spinal surgery? a preliminary survey among spine surgeons of the sse and european spine patients. eur spine j. 2008;17(1):104–16. 4. haywood kl. patient-reported outcome i: measuring what matters in musculoskeletal care. musculoskelet care. 2006;4(4):187–203. 5. jansson ka, németh g, granath f, jönsson b, blomqvist p. healthrelated quality of life in patients before and after surgery for a herniated lumbar disc. j bone joint surg br. 2005;87-b(7):959–64. 6. miyamoto h, sumi m, uno k, tadokoro k, mizuno k. clinical outcome of nonoperative treatment for lumbar spinal stenosis, and predictive factors relating to prognosis, in a 5-year minimum follow-up. j spinal disord tech. 2008;21(8):563–8. 7. yamashita k, ohzono k, hiroshima k. five-year outcomes of surgical treatment for degenerative lumbar spinal stenosis: a prospective observational study of symptom severity at standard intervals after surgery. spine. 2006;31(13):1484–90. 8. sigmundsson fg, kang xp, jönsson b, strömqvist b. prognostic factors in lumbar spinal stenosis surgery. acta orthop. 2012;83(5):536–42. 9. arinzon zh, fredman b, zohar e, shabat s, feldman js, jedeikin r, et al. surgical management of spinal stenosis: a comparison of immediate and long term outcome in two geriatric patient populations. arch gerontol geriatr. 2003;36(3):273–9. 10. thornes e, ikonomou n, grotle m. prognosis of surgical treatment for degenerative lumbar spinal stenosis: a prospective cohort study of clinical outcomes and health-related quality of life across gender and age groups. open orthop j. 2011;5(1):372–8. 11. mariconda m, zanforlino g, celestino ga, brancaleone s, fava r, milano c. factors influencing the outcome of degenerative lumbar spinal stenosis. j spinal disord. 2000;13(2):131–7. 12. shabat s, folman y, arinzon z, adunsky a, catz a, gepstein r. gender differences as an influence on patients’ satisfaction rates in spinal surgery of elderly patients. eur spine j. 2005;14(10):1027–32. 13. amundsen t, weber h, nordal hj. lumbar spinal stenosis: conservative or surgical management ? a prospective 10-year study. spine. 1976;25(11):1424–36. 14. aalto tj, malmivaara a, kovacs f. preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis. spine. 1976;31:648–63. 15. solberg tk, johnsen lg, nygaard op. can we define success criteria for lumbar disc surgery? estimates for a substantial amount of improvement in core outcome measures. acta orthop. 2013;84(2):196–201. 16. werner dat, grotle m, gulati s, austevoll im, lønne g, nygaard øp, et al. criteria for failure and worsening after surgery for lumbar disc herniation: a multicenter observational study based on data from the norwegian registry for spine surgery. eur spine j. 2017;26(10):2650–9. author biography bhavuk kapoor lecturer mayank kapoor pg resident parul vaid senior resident bharat b kapoor former professor and head sharda kapoor former divisional nodal officer cite this article: kapoor b, kapoor m, vaid p, kapoor bb, kapoor s. effect of surgery on the relief of pain in patients of degenerative lumbar spine disease. panacea j med sci 2020;10(2):79-82. introduction materials and methods inclusion criteria exclusion criteria methodology numeric pain rating scale (nprs) stastistical evaluation results discussion conclusions source of funding conflict of interest acknowledgement 429 too many requests you have sent too many requests in a given amount of time. original research article http://doi.org/10.18231/j.pjms.2019.025 panacea journal of medical sciences, september-december, 2019;9(3):117-122 117 issues of reproductive health after child marriage: a study among nt-dnt community in nashik district of maharashtra rahul ravindra sarwade 1* , jagruti hankare 2 , trupti chavan 3 1phd in public health, 2,3master of public health in social epidemiology, 1-3tata institute of social science, mumbai, maharashtra, india *corresponding author: rahul ravindra sarwade email: srahulrr@gmail.com abstract child marriage is common in community but remarriage are exceptional. women’s marriage, divorce, remarriage, sexual behaviour are all controlled by patriarchal norm living women subject to victimization. women from this community suffer from not only discrimination based on their gender but also caste identity and consequent economic deprivation. women’s problems included gender and economic de privation and social exclusion, which in turn results in the denial of their social, economic, cultural, and political rights. it is evident that the denotified and nomadic women and children being anaemic and live in unhygienic conditions which is confirmed by the field functionaries engaged in the development of the dnt community. out of 15 talukas in nashik four villages were selected by purposive sampling and 200 women were selected for interview for quantitative part of study and six key informants, three elderly women who perform delivery and eight tribal women were selected for inter view for qualitative part of study. tribal women gets married at very young age, and thus susceptible to have low knowledge and misconception about reproductive health which may leads to poor outcomes of the reproductive and sexual health. this study reveals that reproductive health knowledge of nomadic tribal women in nashik district is far below from satisfaction and lack of comprehensive knowledge of repr oductive health prevalently noticed. keywords: marriage, divorce, remarriage, sexual behaviour, dnt. introduction according to definition given by world health organization, reproductive health is a state of complete physical, mental and social well-being, and not merely the absence of reproductive disease or infirmity. in 1994, the international conference on population and development (icpd) held at cairo, egypt, segmented prerequisite for human right framework to address reproductive health issues for poverty eradication. india was signatory to this agreement and had accepted reproductive health as essential for sustainable, economic and environmental development. united nations population information network (popin), in its guidelines for reproductive health states that, reproductive health is right of both men and women which allow them to have access to safe, effective, acceptable and inexpensive methods of family planning. also it is right of a women to have access to suitable health care services which would enable women a safe pregnancy and healthy childbirth. reproductive health not only concerned about family planning, std prevention and management and prevention of maternal and perinatal mortality and morbidity but also look after harmful practices, unwanted pregnancy, unsafe abortion, reproductive tract infections including sexually transmitted diseases and hiv/aids, gender-based violence, infertility problems. reproductive health disorders are responsible for to account for 5% and 15% of the overall disease burden. these are also make a major contribution to the global burden of disability, particularly for women, accounting for 21.9% of dalys lost for women annually compared with only 3.1% for men (murray & lopez, 1998). on an average, 40% of women, which accounts for 300 million pregnant women in a given time suffer from pregnancy related health problems and disabilities(family care international,1998). further, estimated more than 529 000 women die of pregnancyrelated causes each year (who 2006). tribal women are lacking in facilities of health care availability, accessibility and they are unaware about available health care facilities (reddy 2008). through nfhs, we succeeded to enhance and update our database. however, we failed to address some major reproductive health issues among women like morbidity of reproductive health have been neglecting since long time. we are still lacking in data regarding quality of care. likewise, women’s ability to exercise reproductive choice is again one factor, which we have not focused much (jejeebhoy 1999). poor knowledge and understanding of reproductive health problems is major issue in tribal population. among various states where nomadic tribes are prevalent, where hiv cases are measured. awareness and knowledge of aids among indian tribal women had studied. national institute of medical statistics (a body under icmr) average 2.5 million people are living with hiv/aids, where women account for around one million. however with such an alarming context majority population don’t even heard about hiv (nfhs-iii, 2005-06). over 30,000 ever-married women had surveyed about their awareness and knowledge of aids result showed very poor level of awareness of hiv. among those, knowledge of transmission and prevention was very poor. result also showed that rural, poorly educated, and poor women were the least likely to be aids aware and whoever were aware they found with poorest understanding of the syndrome (balk and lahiri 1997). in such way, various studies on reproductive health of tribal women revealed their poor understanding of reproductive health problems. rahul ravindra sarwade et al. issues of reproductive health after child marriage: a study among nt-dnt… panacea journal of medical sciences, september-december, 2019;9(3):117-122 118 many women have perceptions that white discharge, painful menses it happens with everyone and such problems remain unfold (jejeebhoy 2005). in rural india, many women not allow to cook or to worship during menstrual period (jejeebhoy 2005). one study showed that 95% women believe white discharge as most severe problem (bang and bang 1994). in bangladesh, women consider their reproductive health problem and vaginal discharge because of internal body heat (rose et al. 1998). these problems shows that the lack of awareness and false perceptions leads to major health illnesses. it is also observed that in a tribal population, culture and customs are seen with tribes influence the knowledge, beliefs and attitude toward reproductive health (basu, 2000; and salehin, 2012). india is hometown to almost more than half of the world’s tribal population. the population of nomadic tribes in india is 150 million, approximately 15% of total indian population (ministry of tribes). on an average, there are 533 tribes were spread throughout various regions of india (swain, 2003) out of which 15 million in maharashtra. nomadic tribes have specific features because of the ever changing habitat also each tribe is unique in its culture, tradition, values, and believes. nomadic tribes, on an account of their “nomadic” and distinct mode of existence are at a disadvantage. for centuries, the tribal groups have remained outside the process of the general development (ministry of tribal affairs 2010).they move from place to place in search of livelihood and hence deprived of benefits of citizenship in the republic as they don’t have “fixed address of residence”. in such a context, nomads face problem of registration as citizens, sequentially deprived of basic human needs. the deprivation and poverty continues in the community. most of the nomads beg food, gather food, live in extreme unhygienic condition and drink any available water. various studies done so far found that health status of women is one of the significant determinant of maternal mortality (global health action, 2013) reproductive health of nomadic tribal women is rarely addressed as it is considered as natural process. there is a general agreement that the health status of tribal population is very poor. different studies have tried to establish this with the help of morbidity and mortality and health statistics. tribal population have distinctive problem not because they have special kind of health but because of special placement in difficult areas and circumstances they live in (naik et al). santhya et al. (2008), carried out a survey among young men and women in two states of madhya pradesh and andhra pradesh in 2005 to 2007 and observed that the dominance of the men over the sexual relations do not allow their female partner to negotiate for safe sexual practices, this shows male dominance over female sexual behaviour in a community. due to the extreme poverty one who get most affected are women. these indigenous are malnourished (samuel et al, 1992 maiti et al, 2005) and their dietary energy intake is not adequate to compensate long and heavy work load. along with that women does not seek medical facilities from health centres. they simply neglect their even serious health problems like rti/std, pregnancy related complications, menstrual disorders. materials and methods the paper aimed to issue of reproductive health after child marriage among nomadic tribal women of nashik district of maharashtra. this is a descriptive type of study. quantitative method is used to assess socio-economic background, age at marriage, menstruation related knowledge and practices, unmet need of contraceptive, abortion and infertility related information, pregnancy and delivery details and qualitative method is used to understand the respondents perception about services available for maternal health care and socio-cultural practices, belief system and health seeking practices among nomadic tribal women of nashik district, maharashtra. among the target sample, 200 women were selected for interview for quantitative part of study and six key informants, three elderly women who perform delivery and eight tribal women were selected for interview for qualitative part of study from each block the villages were selected by purposive sampling due to the higher concentration of nomadic tribal population. four villages were selected from nashik taluka, one villages from niphad taluka, one village from dindori and one village from trimbak taluka. the tribal communities in the nashik district selected for the sampling pardhi, joshi, vaddar, mariaiwale, vaidu, laman, vanjari, madari, sayyed communities. for in-depth interview, the key informants, traditional birth attendant (tba) and community group leader and elderly women were selected. majority of my target samples reside in the following place so purposively selected. in order to have health situation of nt and dnt community reasonable sample of 25 is taken irrespective of size of those communities the participant of the study adolescents and women who are married and belonging to nomadic tribes specifically in the reproductive period of their life. these women are in age group ranging from 12 to 49 years. results and discussion age at marriage is a significant variable which determines reproductive health of women and men. in nomadic tribes average age at marriage is 12 to 16 years and majority of women got married in same age group. nomadic tribes don’t have idea about age. as child marriages have been prohibited by government communities have raised age limit to 12 to 15 years or according to menarche which is considered as benchmark for deciding age of marriage. it was noted that women in most of the nomadic tribal communities generally got married at a very early age. women in tribal areas could not tell the age at which they marry, but said that usually they get married on commencement of menstruation or within two years of the onset of menstruation. sometimes they decide the marriage or select the groom and wait for menarche to take place. the minimum age of marriage is as low as 8 years. almost half of the population, 43.5 percent women married at the age below 14 years, which can be considered as child marriage. about 54.5% women married at 15 to 18 years of rahul ravindra sarwade et al. issues of reproductive health after child marriage: a study among nt-dnt… panacea journal of medical sciences, september-december, 2019;9(3):117-122 119 age and only 2% women married at age above legal age of marriage. altogether there are 98% respondents who got married before 18 years. mean age of marriage is 14.45%. the elderly women agreed to the fact that, they get their children married just immediately after menarche. reason quoted for this are poverty, culture, fear getting sexually abused. table 1 age of respondent at the time of marriage frequency percentage (%) 08 to 14 years 87 43.5 15 to 18 years 109 54.5 19 and above 2 2.0 the problem of reproductive health of women in india is characterized by its ubiquitous silence. reproductive health status of women is characterized by lack reproductive health knowledge and lack of autonomy of women in india. in general, poor knowledge and rigid patriarchal society creates difficulties for women to fulfil their reproductive health needs. women from marginalized and vulnerable community like nomadic tribal population face additional difficulties to fulfil their unmet need of reproductive health. tribal population of india is recognized as the marginalized section of the society which is characterized by prevalent low knowledge and misconceptions about health related matters. tribal women get married at very young age, and thus susceptible to have low knowledge and misconception about reproductive health which may leads to poor outcomes of the reproductive and sexual health. tribal women faces double burden of environmental difficulties and societal exclusion compared to other communities. various data from national health surveys as well as many other research studies suggested that the reproductive health status of tribal women is poor as compared to the women from other community. most of the earlier studies have focused hiv and contraception of tribal community however comprehensive efforts are essential to understand the reproductive health status of tribal women. the nature of patriarchal society creates difficulties for women in fulfilling their reproductive health needs. the low socioeconomic condition is associated with poverty, lack of awareness about personal hygiene, sanitation, health care & nutrition and livelihood skills to increase productivity using local resources. in reproductive health problems of women, menstrual health problems, rti, abortion and contraception has been explored in this study. respondents who were heard of health problems related to menstruation reported the symptoms related to menstrual problems, menarche is occurrence of first menstrual period in females. majority of respondent had menarche in the age group of 13 to 15 years. 5.5% respondent had experienced it in 16 to 18 years of age group. mean age of menarche 13.48%. further respondent were asked regarding problems suffered during last 6 months. some (31.5%) reported problem related to menstruation. among those who had problem, 16.6 reported painful menstruation, 1.38% reported frequent or short period of menses, 3.47% reported irregular menses while 2.08% have problem of scanty bleeding, 3% had experienced blood clots or excessive bleeding while 4.5% had white or other coloured discharge. few respondent sought medical treatment for these disorders. they consider it normal and expected to occur sometime later in life. practices related to menstruation 66% respondent use old washed cloths while only 4% use sanitary napkin and 3% use new cloths. almost 15% of the respondent do not use any of the absorbent material during menses which they had experienced in the last three months. around 25% of the women in same place of study region reported to have experienced menstruation related problems. most prevalent problems reported by respondents were painful period, irregular periods and scanty bleeding. this result of the study was inconsistent with many other studies (singh et al. 1999; karthiga, 2011; kulkarni and durge 2011; nair et al. 2012; mohite et al. 2013) which reported, lower abdominal pain during menstruation as most frequent menstrual complaint. majority of the women used cloths as menstrual napkins and. 15% of the respondents not even using any absorbent material, respondent were asked about their pattern of using material on first and second day of menstruation. one respondent stated that absorbent material is not used by them. according to them there is no place to reside, the question storage of cloths is not valid. her response regarding changing cloths was, “aamchyat kunibi asal vaparat nahi. aamacha rahayacha thikana nahi mag kapde kuth sathavnar? municipality yeun aamach saman fekun detyat, ithun haklun detat, samanach kam rahyal? (24 years, female, nashik)”. there is always fear of leaving place due to pressure from municipality administrator, then it is difficult to store any stuff. again privacy is the major issue. open places where pal are situated privacy is serious problem for women, they have to get up early at 4-5 o’ clock for bath. when asked regarding bath and hygiene during menstrual cycle, one respondent said, “anghol “kay kay bayka kartat parda laun hitach, tith bathroomch pach rupay ghetyat an kapde dhuvayach dha rupay, mag kapad dhuvayala kuthun parvadnar?”. this means only few women can manage to take bath on the open space with the help of cloths as a curtain in early morning. it is difficult for women residing here to spend five rupees for bathing and 10 rupees for washing clothes. affordability bring restriction over hygiene and sanitation. income affects adversely the use of bathroom and toilet facilities. a14 year old married girl from pardhi community) said, “aami asal kay nay vaparat, sadi na petikotach vaprato, an pali geli ki dhuvun takto.” which means all in our tribe don’t use any absorbent material, what we do is let soak cloths (saree and petticoat) with blood and according to availability of money, go to bathroom for washing. mostly they take bath after four to five days, after menstruation is over. a 13 year gajra vendor girl said, “pali ali ki hitach basun rhav lagat, pais hatat astil tas angholila jato.” respondent tries to explain that whenever i have menses i have to sit at one place. if i would have money then i would go to have bath. which suggest restriction laid by rahul ravindra sarwade et al. issues of reproductive health after child marriage: a study among nt-dnt… panacea journal of medical sciences, september-december, 2019;9(3):117-122 120 menses compel women to sit at a place for 14 to 15 hours a day for 3 to 5 days just to avoid mobility. while answering frequency of changing pads, respondent said that there is scarcity of drinking water, it if difficult to waste water for changing cloths, thus we use cloths and through them after use. these are those old cloths which they get from houses. elderly key informant respondent from madari tribe said, “ladki log lagate purana kapada, vaparneke baad fenk dete kachare me, pani kahaa hai dhone ke lie, yahaan pe pine ke pani ka vaanda hai”. this suggest that lack of water resource restrict the use of water for menstrual and personal hygiene. their personal hygiene during menstrual period is very poor which is mainly due to lack of knowledge about the diseases that occur can occurred due to unsanitary condition, lower socio-economic status and the inaccessibility to sanitary pads. though unlike hindu culture there aren’t social or cultural rituals which restricts women or seclude them but problem is with availability of bathroom or toilet, accessibility of clean and sufficient water are major issues. not having toilet or secure place with adequate privacy for managing menstrual hygiene existed for many respondent at which would normally be changed around two to four times during menstruation. they usually take bath on fifth day of menstruation as bathrooms are not affordable to them. they wash their genitals with water only when they go to toilet which shows agony through which women has to go. lack of water, absorbent material, lack of awareness about menstrual hygiene, community perception and taboos these are multiple factors which make situation complex. though most of the women were experiencing their menstrual problems since long duration, very few women had discussed about it with husbands. as compared to other reproductive health problems like abortion, rti, infertility, women had discussed less regarding menstrual health problems. the reason could be lack of privacy or stigma and their habit and belief to consider it as general problem. this becomes the most difficult task while educating the people. ronald had discussed the same culture and beliefs in his article (andersen 1995). respondents who had received treatment for the problem of menstruation largely prefer the traditional healers followed by government hospital (phc). this might be because tribal respondents were engrossed with superstitions. these people have faith in traditional healers who practice magical and religious rites. along with this, traditional healers also use indigenous herbal treatment for the common symptoms of diseases. similar situation had explored in one study where author had studied determinants of tribal health care in chhattisgarh state. study had suggested that the traditional folk medicine and health culture play a significant role in shaping tribal life (balgir 2011). in studied population, majority of respondents were aware about the problem of difficulty in conceiving and 12.3% respondent had experienced problem in conceiving. prevalence of problem in conceiving was reported for the first conception. respondents had received treatment for the problem of difficulty in conceiving but they did not have knowledge about the treatment. respondents were unaware about who exactly had problem, which was causing difficulty in conceiving. majority of respondents received treatment from traditional healers followed by government hospital for, their problem of difficulty in conceiving. majority of respondents had heard about the abortion, but did not know exact knowledge about spontaneous and induced abortion. around 23% respondents have experienced abortion, which is very high. women don’t have any source of information about abortion and appropriate places for abortions. most common methods of contraception known to the respondents were female sterilization, followed by contraceptive pills and condom. awareness of respondents found to be very low about male sterilization, iud and emergency pills. use of contraception found to be low negligible. most prevalent method of contraception used by respondents was female sterilization followed by contraceptive pills and condom. majority of respondents had utilized government health sector for contraception. almost 90% admit that they don’t have any idea about contraceptives and whatever they know is about female operation. a 22 years old respondent working as a construction worker who had given a still birth at 9 months pregnancy said,“potat rahilel na navava mahinyat dactarla dakhival ter te mhanal por halat nahi tela baher kadhav lagel, te pani laun baher kadhal tar par jalal (maceration due to stillbirth) hot, konachi tar baa karni zali asal.” a respondent had stillbirth at ninth month of pregnancy which required delivered with medical aid. as there was no fetal movements baby was macerated. but event is associated with supernatural powers and black magic. women don’t have any check-up before and after delivery, neither they have awareness of those check-up for wellbeing of baby and new-born. result of this, they give adied children after going through pain for whole nine months, which is absolutely distress for women. a women working for telephone cables road digging work on contract basis, said, ‘unha tanhach kama karav lagat bai, techyat potat kas rhail. don vel pot khali zal mah gharatach. kunala dakhvav. garibacha kuth dactar? (29 years, vadar tribe) a women shared her experience of abortion twice in past. she had not visited any medical personnel and associate it with hard physical work. also issue of poverty is also mentioned. it shows sheer agony of women who has to work hard irrespective of any whether. though she is not able to have money which could be used for her abortion treatment. it is miserable condition where women can’t access treatment doe to extreme poverty. it clearly indicate poor knowledge and awareness about contraceptives. women wanted to use spacing methods but don’t have any idea about how to get privilege of contraception. high fertility and subsequent deliveries made women suffer. pregnancy related information-the wide range of population have not registered themselves in the institution for pregnancy. number of visits to institute for anc check-up are very less. women hardly go to hospital. hospitals are last option for complications during pregnancy. less than 30 percent women had visited for any kind of anc check-up during their last pregnancy. though prevalence of complication is less in community, women are reluctant to visit even to get iron and folic acid supplementation. due to extreme poverty, rahul ravindra sarwade et al. issues of reproductive health after child marriage: a study among nt-dnt… panacea journal of medical sciences, september-december, 2019;9(3):117-122 121 gender differential, cultural norms and lack of awareness about pregnancy there isn’t concept of supplementary nutrition. pregnancy is treated as natural phenomenon and women doesn’t get any additional befit even at household level. as a result of this, women are malnourished and underweight. home delivery is choice of delivery and hospital delivery are preceding options to complications. most of the time deliveries are carried out by mother in laws and traditional birth attendant and measures adopted buy them are unethical and unhygienic. the abandoned mothers do deliveries of their own at times husband carries out delivery. it put light on the fact that community need assistance for safe motherhood, else life of women is on the edge of death. those who have awareness about institutional delivery but have many barriers in accessing these services. majority of population could not access due to expensive hospital treatment. 90% were reluctant to go to hospital as the environment is not comfortable and stay is long at hospital because of which families suffer. the influence of societal pressure is so much so family does not allow them to go to hospital. even wide range of population have not realized benefits of institute delivery and thus they don’t feel it is required to go to hospital during pregnancy. sheer 14.2% women could receive post -natal care. 48 hours post delivery are considered as crucial period. but none of the government scheme could reach these women. it is ironical that 70% women have to resume to her work immediately post delivery. she hardly get 10 days rest after such exhaustive physiological process. prevalence and awareness of rti/sti. an attempt was made to assess whether respondents were aware of rti/sti. forty percent respondents were reported that they had heard of rti. information was collected on the common symptoms of reproductive tract infections and sexually transmitted infections from women. the prevalence of reproductive tract infections (rti) and sexually transmitted infections (sti) is judged by their symptoms. 31% of respondents reported that they had experienced symptoms related to rti. low backache was the prevalent symptom reported by respondents followed by abnormal vaginal discharge, respondents reported, itching or irritation over vulva, significantly, also found vaginal discharge as the most frequent symptom of reproductive tract infection. majority of respondents had not discussed about their problem of rti with their husband. respondents with vaginal discharge reported that vaginal discharge was wet, mucoid and with blood stain. studies by khanna et al. (2005), jain et al. (2009) and nair et al. (2012) also found abnormal vaginal discharge as the most frequent symptoms of reproductive tract infection. majority of respondents recorded their source of information for rti. husband and relative were found to be major source of information for the high proportion of respondents. proportion of respondents reported for the print media as source of information was very low; it might be because of illiteracy they are not convenient with print media. in case of the presence of at least one symptom, healthseeking behaviour of respondents was reported for rti/sti. conclusion reproductive health of women is important indicator for the good health status of women. this study reveals that reproductive health knowledge of tribal women in nashik district is far below from satisfaction and lack of comprehensive knowledge of reproductive health prevalently noticed. reproductive morbidities found to be more prevalent among tribal women of study area. mean age of marriage is 14 years for female and 17 years for men, both less than legally defined marriage age. total fertility rate, high early marriage, successive pregnancies accompanied with low calorie of food intake and inaccessibility, and underutilization of medical facilities lead to high maternal morbidity and mortality rate. 'maternal depletion' is thus the result of early mating, continuous cycles of pregnancy. more than half of the women reported with one or more symptoms related to menstruation and rti. among these respondents, pain in abdomen related to menses, abnormal vaginal discharges, low backache and genital itching and boils over vulva are the main reproductive morbidities reported during this study. with this scenario, more than two third of women did not seek any treatment. hence, their treatment seeking behaviour has been found to be very poor. very significant difference has been found in awareness and use of contraception normal thing. this makes delay in diagnosis and treatment of diseases. due to the geographical constraint, respondents could not seek treatment easily. to travel to phc and district hospital become very difficult through this hilly area, therefore patient mostly prefers traditional healer first as the service is readily available in village. for the first step, respondents in this study area approach to traditional healers and then if disease not get cure they approach to the government hospital. while concluding the topic paper would like to mention there is lot of scope to improve reproductive health of women through health education. there are some socio-economic and social determents, which are deeply rooted in community and responsible for the vulnerability of women. by addressing these determinants, it is possible to improve reproductive health of women in study area. source of funding none. conflict of interest none. references 1. anderson, j. (1973). health services utilization: framework and review europepmc.org/articles/pmc1071757/pdf/hsresearch005640011 2. bokil m. de-notified and nomadic tribe: a perspective, economic and political weekly, 2002;37(2):148-15. 3. chauhan p. maternal mortality among tribal women as per gravidity at a tertiary level of care in baster chhattisgarh, india. int j biol med res 2012;3(1):1377-84. 4. ekka n. impact of modernization on tribal religious customs and traditions: a case study of rourkela. 2013. rahul ravindra sarwade et al. issues of reproductive health after child marriage: a study among nt-dnt… panacea journal of medical sciences, september-december, 2019;9(3):117-122 122 5. freedman l. (2004). interim report of millennium project taskforce 4 on child health and maternal health. new york: undp. 6. fuchs s. (1979). aboriginal tribes in india. delhi: macmillan india ltd. 7. gaikwad l. (1987). uchlya (marathi). shree prakashan pune. 8. galaty. (1981).the world of pastoralism, the guilford press, new york and london. 9. glacier. sexual and reproductive health: a matter of life and death, lancet 2006;368:1595–607 10. glacier a, ahmet. sexual and reproductive health: call for papers, 2005;366. 11. http://www.epw.in/journal/2007/40/editorials/denotified-andnomadic-tribes-nowhereexistence.html#sthash.roz9dc3x.dpuf. 12. http://www.thehindu.com/thehindu/mag/2003/07/06/stories/20 03070600770100.htm..(vaidu) 13. jayakrishnan. health problems of construction workers. int j med public health 2013;3(4). 14. jejeebhoy, sandhya. (2011). sexual, reproducyive health of young people in india: a review of policies, law and programmes. 15. langer a. cairo after 12 years: successes, setbacks, and challenges. lancet, 2006;368. 16. lashkar v. denotified and nomadic tribes of maharshtra in india. int j ideas, 2012;26(309). 17. mahapatro s. utilization of maternal and child health care services in india: does women’s autonomy matter? j family welf. 2012;58(1). 18. mahatribal.gov.in. doi: 02/03/2017. tribal development commisionarate, tribal development department, government of maharashtra. 19. majumdar, n. (1944). the fortunes of primitive tribes. lucknow: universal publishers. 20. national commission for denotified, nomadic and seminomadic tribes. ministry of social justice and empowerment, government of india, report, vol.1, 2008. 21. newman l. global estimates of syphilis in pregnancy and associated adverse outcomes: analysis of multinational antenatal surveillance data. plos med 2013;10(2):e1001396. doi:10.1371/journal.pmed.1001396 niti.gov.in/content/maternal-mortality-ratio-mmr-100000-livebirths. doi: 02/03/2017. 22. pachauri, s and subramanian s. management of reproductive tract infections in women: lessons from the field, implementing a reproductive health agenda in india: 1998;435–505. 23. prashant. determinants of maternity care services utilization among married adolescents in rural india. preventing low birth weights, national law academics, institute of medicine, 1985. 24. radhakrishna m. colonial construction of a ‘criminal’ tribe: yerkulas of madras presidency, economic and political weekly. 2000;35;(28):2553-63. 25. rathod, m. “the denotified and nomadic tribes rights action group newsletter”, dnt rights action group 6 united avenue, near dinesh mills, vadodara, india. 26. ray s, dasgupta a. determinants of menstrual hygiene among adolescent girls: a multivariate analysis. natl j community med. 27. reddy s. health of tribal women and children -: an interdisciplinary approach. indian anthropologist. 2008;38(2):61-74. 28. reproductive health in india (1994). forum for women's health. womens health newsl. 29. reproductive health in india, (1994). forum for women’s health, national library of medicine, national institute of health. 30. sabharwal, n and sonalkar, w. (2015). dalit women in india: at the crossroads of gender, class, and caste global justice: theory practice rhetoric. 31. salehin m. (2012). reproductive health of tribal populations in india: a sustainability approach, the university of texas at arlington. 32. salehin m. (2012). reproductive health of tribal populations in india: a sustainability approach. 33. sexual & reproductive health: http://www.unfpa.org/sexualreproductive health#sthash.dqdicv9f.dpuf 34. shweta. (2004). health and social welfare of de-notified and nomadic tribes in india). 35. shweta. an intense blind spot of gender and health in india three times the size of nordic countries: health & reproductive health concerns of denotified and nomadic tribe women & girls. indian streams res j 2014;4(2). 36. singh, b. (2012). intervention of female identity in denotified tribes. 37. tarafder t. reproductive health beliefs and their consequences: a case study on rural indigenous women in bangladesh. aust j reg studies 2014;20(2):351. 38. the millennium development goals report (2015). the united states government global health initiative: strategy document, 39. unicef. (2008) state of the world’s children 2009. new york. 40. united nations news center, 2010. 41. vinitha c, singh s, rajendran a. health and population perspectives and issues: level of reproductive health awareness and factors affecting it in a rural community of south india. 2007;30(1):24-44. 42. voices of dnt/ nt communities in india. (2016). government of india. 43. vora s. maternal health situation in india: a case study. j popul nutr 2009;27(2):184-201. 44. www.mapsofindia.com › maps › maharashtra map › districts. doi: 01/03/2017. 45. www.unfpa.org/maternal-health. doi: 02/03/2017. 46. www.shodhganga.inflibnet.ac.in/bitstream/10603/2019/1 http://www.epw.in/journal/2007/40/editorials/denotified-and-nomadic-tribes-nowhere-existence.html#sthash.roz9dc3x.dpuf http://www.epw.in/journal/2007/40/editorials/denotified-and-nomadic-tribes-nowhere-existence.html#sthash.roz9dc3x.dpuf http://www.epw.in/journal/2007/40/editorials/denotified-and-nomadic-tribes-nowhere-existence.html#sthash.roz9dc3x.dpuf http://www.thehindu.com/thehindu/mag/2003/07/06/stories/2003070600770100.htm..(vaidu) http://www.thehindu.com/thehindu/mag/2003/07/06/stories/2003070600770100.htm..(vaidu) http://www.unfpa.org/sexual-reproductive http://www.unfpa.org/sexual-reproductive editorial http://doi.org/10.18231/j.pjms.2020.001 panacea journal of medical sciences, january-april, 2020;10(1):1-2 1 covid-19: a dreaded pandemic tanuja p. manohar 1* , ramesh p mundle 2 1professor, dept. of medicine, n. k. p. salve institute of medical sciences & research centre and lata mangeshkar hospital, digdoh hills, hingna road, nagpur, maharashtra, india *corresponding author: tanuja p. manohar email: tanuja.manohar9@gmail.com what started as an unusual respiratory tract infection in wuhan, china in december 20191, has spread it’s roots across the globe, in all continents except antarctica. controversy related to origin of this virus is still remained unanswered. because of it’s resemblance to sars virus, this new virus was labeled as severe acute respiratory syndrome-corona virus 2 (sars-cov2) 2 and disease caused by sars-cov2 is referred to as covid-19. 3 disease predominantly spreads by respiratory droplets, directly or through fomites.4 clinical spectrum of covid-19 varies from asymptomatic or mild to severe life threatening cases. incubation period is 2-14 days. fever,cough and shortness of breath being commonest symptoms, fatigue, shaking chills and loss of sense of smell and taste are also commonly found symptoms. almost 81% patients have mild symptoms while 14% need admission to hospital and only 5% become critical and require icu care.5 older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) appear to be more vulnerable to becoming severely ill with the virus.5 diagnosis is based on detection of viral antigen in respiratory secretion by reverse-transcriptase polymerase chain reaction (rt-pcr).6 we are adopting guideline laid by icmr for testing the samples. who has advised measures like aggressive case finding, test all suspect cases, and test all of their contacts who develop symptoms. amongst all states kerala adopted these measures meticulously and to great extent able to contain spread of virus. many experts from our own country and also globally criticized india for testing less number of samples and thereby projecting less number of cases than actual. however resource limited country like india, possibly this is the best policy. who declared covid-19 as pandemic on 12th march 2020. government of india took many proactive steps right from beginning of pandemic even before first case was detected in india. measures like screening of incoming air passengers, followed by suspension of visas and a ban on international flights were done much ahead of any other country. thermal screening of incoming international passengers from china and hong kong was started on 18th january. in india first case of covid-19 was detected on 30th january in a person who was returned from wuhan, china. india started taking social distancing measures like closing workplaces and schools before reaching 100 confirmed cases. social awareness related to importance of hand wash, social distancing was also started simultaneously. when india was struggling to reduce spread of virus by all means, an important major lapse occured as a result of a religious gathering at delhi. from then onwards cases started increasing all across the country. on 25th march nationwide lock down was imposed on india, initially for 3 weeks and was extended further twice in majority of states. this was necessary step taking into consideration, population density, proportion of patient below poverty line and less developed public health-care system especially in rural india. whatever may be the reason, like immunity of indian people, less virulent strain of virus, climatic condition or proactive government initiatives, so far india is able contain disease as compared to western world, where there is robust health care system, more aggressive testing strategy and better literacy level. according to some experts, a lockdown might delay severe cases for a while, but once restrictions are eased, cases will reappear.7 the key health care challenge of the covid‐19 pandemic is the safe delivery of respiratory support on a large scale. post lock down, there can be surge or steep rise in number of covid-19 cases. ultimately it is predicted by experts in the field that major population will get infected at the end of an year or so7. because of lockdown indian authorities got time to prepare ourselves to face this dreaded pandemic. government is trying to strengthen our health care system by training doctors, developing infrastructure and revitalizing already existing health schemes. also during this period scientists across the globe may get at-least some direction towards development of new drug or vaccine. as countries around the world are preparing for reopening of their economies and a gradual return to normal life, we in india should also start thinking in those lines about new post-covid era. there is no doubt that covid-19 is going to dictate every aspect of our lives in almost every corner of the country. also there will be huge effect on various industries especially hospitality, entertainment, airlines, shopping malls etc. drastic changes are also expected to occur in funding for health-sector, which has remained neglected so far in india. the covid19 pandemic crisis is a true eyeopener reminding the governments across the globe about importance of investing in healthcare sector. conflict of interest none. mailto:tanuja.manohar9@gmail.com tanuja p. manohar et al. covid-19: a dreaded pandemic panacea journal of medical sciences, january-april, 2020;10(1):1-2 2 source of funding none. references 1. world health organization. pneumonia of unknown cause china. emergencies, preparedness, response, disease outbreak news, world health organization (who) 2020 jan. disease outbreak news, 5 january. 2. coronaviridae study group of the international committee on taxonomy of viruses. the species severe acute respiratory syndrome-related corona virus: classifying 2019-ncov and naming it sars-cov-2. nat microbiol. 2020;5(4),536-44. https://doi.org/10.1038/s41564-020-0695-z. 3. who director-general’s remarks at the media briefing on 2019-ncov on 11 february 2020. available on: https://www.who.int/dg/ speeches/detail/who-director-general-s-remarks-at-themedia briefing-on-2019-ncov-on-11-february-2020. 4. modes of transmission of virus causing covid-19: implications for ipc precaution recommendations. scientific brief 29 march 2020 who/2019-ncov/sci_brief/transmission_modes/2020. 5. pauline v, lan vd, l’huillier a g, manuel s, laurent k, frederique j. clinical features of covid-19. bmj. 2020;369:m1470. 6. tang yw, schmitz je, persing dh, stratton cw. the laboratory diagnosis of covid-19 infection: current issues and challenges. j clin microbiol. 2020. doi:10.1128/jcm.00512-20. 7. giesecke j. the invisible pandemic. www.thelancet.com, 2020. https://doi.org/10.1016/s0140-6736(20)31035-7 how to cite: manohar tp, mundle rp. covid-19: a dreaded pandemic. panacea j med sci. 2020;10:1-2. https://doi.org/10.1038/s41564-020-0695-z jan june 2012 for pdf for website non invasive mechanical ventilation in clinical practice and cons pros 1 choudhary sumer s abstract noninvasive positive-pressure ventilation is a type of mechanical ventilation that does not require an artificial airway. studies published in the 1990s that evaluated the efficacy of this technique for the treatment of diseases like chronic obstructive pulmonary disease, congestive heart failure and acute respiratory failure have generalized its use in recent years. important issues include the selection of the type of ventilation interface and the type of ventilator. currently available interfaces include nasal, oro-nasal and facial masks, mouthpieces and helmets. comparisons of the available interfaces have not found any one of them to be superior. both critical care ventilators and portable ventilators can be used for noninvasive positive-pressure ventilation; however, the choice of ventilator type depends on the patient's condition and therapeutic requirements. the best results (decreased need for intubations and decreased mortality) have been reported among patients with exacerbations of chronic obstructive pulmonary disease and cardiogenic pulmonary edema. key words: non invasive, mechanical ventilation, respiratory, interfaces 1 associate professor, dept of pulmonary medicine nkpsims & rc, digdoh hills, hingna road, nagpur-440019 sumer_choudhary@yahoo.co.in objectives 1) to review recent scientific advances in non invasive mechanical ventilation that is important for a clinical practitioner. 2) to understand the utility and limitations. 3) to understand appropriate method and indication of non invasive mechanical ventilation. 4) to appreciate noninvasive mechanical ventilation when interpreted in context of relevant patient information. 5) to understand that additional study is required to further characterize both current and future roles of non invasive mechanical ventilation. introduction non invasive mechanical ventilation (niv) is the delivery of mechanical ventilation to patients with respiratory failure without the requirement of an artificial airway. the key change that led to the recent increase in the use of this technique occurred in the early 1980s with the introduction of the nasal continuous positive airway pressure mask for the treatment of obstructive sleep apnea. studies published in the 1990s that evaluated the efficacy of noninvasive positivepressure ventilation for treatment of diseases such as chronic obstructive pulmonary disease, congestive heart failure and acute respiratory failure have generalized its use in recent years(1). the aim of niv includes not only the correction of alveolar hypoventilation, but also unloading of the respiratory muscles. non invasive ventilation reduces the work of breathing, allowing resting of respiratory muscles and recovery of muscle function. noninvasive positive-pressure ventilation includes various techniques for augmenting alveolar ventilation without using endotracheal airway. the clinical application of noninvasive ventilation by use of continuous positive airway pressure alone is referred to as "mask cpap," and noninvasive ventilation by use of intermittent positive-pressure ventilation with or without continuous positive airway pressure is called noninvasive positive techniques and equipment used for noninvasive ventilation interfacesthe major difference between invasive and noninvasive ventilation is that with the latter technique gas is delivered to the airway via a mask or "interface" rather than an invasive tube. interfaces are devices that connect the ventilator tubing to the patient's face and facilitate the entry of pressurized gas into the upper airway. the choice of interface is a crucial issue in noninvasive ventilation. currently available interfaces include nasal, oronasal and facial masks, mouthpieces and helmets. comparisons have not shown a clear superiority of one interface over the others. for treatment of acute respiratory failure, facial masks are most commonly used (70% of cases), followed by nasal masks (25%) and nasal pillows (5%) (2). a full face mask is often a superior choice for patients with predominant mouth breathing because it reduces oral air leakage. the face mask permits mouth breathing, and it delivers higher ventilation pressures with less leakage and requires less patient cooperation than other interfaces. compared with nasal masks, the more common use of full-face masks for the treatment of chronic respiratory failure is a reflection of better quality of ventilation (at least initially) in terms of improved minute ventilation and blood gases (3,4) however, face masks generally increase claustrophobia, impede communication, limit oral intake and expectoration of airway secretions and increases dead space, which may cause co2 rebreathing. 7 pjmsvolume 2 number 1: january-june 2012 review article bronchospasm airway mucus airway inflammation diaphragm flattening air trapping raw elastic recoil peepi muscle weakness cpap/ peep dyspnoa work of breathing ippv respiratory muscle failure vt paco2 figure1 when paco2 is increased, and minute ventilation is normal or increased, the respiratory muscles are failing to generate sufficient alveolar ventilation to eliminate the co2 being produced . means of correcting this patho-physiology include increasing alveolar ventilation by increasing tidal volume and/or respiratory rate, and reducing co2 production (vco2) by decreasing the work of breathing. respiratory muscle failure can occur when the work of breathing is normal (e.g. numerous acute or chronic neuromuscular problems), or increased (e.g. patients with chronic obstructive pulmonary disease, asthma, or the obesity hypoventilation syndrome), and presumably because of inadequate delivery of oxygen to the respiratory muscles (e.g. approximately one third of patients presenting with cardiogenic pulmonary edema). when paco2 is increased and minute ventilation is low, the level of consciousness is generally impaired. such patients usually require intubation for airway protection in addition to ventilatory assistance, unless the hypercapnia can be reversed within minutes. figure1 mechanism of respiratory failure in copd the helmet interface, which is a recent introduction, has important advantages over other interfaces. it is well tolerated by patients, allows acceptable interaction with the environment and can be used in difficult anatomic situations, such as for patients who are edentulous or have facial trauma. in contrast to facial masks, helmets do not make contact with the patient's face and therefore do not cause skin lesions. helmets improve comfort, which permits longer periods of noninvasive positive-pressure ventilation delivery. however, because helmets are larger than facial masks, the pressure within the system during ventilation may be dissipated against the high compliance of the helmet, thus interfering with correct pressurization and ventilator function (5-7). ventilators and modes of ventilation the choice of ventilator type should depend on the patient's condition and on the expertise of the attending staff, the patient's therapeutic requirements and the location of care (8,9). the most common modes of non-invasive ventilation are continuous positive airway pressure and pressure support. although continuous positive airway pressure is not a true ventilation mode, it is often referred to as a form of noninvasive ventilation. this technique delivers constant positive pressure during both inspiration and expiration, either by use of a flow generator with a high pressure gas source or by use of a portable compressor. continuous positive airway pressure can only be used if the patient is breathing spontaneously because it cannot support ventilation in the absence of a respiratory drive. the physiologic effects of continuous positive airway pressure include augmentation of cardiac output and oxygen delivery, improved functional residual capacity and respiratory mechanics, reduced effort for breathing and decreased left ventricular afterload. in patients with left-sided heart failure, continuous positive airway pressure improves the shunt fraction and reduces the inspiratory work of breathing(10). in chronic obstructive pulmonary disease, continuous positive airway pressure reduces the work of breathing by counterbalancing the respiratory threshold load imposed by the intrinsic positive end-expiratory pressure created by airflow obstruction(11). pressure support ventilation allows the patient to control inspiratory and expiratory times while providing a set pressure. in conjunction with patient effort and respiratory mechanics, the set pressure determines the inspiratory flow and tidal volume. the combination of inspiratory assistance with expiratory positive airway pressure (also known as bilevel ventilation or bilevel positive airway pressure) is thought to 8 pjmsvolume 2 number 1: january-june 2012 review article pathophysiology reduce the work of breathing and to alleviate respiratory distress more effectively than continuous positive airway pressure alone. indications: exacerbations of chronic obstructive pulmonary table 1 : recommendations from the international consensus conference in intensive care medicine for the use of noninvasive positive pressure ventilation in acute respiratory failure : l noninvasive positive-pressure ventilation can be initiated in the emergency department if staff have been adequately trained. l until more data are available, most patients who receive noninvasive positive-pressure ventilation should remain in an intensive care unit or in a system of care that is capable of providing high-level monitoring and where immediate access is available to staff skilled in invasive airway management. l for selected patients with exacerbations of hypercapnic chronic obstructive pulmonary disease (ph>/=7.30), noninvasive positive-pressure ventilation may be initiated and maintained in the ward if staff training and experience are adequate. l if noninvasive positive-pressure ventilation is initiated outside the intensive care unit, failure to improve gas exchange, ph, respiratory rate or dyspnea or the deterioration of either hemodynamic or mental status should prompt referral to the intensive care unit. diseaseconventional management of exacerbations of c h r o n i c o b s t r u c t i v e p u l m o n a r y d i s e a s e i n c l u d e s bronchodilators, steroids, antibiotics and oxygen. non responders and patients whose condition is severe may require ventilation support. noninvasive positive-pressure ventilation is a well-evaluated intervention for these indications. an international consensus conference on noninvasive ventilation has recommended noninvasive positive-pressure ventilation as first-line treatment for exacerbations of chronic obstructive pulmonary disease that meet the criteria described in table 1 (12). the recommendations of the british thoracic society for treatment failure in noninvasive ventilation are shown in table 2 (13). noninvasive positive-pressure ventilation has been compared with invasive mechanical ventilation in a randomized controlled trial (14) that included 49 cases of chronic obstructive pulmonary disease with severe acute respiratory failure in which ventilator support was necessary. respiratory failure was more severe in the cases enrolled in this study compared with previous studies. in addition, in previous trials noninvasive positive-pressure ventilation was used at an earlier stage (indicated by an average ph on study entry of 7.20). within the noninvasive positive-pressure 9 surfactant abns airspace filling crs post-op changes venous return l v afterload airspace closureairway narrowing alveolar hypoventilation cpap/peep ipap cpap/peep ipap shunt low v /qa f o1 2 hypoxemia airspace collapse alveolar filling obesity shunt f o1 2 peep peep hypoxia low v /qa hypoxemia develops as a result of alveolar hypoventilation (which is accompanied by increases in paco and is addressed in figure 1) and from perfusion going to areas where the ratio of alveolar ventilation (va ) to perfusion (q) is < 1 0 (i e low va /q or , in the extreme, shunt, where perfusion is going to areas of no ventilation). hypoxemia is treated by augmenting the inspired fio2 (the lower the va /q, the less the effect), and by recruiting airspaces. airspace recruitment occurs when the transpulmonary pressure falls below the airspace collapsing or closing pressure (as occurs in numerous conditions that alter surfactant or that decrease the lung or the chest wall compliance), and when the trans-pulmonary pressure applied during inhalation fails to exceed airspace opening pressure. accordingly , airspace opening can be facilitated by increasing the trans pulmonary pressure applied at end exhalation (cpap) and at end inhalation (i.e. pap) an additional beneficial effect of cpap and pap may be seen in patients with cardiogenic pulmonary edema as they reduce venous return and functionally reduce left ventricular after load. figure2 mechanism of action of non invasive ventilation pjmsvolume 2 number 1: january-june 2012 review article control group. additional evidence of the long-term benefits of noninvasive positive-pressure ventilation was presented by confalonieri and colleagues (15). among patients with chronic obstructive pulmonary disease exacerbations, patients who received noninvasive positive-pressure ventilation had increased survival at 6 months and at 1 year. therefore, for selected patients with exacerbation of chronic obstructive pulmonary disease, the early use of noninvasive positive-pressure ventilation as a first-line therapy is associated with increased survival and decreased length of stay in hospital. although the use of this therapy at advanced stages of acute respiratory failure is more likely to fail, a trial of noninvasive positive-pressure ventilation before proceeding to intubation and invasive ventilation does not seem to harm the patient and may be attempted cautiously. however, the patient should be closely monitored in an intensive care unit and, if required, intubation should be performed without excessive delay. a schematic approach, initially proposed by sinuff and colleagues (16), for the use of noninvasive positivepressure ventilation in cases with exacerbations of chronic obstructive pulmonary disease is shown in figure 3. there is limited available information about the withdrawal of noninvasive positive-pressure ventilation; thus, the strategy proposed by sinuff and colleauges (16) may be helpful in cases of chronic obstructive pulmonary disease (figure 4). asthmathe low incidence of acute respiratory failure secondary to status asthmaticus (17) may be the reason why few studies have evaluated the efficacy of noninvasive positive-pressure ventilation in this setting. in a prospective study involving 17 patients with status asthmaticus, meduri and colleagues (18) reported that noninvasive positivepressure ventilation (by use of a face mask) with a low inspiratory pressure is highly effective in correcting gas exchange abnormalities. of the 17 included patients, 2 (12%) required intubation and none developed complications. in a retrospective study involving 33 patients who had been admitted to an intensive care unit for status asthmaticus, fernández and colleagues (19) reported that 11 patients received invasive mechanical ventilation and 22 patients received noninvasive positive-pressure ventilation. they found no differences in the median length of stay in an intensive care unit or hospital. they also found no difference in mortality. a recent systematic review identified only 1 randomized controlled trial of noninvasive positive-pressure ventilation in patients with status asthmaticus (20,21). in this study, which included 30 patients, noninvasive positivepressure ventilation significantly, improved lung function test results.(21) in the noninvasive positive-pressure ventilation group, 80% of patients reached the predetermined primary ventilation group, treatment failed in 12 (52%) cases in which invasive mechanical ventilation was required. the authors found no significant differences between the treatment and control groups for mortality (intensive care unit or hospital), overall complications, duration of mechanical ventilation and length of stay in an intensive care unit. at 12-months followup, the rate of hospital re-admissions was lower in the noninvasive positive-pressure ventilation group than in the 10 table 2 : recommendations of the british thoracic society standards of care committee fro treatment failure in noninvasive ventilation is treatment of the underlying condition optimal? l check what medical treatment has been prescribed and that it has been given. l consider physiotherapy for sputum retention. have any complications developed ? l consider pneumothorax or aspiration pneumonia if paco remains elevated :2 l is the patient receiving too much oxygen ? adjust fio2 to maintain spo2 between 85%-90% l is there excessive leakage ? check mask fit if using a nasal mask, consider a chin strap or a full-face mask l is the circuit set up correctly ? check that connections have been made correctly. check the circuit for leaks l is rebreathing occurring ? check potency of expiratory valve (if fitted) consider increasing expiratory positive airway pressure (if receiving bilevel pressure support) l is the patient's breathing synchronized with the ventilator ? observe patient adjust rate or inspiration-expiration ratio (with assist/control mode) check inspiratory trigger (if adjustable) check expiratory trigger (if adjustable) consider increasing expiratory positive airway pressure (with bilevel pressure support in chronic obstructive pulmonary disease) l is ventilation inadequate ? observe chest expansion increase target pressure or volume consider increasing inspiratory time consider increasing respiratory rate (to increase minute ventilation) consider a different mode of ventilation or ventilator, if available. if paco improves but pao remains low:2 2 l increase fio2 l consider increasing expiratory positive airway pressure (with bilevel pressure support) pjmsvolume 2 number 1: january-june 2012 review article if the patient does not respond to standard medical therapy, consider a trial of noninvasive positive-pressure ventilation initial order for and initiation of nonivasive positive-pressure ventilation l continuous positive-pressure ventilation for congestive heart failure l bilevel positive airway pressure or pressure support for chronic obstructive pulmonary disease l pulmonary consultation for noninvasive positive-pressure ventilation parameters and follow-up full face mask eligibility criteria clinical (all must be met) exacerbation of congestive heart failure or chronic obstructive pulmonary disease > 17 yr able to protect airway able to clear airway secretions respiratory rate > 30 bpm gas exchange (all should be met) ph < 7.35 paco > 50 mm hg2 pao < 60 mm hg on fio 0.21 or pao /fio <2002 2 2 2 readiographic (must be met) no pneumothorax contraindications cardiac arrest or dysrhythmias acute coronary syndrome hemodynamic instability (systolic blood pressure < 90 mm hg) immediate endotracheal intubation necessary apnea upper airway obstruction decreased level of consciousness (moderately servere to severe) upper gastrointestinal bleeding facial trauma vomiting pregnancy patient declines invasive ventilationphysician assessment clinical assessment chest radiograph arterial blood gases electocardiogram nursing assessment clinical assessment acclimatize patient 1 : 1 nursing patient stability continue optimizing medical therapy ongoing clinical assessment monitor patient l monitor vitals (heart rate, blood pressure, respiration rate, arterial oxygen saturation, clinical status) every 5 minutes until stable, ongoing clinical assessment patient stability arterial blood gases at 3 hours 11 fig3 pjmsvolume 2 number 1: january-june 2012 review article end points (an increase of at least 50% in fev1 compared with baseline), yet only 20% of patients in the control group reached the end points. the mean rise in fev1 was 53.5% in the noninvasive positive-pressure ventilation group and 28.5% in the conventional treatment group. the application of noninvasive positive-pressure ventilation in patients suffering from status asthmaticus remains controversial, despite some interesting and very promising preliminary results. large randomized controlled trials are needed to determine the role of noninvasive positive-pressure ventilation in status asthmaticus. acute cardiogenic pulmonary edemat h e b e s t specific respiratory support for treatment of acute respiratory failure due to cardiogenic pulmonary edema remains unclear. in its guidelines for the diagnosis and treatment of acute heart failure, the european society of cardiology recommend the u s e o f n o n i n v a s i v e p o s i t i v e p r e s s u r e v e n t i l a t i o n (recommendation: class iia, level of evidence: a) (22). three randomized controlled trials have suggested that the use of noninvasive intermittent positive-pressure ventilation in the setting of acute cardiogenic pulmonary edema (23-25) decreases the need for intubation; however, this does not translate into reduced mortality or improved long-term function. in a recent meta-analysis (26) that included a total of 29 randomized controlled trials of continuous positive airway pressure and bilevel positive airway pressure, peter and colleagues reported on 12 studies that compared continuous positive airway pressure with standard care, 7 that compared bilevel positive airway pressure with standard care and 10 that compared continuous positive airway pressure with bilevel positive airway pressure. continuous positive airway pressure was associated with a significant reduction in hospital mortality compared with standard therapy. however, the effect of bilevel positive airway pressure was not significant. both continuous positive airway pressure and bilevel positive airway pressure were associated with significant reductions in the need for invasive mechanical ventilation compared with standard therapy. compared with standard therapy, neither continuous positive airway pressure nor bilevel positive airway pressure had an effect on new myocardial infarction rates or length of hospital stay. uses in other causes of acute respiratory failure noninvasive positive-pressure ventilation has been used in patients with acute respiratory failure that occurred postsurgery or that occurred because of community-acquired pneumonia. a systematic review by keenan and colleagues (27) analyzed the efficacy of this technique in patients with hypoxemic respiratory failure. they reported on the outcome of 2 trials that included immunocompromised patients, 1 that included patients who had undergone lung resection, 1 that included patients with community-acquired pneumonia, 1 that included patients with post-extubation respiratory failure and 3 that included heterogeneous groups of patients. overall, noninvasive positive-pressure ventilation was associated with a significantly lower rate of intubation compared with standard management. also, noninvasive positive-pressure ventilation was associated with a reduction in mortality in intensive care units of 17%, with the same subgroup of 6 trials reporting a similar reduction of 16%. 2 additional studies have been performed (28, 29). squadrone and colleagues (28) examined the effectiveness of continuous positive airway pressure in patients with acute hypoxemia after elective major abdominal surgery. patients who received oxygen and continuous positive airway pressure had a lower intubation rate and none of these patients died in hospital, compared with 3 deaths among the group of patients initiation of weaning from noninvasive positive pressure ventilation consider different methods of weaning restart noninvasive positive-pressure ventilation at any sign of clinical worsening or respiratory failure reduce level of ventilation support trials of spontaneous respiration for increasing periods throughout the day combination of reduced ventilation support a incremental periods spontaneous respiration 12 fig4 pjmsvolume 2 number 1: january-june 2012 review article who received oxygen alone (28). the study by honrubia and colleagues (29) included 64 patients with acute respiratory failure from various causes. these patients were randomized to receive either noninvasive positive-pressure ventilation through a face mask with pressure support and positive endexpiratory pressure or to receive conventional invasive ventilation. noninvasive ventilation reduced the need for intubation. mortality in intensive care units was 23% in the noninvasive group and 39% in the conventional therapy group. noninvasive ventilation as a mode of weaning from mechanical ventilationinterest has emerged in the use of noninvasive positive-pressure ventilation as a mode of ventilation weaning. recently, several studies have assessed the role of this type of ventilation in facilitating earlier extubation. (30-32) burns and colleagues (33) performed a meta-analysis of 5 studies that included a total of 171 patients. they found that compared with weaning strategies that involved invasive mechanical ventilation alone, noninvasive positive-pressure ventilation decreased mortality, incidence of ventilator-associated pneumonia, length of stay in an intensive care unit, total duration of mechanical support and the duration of invasive mechanical ventilation. they found that the mortality benefit of noninvasive positive-pressure ventilation was greatest among patients with chronic obstructive pulmonary disease. noninvasive ventilation for prevention of respiratory failure in recent years, useful guidelines for weaning from mechanical ventilation have developed; however, the rate of extubation failure (the need for reintubation within 48–72 hours) is close to 18% (34). the main cause of extubation failure is the development of respiratory failure within a few hours. noninvasive positivepressure ventilation has been evaluated in the prevention and management of this condition. until recently, experience with noninvasive positive-pressure ventilation was limited to observational studies with physiologic evaluation as the main objective. in a randomized controlled trial that included 93 patients, jiang and colleagues (35) reported on the outcomes of 56 patients who received elective extubation and 37 patients who received unplanned extubation. after extubation, patients were randomly assigned to receive either bilevel positive airway pressure or unassisted oxygen therapy. they found no significant difference in the rate of reintubation for either technique. nava and colleagues (36) performed a randomized controlled trial that included 97 consecutive patients who required more than 48 hours of mechanical ventilation and who were considered at risk for post-extubation respiratory failure. after a successful weaning trial, patients were randomized to receive either noninvasive positive-pressure ventilation or standard medical therapy. compared with standard therapy, there was a lower rate of reintubation among those in the noninvasive positive-pressure ventilation group. noninvasive positive-pressure ventilation did not affect overall mortality in the intention-to-treat analysis, but the authors reported reduced mortality in the intensive care unit setting owing to a reduced need for reintubation. in 2006, ferrer and colleagues (37) conducted a randomized controlled trial that included 162 patients receiving mechanical ventilation who tolerated a spontaneous breathing trial but who were at increased risk for respiratory failure after extubation. after extubabtion, patients were randomly allocated to receive 24 hours of either noninvasive positive-pressure ventilation or conventional management with oxygen therapy. among patients who received noninvasive positive-pressure ventilation, respiratory failure after extubation was less frequent, but 90 day mortality was not reduced. subgroup analysis showed that the use of noninvasive positive-pressure ventilation was associated with reduced mortality among patients with hypercapnia. based on these studies, the early use of noninvasive positive-pressure ventilation can prevent respiratory failure after extubation and decrease the need for reintubation. however, further studies that better define the population of patients at risk for respiratory failure after extubation may be necessary. noninvasive ventilation for management of respiratory failurethe treatment of respiratory failure after extubation must be considered separately. two randomized controlled trials that examined the effectiveness of noninvasive positive-pressure ventilation in this context have been published. keenan and colleagues (38) enrolled 81 patients who required ventilatory support for more than 2 days and who developed respiratory distress within 48 hours of extubation. patients were randomly assigned to receive standard medical therapy alone or to receive noninvasive positive-pressure ventilation by use of a face mask and standard medical therapy. the authors found no difference in the rate of reintubation or hospital mortality. using similar methodology, esteban and colleagues (39) performed a multicentre international study that included 221 patients. in this study, there was no difference in the need for reintubation among patients receiving noninvasive positive-pressure ventilation and those receiving standard therapy. however, mortality in the intensive care unit was higher in the noninvasive positive-pressure ventilation group compared with the standard-therapy group. a possible explanation for this difference is delayed reintubation among patients who received noninvasive positive-pressure ventilation. the median time from respiratory failure to reintubation was longer in the noninvasive positive-pressure ventilation group compared with standard care. in light of these studies, noninvasive positive-pressure ventilation is not effective for management of post-extubation respiratory failure, and delayed reintubation may increase mortality. utility of noninvasive ventilation in patients 13 pjmsvolume 2 number 1: january-june 2012 review article ordered “do-not-intubate"noninvasive positive-pressure ventilation has been used as an alternative to invasive ventilation in patients with a "do-not-intubate" order. a recent study (39) that included 114 patients with a do-not-intubate order and acute respiratory failure found that 43% of patients survived to hospital discharge. the patient's underlying condition was an important determinant of survival. mortality was 25% among patients with chronic heart failure and 48% among patients with chronic obstructive pulmonary disease. mortality was highest among patients with cancer and pneumonia (77% and 74% respectively). similar results were reported by schettino and colleagues (40) in a prospective observational study that included 131 patients with acute respiratory failure and a do-not-intubate order in a general hospital. they reported an overall mortality of 64.9%. hospital mortality was 37.5% among patients with chronic obstructive pulmonary disease exacerbations, 39% among those with cardiogenic pulmonary edema, 68% among those with nonchronic obstructive pulmonary disease hypercapnic respiratory failure, 77% among those with post-extubation respiratory failure and 88% among patients with hypoxemic acute respiratory failure. advanced cancer was present in 40 patients, and it was associated with increased risk of death. below are few outcome trials of nppv (table 3). 14 pjmsvolume 2 number 1: january-june 2012 review article absolute : l substantially impaired level of consciousness l severe agitation l copious secretions l uncontrolled vomiting l inability to protect airway l repeated hemoptysis or hematemesis l recent esophagectomy l acute myocardial infarct l cardiac arrest l immediate endotracheal intubation necessary l apnea l upper airway obstruction l facial trauma l patient declines relative : l mildly decreased level of consciousness l progressive severe respiratory failure l uncooperative patient who can be calmed or comforted l suspected acute coronary ischemia l hemodynamic instability l pregnancy table4 : contraindications for the use of noninvasive positive-pressure ventilation contraindications although noninvasive ventilation is very useful in many settings, it is not appropriate for all patients. there are a number of absolute and relative contraindications for this mode of ventilation (table 4). noninvasive ventilation for respiratory support requires that patients are cooperative and able to protect their airway. therefore, substantially impaired consciousness or an inability to protect the upper airway should lead physicians to choose another type of respiratory support. it is also unsafe to use facial masks for patients who are vomiting repeatedly or who are bleeding from the airways or the upper gastrointestinal tract. vomiting or bleeding into the facial mask will invariably predispose the patient to aspiration. considerable airway secretions pose a similar problem. one of the potential complications of noninvasive positive-pressure ventilation is abdominal distention due to the air forced into the stomach under positive pressure. if a patient has anastomoses in the upper gastrointestinal tract, physicians should avoid the possibility of disrupted suture lines because of abdominal distention. finally, noninvasive positive-pressure ventilation has not been shown to benefit patients with acute coronary syndromes. the combination of acute myocardial ischemia with hypoxemic respiratory failure and possibly hemodynamic instability may result in worsened myocardial ischemia compared to invasive modalities for which one would expect more immediate control of oxygenation and hemodynamic status. conclusion noninvasive positive-pressure ventilation is effective weapon for acute respiratory failure and reducing hospital mortality in patients with a do-not-intubate order whose primary diagnosis is chronic obstructive pulmonary disease or cardiogenic pulmonary edema. it is a less successful therapy for patients with hypoxemic acute respiratory failure or terminal cancer. of the various interfaces available, there is no significant advantage of either of them, however one should choose which would be cost effective ,safe depending on the underlying disease. more outcome studies are required to ascertain the efficacy in asthma patients. however non invasive positive pressure ventilation proves to be a beneficial tool if properly and appropriately applied, which would definitely help to reduce the morbidity and mortality and improving outcomes of the diseases. references 1. mehta s, hill ns. noninvasive ventilation. am j respir crit care med 2001; 163:540-77 2. schonhofer b, sortor-leger s. equipment needs for noninvasive mechanical ventilation. eur respir j 2002; 20:1029-36. 3. meduri gu, turner re, abou-shala n, et al. noninvasive positive-pressure ventilation via face mask. first-line intervention in patients with acute hypercapnic and hypoxemic respiratory failure. chest 1996; 109:179-93 4. navalesi p, fanfulla f, frigerio p, et al. physiologic evaluation of noninvasive mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic respiratory failure. crit care med 2000; 28:1785-90 5. chiumello d, pelosi p, carlesso e, et al. noninvasive positivepressure ventilation delivered by helmet vs. standard face mask. intensive care med 2003; 29:1671-9. 6. costa r, navalesi p, antonelli m, et al. physiologic evaluation of different levels of assistance during noninvasive ventilation delivered through a helmet. chest 2005; 128:2984-90. 7. navelesi p, costa r, ceriana p, et al. noninvasive ventilation in chronic obstructive pulmonary disease patients: helmet versus facial mask. intensive care med 2007; 33:74-81 . 8. carlet j, artigas a, bihari d, durocher a, hemmer m, langer . m, etal.the first european consensus conference in intensive.care medicine: introductory remarks. intensive care medicine. 1992;18:180-1`. 9. esteban a, anzueto a, frutos-vivar f, et al. characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. jama 2002; 287:345-55.. 10. carlucci a, richard jc, wysocki m, et al. noninvasive versus conventional mechanical ventilation. an epidemiologic survey. is j respir crit care med 2001; 163:874-80. 15 pjmsvolume 2 number 1: january-june 2012 review article 11. petrof bj, legare m, goldberg p, et al. continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. am rev respir dis 1990; 141:281-90. 12. evans tw. international consensus conferences in intensive care medicine. noninvasive positive-pressure ventilation in acute respiratory failure. intensive care med 2001; 27:166-78. 13. british thoracic society standards of care committee. noninvasive ventilation in acute respiratory failure. thorax 2002; 57:192-211. 14. keenan sp, sinuff t, cook dj, et al. which patients with acute exacerbations of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? a systematic review of the literature. ann intern med 2003; 138:861-70. 15. confalonieri m., parigi p, scartabellati a, et al. noninvasive mechanical ventilation improves the immediate and longterm outcome of copd patients with acute respiratory failure. eur respir j 1996; 9:422-30. 16. sinuff t, cook dj, randall j, et al. evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure. chest 2003; 123:2062-73. 17. sinuff t, keenan s. clinical practice guideline for the use of noninvasive positive-pressure ventilation in copd patients with acute respiratory failure. j crit care 2004; 19:82-91. 18. meduri gu, cook tr, turner re, et al. noninvasive positivepressure ventilation in status asthmaticus. chest 1996; 110:767-74. 19. fernández mm, villagra a, blanch l, et al. noninvasive mechanical ventilation in status asthmaticus. intensive care med 2001; 27:486-92. 20. ram fs, wellington s, rowe b, et al. noninvasive positivepressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. cochrane database syst rev 2005 ;( 3):cd004360. 21. soroksky a, satv d, shpirer i. a pilot prospective, randomized, placebo-controlled trial of bi-level positive airway pressure in acute asthmatic attack. chest 2003; 123:1018-25. 22. nieminen ms, bohm m, cowie mr, et al. executive summary of the guidelines on the diagnosis and treatment of acute heart failure. euro heart j 2005; 26:384-416. 23. masip j, betbesé aj, páez j. noninvasive pressure-support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema a randomized trial. lancet 2000; 356:2126-32. 24. sharon a, shpirer i, kaluski e, et al. high-dose intravenous isosorbide-dinitrate is safer and better than bipap ventilation combined with conventional treatment for severe pulmonary edema. j am coll cardiol 2000; 36:832-7. 25. mehta s, jay gd, woolard rh, et al. randomized prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. crit care med 1997; 25:620-8. 26. peter jv, moran jl, hughes jp, et al. effect of noninvasive positive-pressure ventilation (nippv) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. lancet 2006; 367:1155-63. 27. keenan s, sinuff t, cook d, et al. does noninvasive positivepressure ventilation improve outcome in acute hypoxemic respiratory failure? a systematic review. crit care med 2004; 32:2516-23. 28. squadrone v, coha m, cerutti e, et al. continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. jama 2005; 293:589-95. 29. honrubia t, garcía lópez fj, and franco n, et al. noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter randomized controlled trial. chest 2005; 128:3916-24. 30. nava s, ambrosino n, clini e. noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonare disease. a randomized controlled trial. ann intern med 1998; 128:721-8. 31. girault c, daudenthun i, chevron v, et al. noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. am j respir crit care med 1999; 160:86-92. 32. ferrer m, esquinas a, arancibia f, et al. noninvasive ventilation during persistent weaning failure: a randomized controlled trial. am j respir crit care med 2003; 168:70-6. 33. burns ke, adhikari nk, meade mo. noninvasive positivepressure ventilation as a weaning strategy for intubated adults with respiratory failure. cochrane database syst rev 2003; (4):cd004127. 34. gil b, frutos-vivar f, esteban a. deleterious effects of reintubation of mechanically ventilated patients. clinical pulmonary medicine 2003; 10:226-30. 35. jiang js, kao sj, wang sn. effect of early application of biphasic positive airway pressure on the outcome of extubation in ventilator weaning. respirology 1999; 4:161-5. 36. nava s, gregoretti c, farfulla f, et al. noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. crit care med 2005; 33:2465-70. 37. ferrer m, valencia m, nicolás jm, et al. early noninvasive ventilation averts extubation failure in patients at risk. am j respir crit care med 2006;173:164-70 38. keenan sp, powers c, mccormack dg, et al. noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trail. jama 2002:287; 323844. 39. levy m, tanios ma, nelson d, et al. outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. crit care med 2004; 32:2002-7. 40. schettino g, altobelli n, kacmarek rm. noninvasive ventilation reverses acute respiratory failure in selected "do-notintubate" patients. crit care1976-82. 16 pjmsvolume 2 number 1: january-june 2012 review article page 11 page 12 page 13 page 14 page 15 page 16 page 17 page 18 page 19 page 20 panacea journal of medical sciences 2021;11(1):77–81 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article point prevalence study of hospital acquired infections in intensive care units of a tertiary care teaching hospital in uttarakhand geetika rana1, shantanu aggarwal2,*, dimple raina1, v k kataria1 1dept. of microbiology, sri guru ram rai institute of medical and health sciences, patel nagar, dehradun, uttrakhand, india 2dept. of community medicine, sri guru ram rai institute of medical and health sciences, patel nagar, dehradun, uttrakhand, india a r t i c l e i n f o article history: received 10-09-2020 accepted 09-10-2020 available online 29-04-2021 keywords: hospital acquired infections (hai) intensive care units (icus) point prevalence study a b s t r a c t background: hospital acquired infections (hai) are one the biggest challenges that the hospitals face in patient care. the rates are even higher in patients admitted in intensive care units (icus). the true burden of hai in our state of uttarakhand is still unknown. materials and methods: this study was done to determine the prevalence rate of hai in the icus of a tertiary care teaching hospital in uttarakhand. a series of two 1day point prevalence studies was conducted in our hospital in october 2017 and february 2018 in all the icus of our hospital. the study comprised of 92 patients admitted for more than 48 h in the icu. the nurses were trained to collect the data collection form according to centers for disease control and prevention definition of hais. results: out of 92 eligible patients in icu, 25 (27.2%) had acquired hai. overall a total of 37 hais were identified as few patients had >1 type of hai. respiratory tract infection (rti) had the highest prevalence of 16.3% followed by bloodstream infections (14.1%). mechanical ventilation was found to have maximum association with hai (43.6%). this association was found to be statistically significant (p = 0.002). acinetobacter was the most common isolate (33%). conclusions: the highlight of this study was raising awareness about the current hai rates in our hospital and reinforcing the importance of correct infection control practices amongst the doctors and nursing staff. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction hospital acquired infections (hai) are the infections acquired by the patient during hospital care which are not present or incubating at the time of admission. infections occurring more than 48 hours after admission are usually nosocomial. 1 hai rate of a hospital is a direct indicator of quality and patient care. a patient comes to the hospital with a lot of faith and hope. it is our duty to ensure that he doesn’t go back with hai. hais are most commonly caused by multidrug resistant (mdr) organisms that leads to a prolonged antibiotic treatment, longer hospital stays, escalating hospital bills and ultimately increasing morbidity and mortality rates. * corresponding author. e-mail address: drshantanu.psm@gmail.com (s. aggarwal). though the threat of hai is a globally recognised and prioritized phenomena but the scenario in indian hospitals still varies. till now, majority of hospitals in india fail to identify the threat of raising hai rates and fail to implement any preventive measures to rectify this problem. inadequate resources, no infection control surveillance teams, nonexistent/ poorly implemented antibiotic policy, injudicious use of invasive devices and antibiotics, non – compliant staff, poor hygiene and sanitation are some of the major issues leading to high hai rates in indian hospitals. 2 in fact, as per a review by world health organisation (who), the pooled prevalence of hai in low income countries is 10.1% which is double the prevalence in high income countries. 3 periodic and routine surveillance of hai is an essential first step to identify local problems and https://doi.org/10.18231/j.pjms.2021.018 2249-8176/© 2021 innovative publication, all rights reserved. 77 https://doi.org/10.18231/j.pjms.2021.018 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.018&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:drshantanu.psm@gmail.com https://doi.org/10.18231/j.pjms.2021.018 78 rana et al. / panacea journal of medical sciences 2021;11(1):77–81 priorities. it also helps to monitor the implementation and efficiency of infection control measures. this is essential to prevent the emergence and spread of multidrug resistant organisms. routine surveillances also spread awareness on the importance of infection control measures and helps to increase the compliance of healthcare personals. thus, reducing the hai rates in the hospital. 4 prospective surveillance for hais are routinely done in developed countries on national level. but very scanty data is available for developing countries like india. although, continuous prospective surveillance is the best approach but it requires comprehensive resources. the biggest advantage of point prevalence study is that it can be done on a single day with minimum resources. along with the hai rates, it also provides data on associated risk factors. such data can then be used to focus any interventional programmes to reduce the burden of disease. such a study helps to identify target areas in hospitals for quality improvement. hence, in a resource limited country, point prevalence surveys are an efficient way for determining magnitude of hai. 5 intensive care units (icus) are the most vulnerable sites for hais in a hospital. icus have patients with serious medical ailments, complications and pre-existing co-morbidities. they are commonly exposed to multiple invasive devices and procedures which make them an easy target for mdr organisms. poor reflexes and low immunity favour the multiplication of pathogens thus leading to development of various hais. therefore, our study aimed to estimate the burden of various hais in the icus of our hospital and associated risk factors. 2. materials and methods the point prevalence study of hai was conducted in all the icus of a 1500bedded tertiary care teaching hospital in uttarakhand. the study was conducted in two phases: first in october 2017 and next in february 2018 in all the icus. since this was the first time that such a survey was being done in our hospital, it was decided to restrict the survey to only icus due to restriction of human and financial resources. all admitted icu patients who had been in the hospital for at least 48 hours were included in the study. ethical approval was obtained from the institutional ethics committee. nursing staff of all the icus was trained by the department of microbiology in a series of lectures. they were taught about hais and how to identify them according to cdc definitions. 6 they were shown how to fill the data collection performa by the help of various real case examples. the data collection form included patient’s demographic details, admission date, consultant speciality, icu location, use of urinary catheter, any surgical procedure (during last 30 days), mechanical ventilation, intravascular catheter, antimicrobial therapy, presence of hai and type of hai. re-enforcement of the importance of infection control measures was also established during these sessions. on the day of the survey, a team comprising of microbiologist, respective doctors and nurses incharges of various icus collected data from all the eligible patients. 2.1. statistical analysis data was entered and analysed in spss version 22. 3. results a total of 92 patients were included in this study (44 and 48 in each phase respectively). males (58, 63%) were more in number than females (34, 37%). maximum patients belonged to the > 60 years (37%) and <18 years (32.6%) age group (table 1). 45 patients were in surgical icu, 17 in neonatal icu, 10 in medical icu, 10 in paediatric icu, 7 in cardiac icu and 3 in respiratory icu. 85.9% patients had intravascular catheter, 70.65% had urinary catheter, 42.4% had mechanical ventilator and 35 had undergone a surgical procedure. out of 92 eligible patients in icu, 25 (27.2%) had acquired hai. overall a total of 37 hais were identified as few patients had >1 type of hai. hai prevalence was found to be highest in nicu (47.1%) followed by sicu-ii (41.7%), micu (30%), sicu-i (14.3%) and picu (10%) (table 2). mechanical ventilation was found to have maximum association with hai (43.6%). this association was found to be statistically significant (p = 0.002) (table 3). respiratory tract infection (rti) had the highest prevalence of 16.3% followed by bloodstream infections (14.1%), line related (4.34%), others (4.34%), urinary tract infection (1%) and surgical site infection (0%) (table 4). microbiological culture results were available for 29 hai (78.3%). acinetobacter was the most common isolate (33%) followed by klebsiella spp. (19%), pseudomonas spp. (9%), e.coli (9%), proteus (5%), s. maltophila (5%), enterococcus spp. (5%), enterobacter spp (5%) serratia spp. (5%) and candida spp. (5%). 4. discussion ours was the first point prevalence study conducted in our hospital. though there have been many similar studies reported from india and abroad but none have been reported from uttarakhand. in our study the overall hai prevalence in icus was found to be 27.2%. in a similar point prevalence study conducted in a tertiary care hospital in pune, the hai rates in icu was 25%. 7 malhotra et al in their point prevalence study of hai in a tertiary care hospital in delhi reported a high prevalence of 33.3% in their icus. 8 a study done in 7 cities of india reported hai prevalence of 9.06 per 1000 icu days. 9 whereas, a study conducted by ecdc in european acute care hospitals showed a prevalence rana et al. / panacea journal of medical sciences 2021;11(1):77–81 79 table 1: age – wise and gender-wise distribution age group gender total male female number (%) number (%) number (%) 0 – 18yrs 18 (31.0) 12 (35.3) 30 (32.6) 19 – 25yrs 4 (6.9) 1 (2.9) 5 (5.4) 26 – 40yrs 3 (5.2) 5 (14.7) 8 (8.7) 41 – 60yrs 12 (20.7) 3 (8.8) 15 (16.3) >60yrs 21 (36.2) 13 (38.2) 34 (37.0) total 58 (100) 34 (100) 92 (100) table 2: hai prevalence by icu type icu total patients patients with hai hai prevalence (%) odds ratio 95% c.i ccu 7 0 0.0 0.00 micu 10 3 30.0 0.60 0.12 – 2.91 nicu 17 8 47.1 1.24 0.36 – 4.35 picu 10 1 10.0 0.16 0.02 – 1.43 ricu 3 0 0.0 0.00 sicui 21 3 14.3 0.23 0.05 – 1.01 sicuii 24 10 41.7 1.00 total 92 25 27.2 icu: intensive care unit, ccu: cardiac care unit, micu: medical intensive care unit, nicu: neonatal intensive care unit, picu: paediatric intensive care unit, ricu: respiratory intensive care unit, sicu: surgery intensive care unit table 3: hai prevalence by risk factors type s. no risk factors no. of patients presence of hai hai prevalence % odds ratio (95% ci) p value 1 surgery 35 11 31.4 1.41(0.55 – 3.58) 0.47 2 urinary catheter 65 16 24.6 0.65(0.24 – 1.74) 0.39 3 mechanical ventilator 39 17 43.6 4.35(1.63 – 11.62) 0.002 4 intravascular catheter 79 23 29.1 2.26(0.46 – 10.99) 0.30 table 4: number, percentage and prevalence of hai, by type hai site total % of total prevalence (%) ssi 0 0 0 uti 1 2.7 1 bsi 13 35.13 14.1 rti 15 40.54 16.3 line related 4 10.8 4.34 others 4 10.8 4.34 total 37 100 ssi: surgical site infection, uti: urinary tract infection, bsi: bloodstream infection, rti: respiratory tract infection of 19.5% in their icus. 10 aliki m et al in their point prevalence study done in three swiss hospitals reported hai prevalence in icu as 26.2%. 11 similar multicentic study done in hospitals of ireland reported a prevalence of 23.3%. 12 while a multicentre 1-day point prevalence study in hospitals of turkey reported a high prevalence of 48% in their icus. 13 a review of literature done on similar studies showed icus to have the highest burden of hais in hospitals. this is because of many associated risk factors. exposure to medical devices, underlying immunocompromised conditions, co morbidities, antimicrobial therapy, any surgical procedures, prolonged stay are some of the important risk factors. as a result patients in icus suffer from increased morbidity, mortality and financial costs. 7,9,14 our study included all the icus of our hospitals including neonatal and paediatrics. neonatal icu was shown to have the highest hai prevalence (47.1%) followed by surgical icu (41.7%) but this association was not found to be significant. in our study, respiratory tract infection (rti) had the highest prevalence of 16.3% followed by bloodstream 80 rana et al. / panacea journal of medical sciences 2021;11(1):77–81 infections (14.1%). our results were corroborated by esen s et al, in which lower respiratory tract infection (28.0%) followed by bloodstream infection (23.3%) were the most frequent types of hai. 13 dasgupta et al also reported pneumonia as the most frequent type of hai (62.07%) in their study. 15 whereas, nair et al in their study reported surgical-site infections (ssis) as the most common hai (23.94%) followed by hospital-acquired pneumonia (hap) (18.31%). 7 malhotra et al reported uti to be the most common type of hai in their study. 8 this difference could be because of the fact our study was restricted only to icus of our hospital whereas these studies also included the wards. we studied common risk factors for hais like surgery, mechanical ventilation, urinary catheter and intravascular catheter. it was found that mechanical ventilator had a statistically significant association (p = 0.002) and the highest odds of acquiring hai (or = 4.35, 95% confidence interval = 1.63 – 11.62). our findings were also corroborated with study by nair et al which reported mechanical ventilation having the highest odds of acquiring hai (18.57). 7 other similar studies also reported mechanical ventilation as a common risk factor for acquiring hais. 13 these results highlight the importance of following correct practices during device insertion and maintenance. acinetobacter spp. was found to be the most common causative agent of hai (33%) followed by klebsiella spp. (19%), pseudomonas spp. (9%) and e.coli (9%). similar results were reported in a study by kolpa m et al in which the most common isolated microorganism was acinetobacter baumannii (25%). 16 acinetobacter spp is a known multi drug resistant pathogen found commonly in the hospital environment. on the other hand, esen s et al 13 reported pseudomonas aeruginosa (20.8%) and dasgupta et al 15 reported enterobacteriaceae (37.5%) as the most frequently reported isolate in their respective studies. acinetobacter spp. isolated in our study was found to be multi drug resistant. the antibiotic resistance pattern showed 100% resistance to flouroquinolones, tetracycline and 95% resistance to carbapenems. no resistance was observed for polypeptides. the highlight of this study was raising awareness about hai and correct infection control practices amongst the nursing staff. extensive training during every phase of the study helped in re-enforcing the importance of following correct infection control practices. this study provided a baseline data for monitoring the prevalence of hais in icus of our hospitals. it also highlighted the need to strengthen the infection control practices especially during device insertion and maintenance. ours was the first point prevalence study undertaken at our 1500 bedded teaching hospital in dehradun. there were several limitations in our study. first, due to lack of resources, the wards were excluded from the study. secondly, our study did not cover all risk factors leading to hais, such as underlying disease, previous hospitalisations, types of surgeries and admission to the emergency ward. and finally, such one day studies might not show the true rate of infections. but in resource limited set-ups, repeated point prevalence studies is a practical and cheaper option instead of continuous prospective surveillance. in conclusion, the hai prevalence rate in icus of our hospital was 27.2% and rti being the most common type of hai (16.3%). mechanical ventilation was found to be the biggest risk factor in acquiring hai. acinetobacter spp. was the most common pathogen which was also multi drug resistant. with this baseline information of our hospital, adequate infection control methodologies can be designed to decrease the hai rate of our hospital. 5. source of funding no financial support was received for the work within this manuscript. 6. conflict of interest the authors declare they have no conflict of interest. references 1. garner js, jarvis wr, emori tg, horan tc, hughes jm. cdc definitions for nosocomial infections, 1988. am j infect control. 1988;16(3):128–40. doi:10.1016/0196-6553(88)90053-3. 2. pittet d, allegranzi b, storr j, nejad sb, dziekan g, leotsakos a, et al. infection control as a major world health organization priority for developing countries. j hosp infect . 2008;68(4):285–92. doi:10.1016/j.jhin.2007.12.013. 3. report on the burden of endemic health care-associated infection worldwide. geneva, switzerland: who; 2011. 4. haley rw, culver dh, white jw, morgan wm, emori tg, munn vp, et al. the efficacy of infection surveillance and control programs in preventing nosocomial infections in us hospitals. am j epidemiol. 1985;121:182–205. 5. zhang y, zhang j, wei d, yang z, wang y, yao z, et al. annual surveys for point-prevalence of healthcare-associated infection in a tertiary hospital in beijing. bmc infect dis. 2016;16:161. 6. cdc/nhsn. cdc/nhsn surveillance definitions for specific types of infections, july 2013 cdc/nhsn protocol clarifications; 2013. available from: www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_ current. 7. nair v, sahni ak, sharma d. point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in pune, india. indian j med res. 2017;145:824–32. 8. malhotra s, sharma s, hans c. prevalence of hospital acquired infections in a tertiary care hospital in india. int inv j med med sci. 2015;1(7):91–4. 9. mehta a, rosenthal vd, mehta y, chakravarthy m, todi sk, sen n, et al. device-associated nosocomial infection rates in intensive care units of seven indian cities. findings of the international nosocomial infection control consortium (inicc). j hosp infect . 2007;67(2):168–74. doi:10.1016/j.jhin.2007.07.008. 10. european centre for disease prevention and control. point prevalence survey of healthcareassociated infections and antimicrobial use in european acute care hospitals. stockholm: ecdc; 2013. 11. aliki m. point prevalence of healthcare-associated infections and antibiotic use in three large swiss acute-care hospitals. swiss med wkly. 2018;148:14617. http://dx.doi.org/10.1016/0196-6553(88)90053-3 http://dx.doi.org/10.1016/j.jhin.2007.12.013 www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current http://dx.doi.org/10.1016/j.jhin.2007.07.008 rana et al. / panacea journal of medical sciences 2021;11(1):77–81 81 12. health protection surveillance centre, point prevalence survey of hospital acquired infections & antimicrobial use in european acute care hospitals: may 2012. republic of ireland critical care report: february . 2012;. 13. esen s, leblebicioglu h. prevalence of nosocomial infections at intensive care units in turkey: a multicentre 1-day point prevalence study. scand j infect dis . 2004;36(2):144–8. doi:10.1080/00365540410019156. 14. kumar a, biswal m, dhaliwal n, mahesh r, appannanavar sb, gautam v, et al. point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in india. j hosp infect . 2014;86(4):272–4. doi:10.1016/j.jhin.2013.12.010. 15. hazra a, dasgupta s, das s, chawan ns. nosocomial infections in the intensive care unit: incidence, risk factors, outcome and associated pathogens in a public tertiary teaching hospital of eastern india. indian j crit care med. 2015;19(1):14–20. doi:10.4103/0972-5229.148633. 16. kołpa m, wałaszek m, gniadek a, wolak z, dobros w. incidence, microbiological profile and risk factors of healthcare-associated infections in intensive care units: a 10 year observation in a provincial hospital in southern poland. int j environ res public health. 2018;15(1):1. author biography geetika rana, assistant professor shantanu aggarwal, assistant professor dimple raina, associate professor v k kataria, professor and head cite this article: rana g, aggarwal s, raina d, kataria vk. point prevalence study of hospital acquired infections in intensive care units of a tertiary care teaching hospital in uttarakhand. panacea j med sci 2021;11(1):77-81. http://dx.doi.org/10.1080/00365540410019156 http://dx.doi.org/10.1016/j.jhin.2013.12.010 http://dx.doi.org/10.4103/0972-5229.148633 introduction materials and methods statistical analysis results discussion source of funding conflict of interest 429 too many requests you have sent too many requests in a given amount of time. original research article http://doi.org/10.18231/j.pjms.2020.011 panacea journal of medical sciences, january-april, 2020;10(1):43-46 43 a study of magnitude of anemia and its association with diet pattern in young females neelakandan ramya 1 , sethu prabhu shankar 2 , janarthanan arvind 3* 1,2professor, 3post graduate, dept. of general medicine, aarupadai veedu medical college and hospital, pondicherry, india *corresponding author: janarthanan arvind email: arvinda420@gmail.com abstract background: due to lack of consumption of nutrients by cell the nutritional anemia occurs. iron, folic acid, vitamin b12, vitamin b6, vitamin c and protein are vital nutrients whose deficiency can lead to nutritional anemia. aim: to study the magnitude of anaemia in young females and its association with diet pattern. materials and methods: study was done as a cross-sectional study in young females of age 18 to 40. demographic details like age, height, body weight, and the dietary patterns comprising food habits were recorded. hematological parameters were obtained using automated haematology cell counter and peripheral blood smears by microscopy. results: in this study 100 females were included, 62% of participants were anemic, the mean years of age in the study participants was 26.52±3.48 years. 44% of participants had mild anemia followed by 16% had moderate anemia and 2% had severe anemia. on further analysis of dietary habits, 47% of women not taking green leafy vegetables had mild to moderate anemia, 25% of women drinking tea or coffee after the meal had mild anemia and 14% of women eating junk foods and 5% of women eating less fruits had mild to moderate anemia. conclusion: improving women’s health education on the consumption of iron-rich foods and healthy diet habits is instrumental in preventing nutritional anemia could be the single most important intervention to reduce india’s anemia burden. keywords: anemia, diet, green leafy vegetables. introduction appropriate nutrition is essential to deliver this vital element and other micronutrients to lessen the risk of anemia. world health organisation is determined to decrease anemia universally by 50% till 2025.1 the gender discrimination from their birth in our society even in this modern days leads to the low health status of young girls in our country. discriminatory delivery of health resources inside households and society is the important basis of nutritional anemia among the females.2 according to who most common cause of anemia is iron-deficiency anemia. nutritional anemias may result from various vitamin and mineral, as well as some macronutrient deficiencies, but the most common are megaloblastic anemia, resulting from folic acid or vitamin b12 deficiency, and microcytic, hypochromic anemia, resulting from iron deficiency. among the micronutrients, iron is very essential for cellular growth, immune function, enzymatic reaction, oxygen binding, transport and storage, mental growth and physical growth. dietary iron is available in two forms: heme iron, which is found in meat and nonheme iron, which is found in plant and dairy foods. iron absorption takes place in the duodenum and some part of the jejunum. maximum of total body iron is found flowing in heme, commonly in erythrocyte hemoglobin (hb), the residual one third is deposited in tissues and other cells as ferritin and hemosiderin.3 iron deficiency (id) is a state in which there is inadequate iron to preserve the normal physiological function of tissues.4 nutritional cause of iron deficiency is the intake of cereal-based diets, which provide non-haem iron of poor bioavailability3, extended negative disproportion between a person’s dietary intake of iron and their body’s physiological demand5,6 and non-nutritional causes of anemia includes malaria, hemodialysis patients, hookworm infestation, chronic infection and inflammation, and hemoglobinopathies such as thalassemia.7-11 iron deficiency anemia is the commonest nutritional disorder found all over the world, predominantly in the developing countries, mostly, affecting young children of 624 months of age, adolescents, women of reproductive age group and pregnant/ lactating women.12,13 although iron deficiency affects all age group and both the sexes adolescent females are more predisposed to it. the cause for iron deficiency in females is reduced intake or delay in absorption, increased demand during adolescence, heavy blood loss during menstruation and parasitic infection. iron deficiency during pregnancy is related with maternal mortality, preterm labor, low birth-weight, and infant mortality.3 from the 2005-2006 national family health survey (nfhs) data, the prevalence of anemic females in the age group between 18-49years was 55%.14 globally in 2011, among the pregnant women the prevalence of anemia was about 38% (32.4 million pregnant women), and non-pregnant women is about 29% (496.3 million non-pregnant women), and for all women in the reproductive age group is about 29% (528.7 million women of reproductive age).15 here in our study, we have studied the magnitude of iron deficiency anemia in young females and its association with diet pattern. aim to study the magnitude of anaemia in young females and its association with diet pattern. materials and methods study design and setting it was a hospital based cross-sectional study conducted in the department of general medicine, aarupadai veedu medical college and hospital, pondicherry. https://www.sciencedirect.com/topics/nursing-and-health-professions/anemia https://www.sciencedirect.com/topics/medicine-and-dentistry/macronutrient https://www.sciencedirect.com/topics/nursing-and-health-professions/anemia https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/folic-acid https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/folic-acid https://www.sciencedirect.com/topics/medicine-and-dentistry/hypochromic-anemia https://www.sciencedirect.com/topics/medicine-and-dentistry/hypochromic-anemia neelakandan ramya et al. a study of magnitude of anemia and its association with diet pattern in young females panacea journal of medical sciences, january-april, 2020;10(1):43-46 44 sample size and sampling based on the case load and feasibility the sample size was 100 and all the female patients between age group18-40 years willing to give informed consent were included in this study. the exclusion criteria were patients with chronic systemic illness, on iron or any multivitamins, history of menorrhagia and pregnancy. data collection after obtaining the informed oral and written consent in their native language. demographic details like age, height, body weight and the dietary patterns comprising food habits were recorded. hematological parameters were obtained using automated haematology cell counter and peripheral blood smears by microscopy.22 as per the who criteria the severity of anemia was categorized. according to the who criteria hemoglobin levels below 12.0 gm/dl were considered anemia. hemoglobin levels of 10.0-11.9 gm/dl are graded as mild anemia, hemoglobin 7-9.9 gm/dl and,< 7gm/dl is graded as moderate and severe anemia respectively. data analysis data entry was done and descriptive analysed was done in terms of mean± sd for continuous variables, and frequencies and percentages using ms excel. results in this study 100 females between 18 to 40 years were included, the mean age of these participants was 26.52±3.48 years. majority of study participant was in 18 to 30 years (72%) and 28% in more than 31 years. 61% of study participants are following non-vegetarian diet and 39% of participants are following the vegetarian diet. (fig. 1 and 2) fig. 1: distribution of age group fig. 2: distribution of the diet table 1: distribution of anthropometric and hematological variables variables mean sd age 26.52 3.48 height in cm’s 156.72 6.50 weight in kg 58.92 8.72 body mass index (bmi) 22.52 2.67 hemoglobin in g/dl 10.06 1.87 mean corpuscular volume (mcv) 78.58 13.12 mean corpuscular hemoglobin (mch) 26.00 4.50 mean corpuscular hemoglobin concentration (mchc) 32.50 2.89 the mean bmi of the study participant was 22.52±2.67, with mean height of 156.72cms and weight of 58.92kgs. the mean hemoglobin level of the study participants was 10.06±1.87gm/dl. the mean value of mcv in study participants was 78.58±13.12fl, mean mch was 26±4.50pg and mean mchc was 32.50±2.89gm/dl. (table 1) fig. 3: depicting the dietary habits among participants in this study, 78% of participants were taking junk foods frequently, 32% of participants were taking tea or coffee after a mean, 36% and 39% of participants are taking fruits and green leafy veg. respectively. (fig. 3) fig. 4: describing the severity of anemia in this study, the incidence of anemia is 62%, 44% of participants had mild anemia followed by 16% had moderate anemia and 2% had severe anemia. neelakandan ramya et al. a study of magnitude of anemia and its association with diet pattern in young females panacea journal of medical sciences, january-april, 2020;10(1):43-46 45 fig. 5: distribution of anemia with weight on further analysis weight, it was observed that 55% of underweight, 56% of normal weight and 80% of overweight participants were anemic (fig. 5) fig. 6: distribution of anemia with diet on further analysis of diet patterns, it was observed that 94% of vegetarian and 40% of non-vegetarian participants were anemic. (fig. 6) fig. 7: distribution of anemia with food habits on further analysis food habits, it was observed that 47% of women not taking green leafy vegetables had mild to moderate anemia, 25% of women drinking tea or coffee after the meal had mild anemia, 14% of junk foods eaters and 5% of fruits eaters had mild to moderate anemia. 2% of women in severe anemia did not take green leafy vegetables in their diet in a week in their diet menu (fig. 7). discussion there is an alarming high prevalence of iron deficiency anemia among the young females is due to the concerns on health and productivity. iron acts as the crucial factor in erythropoiesis. prolonged negative iron balance due to the inadequate intake of iron in their diet or its poor bioavailability, augmented necessities for iron all through their growth and pregnancy. during the menstruation and also during the worm infestations there is an increased iron losses.15 in this study, the prevalence was 34% in the age group 18 to 45 years. aggarwal et al. in their study conducted among adolescent girls in the north east delhi showed 45% prevalence of anemia.16 in the district level health survey (dlhs 2002-04), this survey was done about 18 years ago so there difference in the prevalence in our study is due to the lifestyle, urbanization, food pattern, and food taboos. from the same survey dlhs its showed that a higher prevalence of severe anemia (21.1%) which matches with our study (17.6%). in india, bihar has the highest prevalence of anemia according to the national statistic which is 87.6%.18 similar to our study the prevalence of mild and moderate anemia was more in the kaur ip and kaur s et al study. in our study on comparing the diet pattern, anemia seems to be more common among those who prefer vegetarian foods. kaur ip and kaur s observed that almost 98% of the punjabi girls were anemic, maximum number of girls were in moderate category of anemia.18 dixit et al did a study on 596 adolescent girls of lucknow and he found that 83.3% of anemia prevalence and which is interestingly matches with our study outcome.20 in maharashtra, panat el al did a study in ahmed nagar, with 273 girls and they found that maximum number of girls has mild anemia and it was found that anemia was significantly common among the girls who followed the habit of having tea in their post meal, which is comparable to our study.21 panat et al recoded a very weak positive correlation between hemoglobin and the normal body mass index. also they showed a very weak negative correlation among the low, high bmi and hemoglobin which in statistically insignificant. in the present study anemia was identified even in the girls who had normal bmi. in the current study, 47% of women not taking green leaf vegetables had mild to moderate anemia, 25% of women drinking tea or coffee after the meal had mild anemia, 14% of junk foods eaters and 5% of less fruits eaters had mild to moderate anemia. 2% of women in severe anemia did not take green leaf vegetables, fruits in their diet. regarding the young girls it is understood that anemia is the major health concern due to their poor diet pattern which not much included with green leafy vegetables and fruits. rather they prefer for more junk foods and lack of awareness of nutrition and their health. the limitations of the study were the participants were purposive sampling and the study conducted in small small size and with limited resource. though this study didn’t bring explore more, but the outcome of the study have added the value to the already existing literature. neelakandan ramya et al. a study of magnitude of anemia and its association with diet pattern in young females panacea journal of medical sciences, january-april, 2020;10(1):43-46 46 conclusion iron deficiency anemia is common in young females. iron deficiency anemia is appreciated in young females with poor dietary habits. health education among young females with regards to healthy diet habits is instrumental in preventing nutritional anemia. source of funding none. conflict of interest none. references 1. global nutrition targets 2025: anaemia policy brief [internet]. world health organization. 2014 [cited 6 march 2020]. available from: https://www.who.int/nutrition/publications/globaltargets2025_ policybrief_anaemia/en/ 2. shanti d, vidya d, ramesh v. prevalence of anemia among adolescent girls: a school based study. int j basic app med res. 2015;5:95-8. 3. zimmermann mb, hurrell rf. nutritional iron deficiency. lancet. 2007;370(9586):511-20. 4. benoist bd, mclean e, egll i, cogswell m (2008): worldwide prevalence of anemia 1993-2005: who global database on anemia. worldwide prevalence of anemia 19932005: who global database on anemia. https:// www. cabdirect. org/ cabdirect/abstract/20093013528. 5. abbas pn, hurrell r, kelishadi r. review on iron and its importance for human health. j res med sci (j isfahan univ med sci). 2014;19(2):164. 6. hurrell r, egli i. iron bioavailability and dietary reference values–. am j clin nutr. 2010;91(5):1461s-7s. 7. ahmed f, al-sumaie ma. risk factors associated with anemia and iron deficiency among kuwaiti pregnant women. int j food sci nutr. 2011;62(6):585-92. 8. stoltzfus rj, albonico m, chwaya hm, savioli l, tielsch j, schulze k, et al. hem quant determination of hookwormrelated blood loss and its role in iron deficiency in african children. am j trop med hyg. 1996;55(4):399-404. 9. madore f. anemia in hemodialysis patients: variables affecting this outcome predictor. j am soc nephrol. 1997;8(12):1921-9. 10. dreyfuss ml, stoltzfus rj, shrestha jb, pradhan ek, leclerq sc, khatry sk, et al. west jr kp (2000): hookworms, malaria and vitamin a deficiency contribute to anemia and iron deficiency among pregnant women in the plains of nepal. j nutr. 130(10):2527-36. 11. semba rd, bloem mw. the anemia of vitamin a deficiency: epidemiology and pathogenesis. eur j clin nutr. 2002;56(4):271. 12. lokeshwar mr, mehta m, mehta n, shelke p, babar n. prevention of iron deficiency anemia (ida): how far have we reached? indian j pediatr. 2011;78(5):593-602. 13. abu-ouf nm, jan mm. the impact of maternal iron deficiency and iron deficiency anemia on child’s health. saudi med j. 2015;36(2):146. 14. arnold fs. parasuraman, p. arokiasamy, and m. kothari, “nutrition in india,” in national family health survey (nfhs-3) india 2005-06. 15. world health organization. the global prevalence of anaemia in 2011. geneva: world health organization; 2015. [21 may 2019]. 16. shill kb, karmakar p, kibria mg, das a, rahman ma, hossain ms, et al. prevalence of iron-deficiency anemia among university students in noakhali region, bangladesh. j health popul nutr. 2014;32:103-10. 17. aggarwal kn. assessment of prevalence of anemia and iron stores in response to daily/weekly iron folate supplements in adolescent girls(10-18) from urban slums of east delhi. unicef contract no. 95/0075. 1998:i–9. 18. park k. textbook of preventive and social medicine, 24th ed. jabalpur, m/s bansidas bhanot publisher;2016:646-704. 19. kaur ip, kaur s. a comparison of nutritional profile and prevalence of anemia among rural girls and boys. j exer sci physiother. 2011;7(1):11-8. 20. dixit s. a community based study on prevalence of anaemia among adolescent girls and its association with iron intake and their correlates. indian j prev soc med. 2011;42(4):393-8. 21. panat av. iron deficiency among rural college girls: a result of poor nutrition and prolonged menstruation. jcnh. 2013;2(2):56-60. 22. chaturvedi d, chaudhuri pk, priyanka, chaudhary ak. study of correlation between dietary habits and anemia among adolescence girls in ranchi and its surronding area. int j contemp pediatr. 2017;4:1165-8. how to cite: ramya n, shankar sp, arvind j. a study of magnitude of anemia and its association with diet pattern in young females. panacea j med sci. 2020;10(1):43-6. https://www.who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/ https://www.who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/ panacea journal of medical sciences 2021;11(1):13–16 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article type 2 diabetes and inflammation; correlation of commonly used inflammatory biomarker with marker of glycemic control anupama patne1, p j hisalkar2, akanksha dubey3,* 1dept of biochemistry, american international institute of medical sciences, udaipur, rajasthan, india 2dept of biochemistry, govt medical college and hospital, dungarpur, rajasthan, india 3dept of biochemistry, chirayu medical college and hospital, bhopal, madhya pradesh, india a r t i c l e i n f o article history: received 23-08-2020 accepted 24-09-2020 available online 29-04-2021 keywords: type 2 diabetes mellitus hba1c glycemic control crp inflammation a b s t r a c t background: india leads the world with the largest number of diabetic subjects, hence can be called as diabetic capital of world. diabetes is a serious, chronic disease that occurs due to defects in insulin secretion or insulin action or may be both. optimal glycemic control is fundamental and still is the main therapeutic objective for the managing and prevention micro and macrovascular complications arising from diabetes that can impact on quality of life. the linkage of inflammation and type 2 diabetes mellitus (t2dm) has been extensively investigated for over a decade. the main objective of the study is to identify correlation between glycemic control and inflammation. materials and methods: total 500 subjects were studied which were divided into two groups of 250 of diabetic cases and healthy controls after defining proper inclusion and exclusion criteria. gender wise distribution was also done. hba1c and crp were estimated on fully automated analyzers. results: the result had shown that cases have significantly elevated hba1c and crp when compared to age and sex matched healthy controls with p<0.0001. we also identified pearson correlation between crp and hba1c found to be correlated, however positive correlation was weak. conclusion: we can conclude that in developing countries like india estimation of glycated hemoglobin and crp can predict secondary complications of disease. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction india leads the world with largest number of diabetics subjects hence can be called as diabetic capital of world. diabetes mellitus (dm) is nothing but a disorder of glucose metabolism which has been known to human since immemorial time. about 415 million people are suffering from diabetes and this figure is expected to be 640 million by 2040. 1 many research studies have demonstrated importance of monitoring glycemia because there is positive direct relationship between blood sugar level and progression of diabetic complications. 2,3 * corresponding author. e-mail address: akanksha.dby@gmail.com (a. dubey). in last decade though studies hypothesis has been drawn that pathogenesis of diabetes connects to a state of subclinical chronic inflammation. 4,5 as such inflammation is protective mechanism of the body, but in chronic condition like diabetes this protective mechanism becomes important mechanism for progression of disease. 6 c-reactive protein(c-rp) is major acute phase protein which is consider as an indicator of low grade systemic inflammation. 7 in case of type 2 diabetes mellitus, crp is an independent predictor of t2dm. 8–12 over nutrition and physical inactivity leads to excess fat accumulation, acts as a major risk factor for insulin resistance and type 2 diabetes. 13 it has been evident that https://doi.org/10.18231/j.pjms.2021.004 2249-8176/© 2021 innovative publication, all rights reserved. 13 https://doi.org/10.18231/j.pjms.2021.004 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.004&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:akanksha.dby@gmail.com https://doi.org/10.18231/j.pjms.2021.004 14 patne, hisalkar and dubey / panacea journal of medical sciences 2021;11(1):13–16 hypertrophied adipocytes are involved with inflammatory condition. 14–18 inflammatory cytokines released from adipose tissues exert an endocrine effect to promote insulin resistance and also leads to elevated crp. 19–21 hba1c which is also called as glycated hemoglobin is considered as best available biochemical parameter to assess glycemic control in diabetic patients. hba1c is closely associated to response to treatment and risk of developing complications. it provides overall glycemic control for previous 6-8 weeks. 22 in past decades the number of people with type 2 diabetes has been more than doubled globally, making it one of the most important public health challenges to all nations. diabetes is recently known to be an inflammatory disease. the severity of disease and grave complications has been prompted to undertake the following study.hence our study was planned to correlate glycemic marker with pro inflammatory maker (c reactive protein) in type 2 diabetes and its comparison with healthy controls. important objectives of study: 1. to compare efficiency of hba1c in diagnosis of type 2 diabetes. 2. to evaluate crp for further complications of type 2 diabetes 3. to derive correlation b/w crp and hba1c 2. material and methods this study was conducted in peoples college of medical sciences and research centre bhopal and associated people’s hospital bhopal. total 500 subjects included in this study were divided into 2 groups: 1. group i: included 249 normal healthy individuals, who were in the age group 2570 years, of either sex and without any family history of diabetes mellitus. 2. group ii: included 250 diagnosed patients of type 2 dm in the same age group i.e., 25-70 years. 3. subjects were also classified on the basis of gender, 140 males and 110 females were there in controlcase group. 2.1. inclusion criteria type-2 dm diagnosed on the basis of the ada 2015 guidelines was included in the study. 2.2. exclusion criteria type 1 dm, congestive heart failure, tuberculosis, gout, rheumatoid arthritis, renal failure and those who were on hypoglycaemic drugs and on insulin therapy were excluded from the study. criteria for diabetes diagnosis: 4 options a1c ≥6.5%* perform in lab using ngsp-certified method and standardized to dcct assay fpg ≥126 mg/dl (7.0 mmol /l)* fasting defined as no caloric intake for ≥8 hours 2-hour pg ≥200 mg/dl (11.1 mmol /l) during ogtt (75-g)* performed as described by the who, using glucose load containing the equlivalent of 75g anhydrous glucose dissolved in water random pg ≥200 mg/dl (11.1 mmol /l) in persons with symptoms of hyperglycemia or hyperglycemic crisis 23 c reactive protein and hba1c, were analysed on roche cobas c311 test bulb method glycosylated hemoglobin (hba1c) edta immunoturbidimetric method c-reactive protein plain vial/serum separating tube immunoturbidimetric assay statistical analysis of data: all data were expressed as mean ± sd. statistical analysis was done using unpaired students-t-test. a level of p value <0.05 was used to indicate statistical significance in all analyses. the correlation between the parameters was carried out using pearson’s correlation. 3. result the comparison of 250 controls with 250 cases has been shown in following tables: table 1: this table shows comparison of hba1c and crp in controls and cases. the results were statistically significant as p value <0.001. s.no parameters controls cases p value 1. no of subjects 250 250 2. hba1c 4.45±0.64 9.06±2.79 <0.0001 3. crp 4.52±1.09 16.87±0.97 <0.0001 table 2: this table shows comparison of hba1c and crp in healthy male controls and diabetic male cases. the results were statistically significant as p value <0.001.. s.no parameters controls male cases male p value 1. no of subjects 140 140 2. hba1c 4.46±0.37 8.89±2.76 <0.0001 3. crp 4.37±0.34 16.87±0.97 <0.0001 patne, hisalkar and dubey / panacea journal of medical sciences 2021;11(1):13–16 15 table 3: this table shows comparison of hba1c and crp in healthy female controls and diabetic female cases. the results were statistically significant as p value <0.001. s.no parameters controls female cases female p value 1. no of subjects 110 110 2. hba1c 4.43±0.36 9.28±2.82 <0.0001 3. crp 4.37±0.35 16.97±1.00 <0.0001 table 4: this table shows correlation b/w hba1c and crp in diabetic cases. hba1c and c reactive protein showed positive correlation with each other, but correlation was found to be a weak. s.no variable correlation coefficient p value 4 c-reactive protein 0.08 0.18 p<0.05 was considered as statistically significant the pearson correlation b/w crp and hba1c was 0.0.08 (r2= 0.007) which means it is a positive correlation but a weak one 4. discussion the exponential rise in the prevalence of diabetes and hence its complications has been of great concern to health care provider worldwide. in our study hba1c was significantly elevated in diabetic cases when compared with healthy controls. (table 2). we have also compared hba1c on the basis of gender. control males were compared with cases males (table no. 2), and female controls were compared to female cases comparison were statistically significant (p<0.005). the study conducted by prof. k goswami 24 to estimate hba1c among 204 subjects showed similar results as our study. they also demonstrated correlation of hba1c and estimated average glucose and found that on increasing blood sugar level, hba1c % also increases. miza asif baig concluded in his study that hba1c can be used effectively for diagnosis of type 2 diabetes mellitus and also as a predictive marker for complication of diabetes. 25 pro-inflammatory marker crp has also been studied and compared among cases and controls. diabetic cases showed significant elevation of crp when compared to healthy controls (table 2). crp was also compared on the basis of gender within study groups. (tables 3 and 4) and difference among cases and controls was statistically different. one of the hypotheses suggests that crp may have indirect effect on insulin sensitivity and insulin production from pancreatic beta cells through alteration of immune response due to elevated systemic inflammation. high levels of crp is also involved in production of adhesion molecules like e-selectin, icam-1, vcam-1 which play role in vascular endothelial dysfunction insulin transport and insulin resistance. 26 we have also correlated mean hba1c in cases with mean crp level and found weak positive correlation ( p value0.008, r2-0.007). this correlation could be explained by formation of advanced glycation end products (age). ages are product of non enzymatic glycation and oxidation of proteins and lipids, which are formed in hypoglycaemia and diabetes. 27,28 ages produced from glycation is having toxic properties associated with inflammation and oxidative stress. 29 tejan wu 30 et al conducted the third national health and nutrition examination survey which investigated associated between crp and hba1c among 2466 men and 2876 women and conclusion was drawn that crp level was associated with higher hba1c. this study suggests possible role of inflammation in diabetes. 5. conclusion over study revealed that hba1c is elevated in type 2 diabetes and is a most reliable marker and screening tool that can predict complication of diabetes. crp is an pro-inflammatory marker which is elevated in low grade systemic inflammation disease. hba1c and crp when detected together the impact was substantially greater. this hba1c and crp in combination can be a potential predictive marker for type 2 diabetes mellitus. these results support the role of hyperglycemia in development of inflammation and resistance in type 2 diabetes mellitus. early detection of hyperglycemia and blood glycemic control can prevent complication and further decrease morbidity and mortality. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. international diabetic federation. idf diabetes atlas. in: 7th edn. brussels: international diabetic federation; 2015. 2. sarah jb, soma sn, margaret j, jeremy m, shiva s, charles m, et al. adequacy of glycemic, lipid, and blood pressure management for patients with diabetes in a managed care setting. diabetes care. 2004;27:694–8. 3. mahato vr, gyawali p, raut pp, singh k, pandeya dr. association between glycaemic control and serum lipid profile in type 2 diabetic patients: glycated haemoglobin as a dual biomarker. biomed res. 2011;22(3):375–80. 4. pickup jc, crook ma. is type ii diabetes mellitus a disease of the innate immune system? diabetologia. 1998;41(10):1241–8. doi:10.1007/s001250051058. 5. pickup jc, mattock mb, chusney gd, burt d. niddm as a disease of the innate immune system: association of acute-phase reactants and interleukin-6 with metabolic syndrome x. diabetologia. 1997;40(11):1286–92. doi:10.1007/s001250050822. http://dx.doi.org/10.1007/s001250051058 http://dx.doi.org/10.1007/s001250050822 16 patne, hisalkar and dubey / panacea journal of medical sciences 2021;11(1):13–16 6. navarro jf, mora c. role of inflammation in diabetic complications. nephrol dial transplant . 2005;20(12):2601–4. doi:10.1093/ndt/gfi155. 7. ridker pm. clinical application of c-reactive protein for cardiovascular disease detection and prevention. circulation. 2003;107(3):363–9. doi:10.1161/01.cir.0000053730.47739.3c. 8. pradhan ad, manson je, rifai n, buring je, ridker pm. c-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. j am med assoc. 2001;286(3):327–34. 9. festa a, d’agostino r, tracy rp, haffner sm. elevated levels of acute-phase proteins and plasminogen activator inhibitor1 predict the development of type 2 diabetes: the insulin resistance atherosclerosis study. diabetes. 2002;51(4):1131–7. doi:10.2337/diabetes.51.4.1131. 10. han ts, sattar n, williams k, gonzalez-villalpando c, lean mej, haffner sm. prospective study of c-reactive protein in relation to the development of diabetes and metabolic syndrome in the mexico city diabetes study. diabetes care. 2002;25(11):2016–21. doi:10.2337/diacare.25.11.2016. 11. spranger j, kroke a, mohlig m, hoffmann k, bergmann mm, ristow m, et al. inflammatory cytokines and the risk to develop type 2 diabetes: results of the prospective population-based european prospective investigation into cancer and nutrition (epic)-potsdam study. diabetes. 2003;52(3):812–7. doi:10.2337/diabetes.52.3.812. 12. hu fb, meigs jb, li ty, rifai n, manson je. inflammatory markers and risk of developing type 2 diabetes in women. diabetes. 2004;53(3):693–700. doi:10.2337/diabetes.53.3.693. 13. wilding jp. obesity and nutritional factors in the pathogenesis of type 2 diabetes mellitus. in: textbook of diabetes, j. c. pickup. blackwell science, oxford, uk; 2003. p. 21. 14. rupnick ma, panigrahy d, zhang cy, dallabrida sm, lowell bb, langer r, et al. adipose tissue mass can be regulated through the vasculature. proc natl acad sci. 2002;99(16):10730–5. doi:10.1073/pnas.162349799. 15. trayhurn p, wood is. adipokines: inflammation and the pleiotropic role of white adipose tissue. br j nutr. 2004;92(3):347–55. doi:10.1079/bjn20041213. 16. hotamisligil gs, erbay e. nutrient sensing and inflammation in metabolic diseases. nat rev immunol. 2008;8(12):923–34. doi:10.1038/nri2449. 17. wood is, de heredia f, wang b, trayhurn p. cellular hypoxia and adipose tissue dysfunction in obesity. proc nutr soc. 2009;68(4):370– 7. doi:10.1017/s0029665109990206. 18. hotamisligil gs. endoplasmic reticulum stress and the inflammatory basis of metabolic disease. cell. 2010;140(6):900–17. doi:10.1016/j.cell.2010.02.034. 19. hotamisligil gs, spiegelman bm. tumor necrosis factor α: a key component of the obesity-diabetes link. diabetes. 1994;43(11):1271– 8. 20. hotamisligil gs, arner p, caro jf, atkinson rl, spiegelman bm. increased adipose tissue expression of tumor necrosis factoralpha in human obesity and insulin resistance. j clin investig. 1995;95(5):2409–15. doi:10.1172/jci117936. 21. caballero ae, arora s, saouaf r, lim sc, smakowski p, park jy, et al. microvascular and macrovascular reactivity is reduced in subjects at risk for type 2 diabetes. diabetes. 1999;48(9):1856–62. doi:10.2337/diabetes.48.9.1856. 22. farmer a. monitoring diabetes in. in: holt r, cockram cs, goldstein bf, editors. text book of diabetes.5th edn.. vol. 2017. wiley blackwell;. p. 374–84. 23. american diabetes association diagnosis and classification of diabetes mellitus. diabetes care. 2014;37:81–90. 24. goswami k. correlation of hba1c levels with average estimated blood glucose levels in improvement of diabetes management. int j biotechnol biochem;2017(3):205–10. 25. baig ma. comparative evaluation of efficiency of hba1c, fasting and post prandial blood glucose levels, in the diagnosis of type-2 diabetes mellitus and its prognostic outcome. int j res med sci. 2015;3(11):3245–9. doi:10.18203/2320-6012.ijrms20151170. 26. calle mc, fernandez ml. inflammation and type 2 diabetes. diabetes metab. 2012;38(3):183–91. doi:10.1016/j.diabet.2011.11.006. 27. smith ma, taneda s, richey pl, miyata s, yan sd, stern d, et al. advanced maillard reaction end products are associated with alzheimer disease pathology. proc natl acad sci u s a. 1994;91(12):5710–4. doi:10.1073/pnas.91.12.5710. 28. shibata n, hirano a, kato s, nagai r, horiuchi s, komori t, et al. advanced glycation endproducts are deposited in neuronal hyaline inclusions: a study on familial amyotrophic lateral sclerosis with superoxide dismutase-1 mutation. acta neuropathol. 1999;97(3):240– 6. doi:10.1007/s004010050980. 29. takeuchi m, yamagishi s. tage (toxic ages) hypothesis in various chronic diseases. med hypotheses. 2004;63(3):449–52. doi:10.1016/j.mehy.2004.02.042. 30. wu t, dorn jp, donahue rp. associations of serum c-reactive protein with fasting insulin, glucose, and glycosylated hemoglobin the third national health and nutrition examination survey. am j epidemiol. 1988;155:35–71. author biography anupama patne, associate professor p j hisalkar, professor and head akanksha dubey, assistant professor cite this article: patne a, hisalkar pj, dubey a. type 2 diabetes and inflammation; correlation of commonly used inflammatory biomarker with marker of glycemic control. panacea j med sci 2021;11(1):13-16. http://dx.doi.org/10.1093/ndt/gfi155 http://dx.doi.org/10.1161/01.cir.0000053730.47739.3c http://dx.doi.org/10.2337/diabetes.51.4.1131 http://dx.doi.org/10.2337/diacare.25.11.2016 http://dx.doi.org/10.2337/diabetes.52.3.812 http://dx.doi.org/10.2337/diabetes.53.3.693 http://dx.doi.org/10.1073/pnas.162349799 http://dx.doi.org/10.1079/bjn20041213 http://dx.doi.org/10.1038/nri2449 http://dx.doi.org/10.1017/s0029665109990206 http://dx.doi.org/10.1016/j.cell.2010.02.034 http://dx.doi.org/10.1172/jci117936 http://dx.doi.org/10.2337/diabetes.48.9.1856 http://dx.doi.org/10.18203/2320-6012.ijrms20151170 http://dx.doi.org/10.1016/j.diabet.2011.11.006 http://dx.doi.org/10.1073/pnas.91.12.5710 http://dx.doi.org/10.1007/s004010050980 http://dx.doi.org/10.1016/j.mehy.2004.02.042 introduction material and methods inclusion criteria exclusion criteria result discussion conclusion source of funding conflict of interest panacea journal of medical sciences 2020;10(3):334–336 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article increasing bmi is a risk factor for developing pre diabetes hyperglycemia and diabetes saloni1,* 1dept. of biochemistry, pgimer satellite centre, sangrur, punjab, india a r t i c l e i n f o article history: received 11-06-2020 accepted 01-08-2020 available online 29-12-2020 keywords: postmenopausal bleeding histopathology endometrial cancer a b s t r a c t background: postmenopausal bleeding is a frequent finding accounting for 5-10% of women in gynaecology. about 10% of these patients have primary or secondary malignancy. aim: the histopathological patterns of endometrium, in postmenopausal women presenting with bleeding were studied along with the frequency of endometrial cancer. materials and methods: it was both a prospective and retrospective, observational study carried out over a period of one and half year in tertiary care teaching hospital on 112 postmenopausal women ,above 40 year of age with history of one year of amenorrhoea without hormone replacement therapy. the samples were obtained by dilatation and curettage and endometrial pipelle procedure. results and discussion: maximum patients belonged to age group of 46-50 year. the most common histopathological pattern observed was atrophic endometrium in 42(37.5%) patients followed by simple hyperplasia in 13(11.6%) and endometrial polyp in 7(6.25%) cases. irregular shedding of endometrium was diagnosed in 8(7.14%). the maximum patients of endometrial carcinoma (5.35 %) were noted in 6165 age groups. inflammatory pathology was found in 4(3.56%) and atypical hyperplasia was seen a single case (0.89%). in 8 cases, the opinion could not be offered due to inadequacy of sample. conclusion: as the incidence of malignancy in postmenopausal period remains sufficiently high, it requires immediate investigation in the form of endometrial sampling for early diagnosis, prompt treatment and vigilant follow up. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction obesity is increasing at an alarming rate throughout the world. several studies in india have shown that changes in dietary patterns, physical activity level are related to increasing frequencies of obesity. the role of vitamin fortification leading to obesity is becoming more prevalent in recent days. 1 in obesity as excessive adipose tissue accumulates, an altered metabolic profile occurs along with a variety of adaptations and alterations in cardiovascular structure and function even in the absence of co-morbidities. studies indicate that the presence of obesity increases the risk for developing diabetes and cardiovascular diseases. 2 * corresponding author. e-mail address: drsaloni7388@gmail.com (saloni). adipose tissue excess or obesity, particularly in the visceral compartment, is associated with insulin resistance, hyperglycemia, dyslipidemia. hypertension, and prothrombotic and proinflammatory states. the most common cause of insulin resistance occurs when energy intake exceeds the metabolic rate leading to obesity. 3 type ii diabetes mellitus is strongly associated with overweight in both genders in all ethnic groups. 4 men and women with a bmi of 25.0 to 29.9 kg/m2 are considered overweight, and those with a bmi 30 kg/m2 or greater are considered obese. the prevalence of obesity related diseases, such as diabetes, begins to increase at bmi values around 25 kg/m2. obese persons with excess abdominal fat are at higher risk for diabetes, hypertension, dyslipidemia, and ischemic heart disease than obese persons whose fat is located predominantly in the lower body. 5 https://doi.org/10.18231/j.pjms.2020.069 2249-8176/© 2020 innovative publication, all rights reserved. 334 https://doi.org/10.18231/j.pjms.2020.069 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:drsaloni7388@gmail.com https://doi.org/10.18231/j.pjms.2020.069 saloni / panacea journal of medical sciences 2020;10(3):334–336 335 in obese adults, type 2 diabetes develops over a long period, and impaired glucose tolerance can be a predictor for the risk of development of diabetes and cardiovascular disease. 6 fbs < 100 mg/dl is considered normal and between 100–125 mg/dl along with hb a1c 5.7%-6.4% is marked as impaired fasting glucose or prediabetes. fbs≥ 126 mg/dl along with hb a1c ≥6.5% is defined as diabetes mellitus. 7 prediabetic hyperglycemia -fasting plasma glucose of 110 to 125 mg/dl confers an increased risk for cardiovascular disease. 8 the prevalence of diabetes and prediabetes are known to relate with higher ranger of waist circumference, waist /hip ratio and body mass index. 9 2. aims and objectives to study the relation between bmi and fasting blood sugar. 3. materials and methods the subjects for the study were 200 in the age group of 21 to 40 years. control group of 100 patients had bmi of 1824 kg/m2 and study group of 100 patients had bmi of 2529kg/m2. height and weight were recorded. study group excluded people on treatment for diabetes mellitus and cardiovascular diseases. bmi was calculated from the following equation body mass index (kg/m2) = weight in kg height in m2 the body mass index value ranging between 18.5 25.0 is considered as normal, < 18.5 indicates the status as undernourished, while value above 25 as overweight and above 30.0 as obese. 3.1. biochemical analysis the patient was asked to fast overnight for 8-10 hours. fasting blood sugar was estimated by glucose oxidase method. 4. results table 1: comparison of bmi with fasting blood sugar bmikg/m 2 fbs <11o mg/dl fbs 110125mg/dl fbs >126 mg/dl <25 75 20 5 >25 25 50 25 75% of overweight patients had fbs>110 mg/dl whereas 25% of normal weight patients had fbs>110 mg/dl. prediabetic hyperglycemia was noted in 50% of overweight patients. diabetes was diagnosed in 25% of overweight patients. 5. discussion diabetes mellitus is one of the leading risk factors of coronary artery disease and is growing in developing countries because of the changes in lifestyles, increasing high-calorie diet and physical inactivity. 10 all stages of glucose abnormalities like prediabetes and established diabetes mellitus are associated with cad and detection of these abnormalities is of great value in early screening of cardiovascular diseases. 11,12 resistin is an adipokine secreted from adipose tissue and monocytes. it is named for its ability to resist or interfere with insulin action it was proposed as a link between obesity and diabetes. 13,14 in obese individuals, adipose tissue releases increased amounts of non-esterified fatty acids, glycerol, hormones, pro-inflammatory cytokines and other factors that are involved in the development of insulin resistance. 15 our study is done to re-establish the direct relationship between increased body weight and fasting blood sugar. in the control group of bmi <25, majority of people showed fasting blood sugar of less than 100mg/dl.in the study group with bmi>25, majority of people showed fbs >100mg/dl as we have excluded patients of diabetes mellitus and cardiovascular diseases in our study, other causes for the increased fbs leading to prediabetes, like the role of stress in daily life should be considered. stress hormones are known to increase blood glucose levels. physical and emotional stress increases these hormones thereby increasing blood glucose levels. measures should be taken by the prediabetics to keep the sugar levels normal from reaching diabetic levels by changing the lifestyle, increasing physical activity, consuming food having low glycemic index with high fiber content and frequent monitoring of blood glucose levels along with hba1c. prediabetic state is a ‘grey zone’ which implies a declining glucose homeostatic efficiency. though only 25% of cases progress to full blown t2dm, when combined with obesity (bmi >25), it is a definite predictor of onset of t2dm in due course. moreover, complications particularly cardiovascular abnormalities begin in prediabetic phase surreptitiously even before overt diabetes is medically diagnosed 6. conclusion the existence of a significant direct correlation between fbsand bmi was confirmed in the present study. our results therefore suggest that a low bmi is important for maintaining normal blood glucose levels. this study highlights the critical importance of early intervention directed at treatment of obesity in association with normal blood glucose levels to avert the long-term consequences of obesity and diabetes mellitus on the 336 saloni / panacea journal of medical sciences 2020;10(3):334–336 development of various complications 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. zhou ss, zhou y. excess vitamin intake: an unrecognized risk factor for obesity. world j diabetes. 2014;15(5):1–13. 2. cassano pa, segal mr, vokonas ps, weiss st. body fat distribution, blood pressure, and hypertension. ann epidomol. 1990;1:33–48. doi:10.1016/1047-2797(90)90017-m. 3. nelson dl, cox mc, freeman wh. lehninger: principles of biochemistry. in: 4th edn. co., new york; 2004. p. 1119. 4. colditz ga, willett wc, rotintzky a, manson je. weight gain as a risk factor for clinical diabetes mellitus in women. ann intern med. 1995;122:481–6. 5. kissebah a, videlingum n, murray r. relation of body fat distribution to metabolic complications of obesity*. j chin /endoccrinol metab . 1982;54(2):254–60. doi:10.1210/jcem-54-2-254. 6. sinha r, fish g, teagu b, wv t, banyas b, allen k, et al. prevalence of impaired glucose tolerance test among children and adolescents with marked obesity. n engl j med. 2002;346:802–10. 7. american diabetes association. stand med care diabetes. 2015;38(1):1–93. 8. levitzky ys, pencina mj, d’agostino rb, meigs jb, murabito jm, vasan rs, et al. impact of impaired fasting glucose on cardiovascular disease. j am coll cardiol. 2008;51(3):264–70. doi:10.1016/j.jacc.2007.09.038. 9. azizi f, esmaillzadeh a, mirmiran p, ainy e. is there an independent association between waist-to-hip ratio and cardiovascular risk factors in overweight and obese women? int j cardiol. 2005;101(1):39–46. doi:10.1016/j.ijcard.2004.03.011. 10. sadeghi m, roohafza h. diabetes and associated cardiovascular risk factors in iran: the isfahan healthy heart programme. ann acad med. 2007;36:175–80. 11. mellbin lg, anselmino m, lars r. diabetes, prediabetes and cardiovascular risk. eur j cardiovasc prev rehabil. 2010;17(1_suppl):s9–s14. doi:10.1097/01.hjr.0000368192.24732.2f. 12. schnell o. the links between diabetes and cardiovascular disease. j interv cardio . 2005;18(6):413–6. doi:10.1111/j.15408183.2005.00080.x. 13. steppan cm, bailey st, bhat s, brown ej, banerjee rr, wright cm, et al. the hormone resistin links obesity to diabetes. nat. 2001;409(6818):307–12. doi:10.1038/35053000. 14. ge dbs, sewter cp, klenk es. resistin/ fizz3 expression in relation to obesity and peroxisome proliferator-activated receptorgamma action in humans. diabetes. 2001;50:2199–202. 15. kahn se, hull rl, utzschneider km. mechanisms linking obesity to insulin resistance and type 2 diabetes. nat. 2006;444:840–6. doi:10.1038/nature05482. author biography saloni, assistant professor cite this article: saloni. increasing bmi is a risk factor for developing pre diabetes hyperglycemia and diabetes. panacea j med sci 2020;10(3):334-336. http://dx.doi.org/10.1016/1047-2797(90)90017-m http://dx.doi.org/10.1210/jcem-54-2-254 http://dx.doi.org/10.1016/j.jacc.2007.09.038 http://dx.doi.org/10.1016/j.ijcard.2004.03.011 http://dx.doi.org/10.1097/01.hjr.0000368192.24732.2f http://dx.doi.org/10.1111/j.1540-8183.2005.00080.x http://dx.doi.org/10.1111/j.1540-8183.2005.00080.x http://dx.doi.org/10.1038/35053000 http://dx.doi.org/10.1038/nature05482 introduction aims and objectives materials and methods biochemical analysis results discussion conclusion source of funding conflict of interest jan june 2012 for pdf for website isolated torsion of hydrosalpinxa rare presentation 1 2 kose varsha , kawathalkar anjali introduction torsion of the fallopian tube is a rare cause of acute pelvic pain which has never been diagnosed preoperatively. its incidence is one in 1,500,000 (1). diagnosis is very difficult due to its nonspecific presentation, no specific laboratory test, and nonspecific imaging report. being aware of this complication, a clinician can suspect it preoperatively which can make precocious diagnosis and which can allow more conservative management. case report: case 1: an 18 year old unmarried girl was admitted with complaints of severe pain in lower abdomen since 6 hours. there was history of similar pain 9 days back which was relieved by analgesics. there was no complaint of nausea and vomiting. her bowel and bladder habits were normal with no significant medical or surgical illness in past. her menstrual cycles were normal, with last menstrual period 6 days back. on examination she was afebrile, pulse was 118/min and bp 110/70 mm of hg. per abdomen examination showed a suprapubic mass arising from pelvis with tenderness present. per rectal examination revealed a firm, tender mass 3 cm x 5 cm palpable anteriorly. clinical diagnosis was twisted ovarian cyst. her routine blood investigations were normal. ultrasonography showed a cystic lesion in left adnexa and left ovary was not visualized. uterus and right ovary were normal. decision of laparotomy was made with provisional diagnosis of twisted ovarian cyst. intraoperative findings were – uterus, both ovaries, right fallopian tube normal. on left side there was twisted hydrosalpinx. left sided salpingectomy was done. the postoperative period was uneventful, and she was discharged on 7th postoperative day. histopathology report was consistent with hydrosalpinx. case 2: a 40 year old woman was admitted with complaints of pain right side lower abdomen associated with nausea and vomiting since one day. there were no other significant complaints. her premenstrual cycles were normal. her last menstrual period was normal 15 days back. she was g3p2a1; last child birth was 13 yrs back. puerperal tubectomy was done. on examination she was afebrile, pulse 84/min, bp 130/90 mm of hg. on per abdomen examination there was no definite mass palpable. there was pain in right suprapubic region. on per vaginal examination the uterus was normal in size and a firm mass 6.5 cmx 5.5 cm was palpable through right fornices; tenderness was present. a mass of 5 cm x 4 cm was palpable through left fornices; there was no tenderness. her routine blood investigations were normal. ca125 level was less than 4units/ml. ultrasonography report showed a heterogeneous well defined anechoic lesion of size 7.8 cm x 4.7 cm x 4.7 cm on left side and 5 cm x10.1 cm x 4.2 cm on right side of uterus. the right side lesion shows small solid component within it. impression: benign bilateral cystic ovarian lesion,? intramural degenerated fibroid. clinical case 1hydrosalpinx 42 pjmsvolume 2 number 1: january-june 2012 case report 1 2 assistant professor, associate professor department of obstetrics and gynaecology, nkpsims & rc, digdoh hills, hingna road, nagpur-440019 varshadkose@rediffmail.com abstract isolated torsion of the hydrosalpinx is a rare cause of acute pelvic pain. preoperative diagnosis is very difficult because of nonspecific clinical presentation, laboratory characteristic, and nonspecific imaging findings. definitive diagnosis is always made at surgical exploration either by laparotomy or laparoscopy, performed for adnexal torsion. this report describes two cases. case one: an 18 year old unmarried girl was admitted with acute pelvic pain. case two: a forty year old woman was admitted with pelvic pain associated with nausea and vomiting. the clinical and imaging features led to a suspicion of ovarian neoplasm. surgical exploration has revealed twisted left hydrosalpinx in case one and bilateral hydrosalpinx with twisted right hydrosalpinx which developed hematosalpinx in second case. differential diagnosis between adnexal and tubal torsion is very difficult. however both should be managed by surgical exploration which allows proper diagnosis and definitive management. this is an era of minimal invasive surgery. the aim of reporting these cases is that in a setup where endoscopy facilities are available, we can do diagnostic laparoscopy and removal of such isolated benign lesions in same sitting ,avoiding laparotomy . diagnosis of bilateral complex ovarian cyst was made. laparotomy was performed. intraoperative findings were – uterus and both ovaries were normal. right side there was twisted hematosalpinx 7 cm x 3.5 cm. left side hydrosalpinx 5 cm x 3 cm. bilateral salpingectomy was done. postoperative period was uneventful. histopathology report was consistent with hydrosalpinx. patient was discharged on 8th postoperative day. discussion: isolated torsion of the fallopian tube is a rare event that usually occurs in reproductive age group, and rarely in adolescent and postmenopausal women. anatomically, fallopian tube can be divided to two portions – the proximal (intramural segment and isthmus) is fixed to the uterus and has little mobility; the distal portion (ampula and infundibulum) has a large mobility and is in close relation with ovary. fallopian tube and ovary constitute a real functional and anatomical unit so that isolated torsion of one of them is rarely reported and adnexal torsion occurs more frequently (2). many risk factors for isolated tubal torsion have been reported. shukla (3) has proposed etiologic classification for fallopian tube torsion as – a. anatomical abnormalities (long mesosalpinx, tubal abnormalities, hematosalpinx, hydatid of morgagni). b. physiological abnormalities (abnormal peristalsis or hyper motility of tube, tubal spasm and intestinal peristalsis). c. hemodynamic abnormalities (venous congestion in the mesosalpinx). d. sellheim theory (sudden body position changes). e. trauma, previous surgery or disease (tubal ligation, pelvic inflammatory disease). f. gravid uterus. many reports indicate that torsion of the fallopian tube is more common on the right side rather than on the left. this may be due to the presence of sigmoid colon on the left side or to the slow venous flow on the right side, which may result in congestion. it is similar to case two, but in case one twisted hydrosalpinx was on the left, and in an 18 year old unmarried girl which is a rare presentation of a rare entity. hydrosalpinx is a common long term result of pelvic inflammatory disease. the majority of hydrosalpinx are not complicated by torsion because of the high frequency of pelvic adhesions which limit the pelvic organ mobility and prevent torsion. the differential diagnosis of fallopian tube torsion includes acute appendicitis, ectopic pregnancy, pelvic inflammatory disease, twisted ovarian cyst and degenerative leiomyoma (3). based on this experience as well as other similar reported cases, isolated torsion of the fallopian tube should be considered in the differential diagnosis of acute lower abdominal or pelvic pain, so that prompt surgical intervention can be done either by laparotomy or laparoscopy (4,5). the aim of reporting these cases is that in a setup where endoscopy facilities are available, we can do diagnostic laparoscopy and removal of such isolated benign lesions in the same sitting , avoiding laparotomy . references: 1. lineberry t, rodriguez h. isolated torsion of the fallopian tube in an adolescent: a case report. j pediatr adolesc gynecol 2000; 13:135-8. 2. ajit benkaddour y, bennani r. uncommon cause of acute pelvic pain: isolated torsion of hydrosalpinx.afr j reprod health 2009; 13(4):147-150. 3. shukla r. isolated torsion of the hydrosalpinx: a rare presentation. br j radiol, 2004; 77,784-786. 4. ozgum mt, batukan c, and al. isolated torsion of fallopian tube in a postmenopausal patient: a case report. maturitas 2007; 57:325-7. 5. provansal m, courbiere b. and al. isolated tubal torsion: about three cases. gynecol obst fert 2008; 36,173-175. case 2hematosalpinx 43 pjmsvolume 2 number 1: january-june 2012 case report page 46 page 47 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2020;10(3):216–221 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article evaluation of impact of national leprosy eradication programme in a community health centre in eastern india mayadhar panda1, sikata nanda2,*, rabi narayan dhar3 1dept of community medicine, sln medical college, koraput, odisha, india 2dept. of community medicine, s.c.b. medical college and hospital, cuttack, odisha, india 3dept. of orthopaedics, veer surendra sai institute of medical science and research, burla, odisha, india a r t i c l e i n f o article history: received 19-07-2020 accepted 06-10-2020 available online 29-12-2020 keywords: nlep mdt lcdc a b s t r a c t background & aim: leprosy a chronic infectious public health challenge is caused by a slowly multiplying acid fast bacillus mycobacterium leprae. an untreated leprosy-affected person is the only known source of infection. our aim was to study the trend in the prevalence of leprosy in the health care facility, to compare the leprosy burden in urban and rural field practice area under the health facility, to identify any gaps/loopholes in the implementation of the nlep and to recommend remedial measures to address the gaps. materials and methods: a cross sectional study was conducted at community health centre jatni, khordha, odisha during the year 2018-19. a pre-designed questionnaire, personal interview with multipurpose health worker male and review of leprosy records of different years was used as study tool. results: majority i.e., 78.6% of the leprosy patients were from rural areas. overall male predominance of the cases was found both in urban & rural areas. more numbers of cases were registered during 2014-15 & 2015-16 which was declined in 2016-17, but again increased in the subsequent years i.e., 2017-18 and 2018-19. 61.8% diagnosed leprosy cases had successfully undergone treatment and got cured and 24.4% of the cases were the defaulters to mdt. conclusion: defaulter cases are the major source of continuous transmission of infection in the community. active surveillance for leprosy is to be strengthened in both rural and urban areas with special focus on iec and bcc activities along with proper counseling of the family members with involvement of community people. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction leprosy is a chronic infectious public health challenge which is caused by a slowly multiplying acid fast bacillus, mycobacterium leprae. an untreated leprosyaffected person is the only known source of infection. the disease is well known for a long incubation period, which may range from few weeks to 30 years. 1 leprosy; one of the neglected tropical diseases is generally associated with poverty, overcrowding, thereby affecting the most underserved population of the country. as far as the burden * corresponding author. e-mail address: drkitusraban@gmail.com (s. nanda). of leprosy is concerned, global prevalence of leprosy according to global leprosy update 2017 is 0.25 per 10,000 population (total 1,92,713 cases); an increase of 20,765 cases as compared to 2016. the increase in cases was observed in all who regions and the highest prevalence was seen in sear, i.e. 0.6 per 10,000 populations. sear contributes about 73% of the global leprosy burden (india and indonesia contribute 67.4% of new cases globally and 92.3% regionally). 2 as per who data more than 81% of the new cases are reported from three countries i.e., india, brazil and indonesia. 3,4 although the prevalence of leprosy in india is less than 1 per 10,000 since 2005,it still accounts for 62% of the total new cases reported worldwide. 3 https://doi.org/10.18231/j.pjms.2020.046 2249-8176/© 2020 innovative publication, all rights reserved. 216 https://doi.org/10.18231/j.pjms.2020.046 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:drkitusraban@gmail.com https://doi.org/10.18231/j.pjms.2020.046 panda, nanda and dhar / panacea journal of medical sciences 2020;10(3):216–221 217 in spite of the fact that the disease has long incubation period, the time taken for declaration of elimination after attainment of prevalence rate < 1 per10,000, was too short, which is revealed by the continuous emergence of new cases along with a rise in cases amongst children in india from 2006 till date. 1,5 despite advances in all spheres of medical science, leprosy continues to be a public health challenge in countries like india. 6 leprosy is a silent emergency; the real burden of which is underestimated; affecting the most underserved population of the country. 2 “national leprosy eradication programme (nlep) in india is a centrally sponsored health scheme of the ministry of health and fw, government of india. the programme is also supported by who, ilep, and few other nongovernmental organizations (ngos). due to their efforts, from a prevalence rate of 57.8/10,000 in 1983, india has succeeded with the implementation of mdt in bringing the national prevalence down to “elimination as a public health problem” of less than 1 per 10,000 in december 2005 and even further down to 0.66/10,000 in 2016. india by the end of march 2011–2012 succeeded in achieving elimination at the state level in 34 out of the total of 36 states/uts. only the state of chhattisgarh and the ut of dadra & nagar haveli were yet to achieve elimination. by the end of march 2016, 82.36 % i.e. 551 out of the total 669 districts in india achieved the target of elimination; i.e., leprosy as a public health problem, 7 which suggests that leprosy is still a major public health challenge in those districts which have leprosy prevalence of more than or equal to 1 per 10,000 population and they are a long way back from achieving the status of leprosy elimination; rather they contribute to continued transmission. however at present, in spite of availability and implementation of an effective multi-drug therapy (mdt) for more than 30 years and attainment of status of leprosy elimination as defined by who in 2002, india still continues to have a high share of 58.8% of the world leprosy population. 8 in the year 2007, new cases detected in india were 137,685, and nine years later in 2016, the number remained almost the same at 135,485, a significant increase over the 127,326 new cases detected in 2015. this increase in new cases is attributed by nlep to their recent strategy of innovative leprosy case detection campaign (lcdc), which resulted in the detection of 34,000 new cases from highly endemic pockets and accounted 25% of the total annual new cases in 2016. 7 unfortunately, leprosy eradication from community appears as if had been equated with the reaching of the who-defined target of elimination of leprosy as a public health problem. however many districts have not yet reached the target of elimination. rather the use of term “elimination” also creates confusion among the public and also to many even in the medical profession. 8 over two lakh new cases of leprosy are detected each year of which about 7% are associated with grade-2 deformity by the time of diagnosis. hence the disease elimination can be achieved with a wider focus on risk groups and their socio-demographic characteristics; as it is evidenced that elderly age, overcrowding, hunger, and poor ses etc, pose a greater risk for leprosy. thereby special attention should be directed for improving the living conditions of the underserved population and decreasing inequality in low and middle-income countries so as to achieve leprosy elimination. 9 leprosy almost eliminated a decade ago; has been returned back in odisha. the national health profile 2019 released by the union ministry of health and fw says leprosy prevalence rate in odisha is second highest in the country after chhattisgarh. the hansen’s disease is now prevalent in 18 districts of the state. from a prevalence of less than one per 10,000 populations in 2006, it now stands at 1.39 against the national average of 0.65. six districts have recorded annual new case detection rate (ancdr) of more than 50 per one lakh (i.e., >5 cases /10,000) population. according to nhp, as many as 8,754 new cases of leprosy have been detected in odisha in 2018 and 6,445 persons are under mdt. 10 2. materials and methods a cross sectional study was conducted in community health centre, jatni during the year 2018-19. the head quarter multipurpose health worker (mphw-m) of the chc performing the duty of paramedical worker (pmw) leprosy, was interviewed using a pre-designed questionnaire to collect the data. also secondary data were collected for a period of 5 years from 2014-15 till 2018-19 from the leprosy records available with him. 3. results fig. 1: residence wise distribution of male & female leprosy cases 218 panda, nanda and dhar / panacea journal of medical sciences 2020;10(3):216–221 table 1: year wise comparative analysis of new pb leprosy cases according to place of residence (rural population-87958 & urban 57389). year adult pb cases total child pb cases (<15yrs) totalurban rural urban rural m f m f mch fch mch fch 2014-15 1 0 8 5 14(29.8%) 1 0 1 0 2(25%) 2015-16 3 1 5 4 13(27.7%) 1 0 1 0 2(25%) 2016-17 0 0 2 0 2(4.2%) 0 0 0 1 1(12.5%) 2017-18 2 1 3 4 10(21.3%) 0 0 2 0 2(25%) 2018-19 2 2 0 4 8(17%) 0 0 0 1 1(12.5%) total 8 4 18 17 47 (100%) 2 0 4 2 8 (100%) 12(25.5%) 35(74.5%) 2(25%) 6(75%) total pb cases detected = 55 table 2: year wise comparative analysis of mb cases among the urban & rural population year adult mb cases total child mb cases (<15yrs) total urban rural urban rural m f m f mch fch mch fch 2014-15 4 0 10 2 16 (24.2%) 1 1 0 2 4(40%) 2015-16 1 0 13 6 20(30.3%) 1 0 1 0 2(20%) 2016-17 1 0 3 5 9(13.6%) 0 0 0 1 1(10%) 2017-18 2 2 6 3 13(19.7%) 1 0 0 1 2(20%) 2018-19 0 0 5 3 8(12.1%) 0 0 1 0 1(10%) total 8 12.1% 2 (3%) 37 56.1% 19 28.8% 66 100% 3 1 2 4 10 (100%) 10 56 4(40%) 6(60%) total mb cases detected =76 table 3: leprosy cases with deformity amongst urban and rural population. (all mb cases n=76) s. no. year urban (total detected mb cases=14) rural (total detected mb cases=62) grade i grade ii grade i grade ii 1 2014-15 2 1 4 2 2 2015-16 0 0 3 3 3 2016-17 0 0 2 1 4 2017-18 1 0 1 0 5 2018-19 0 0 1 1 total 3 1 11 7 4 out of 14 (28.5%) 18 out of 62 (29%) table 4: comparative analysis of registered leprosy cases (pb+ mb) and place of residence mb cases urban rural total year m f m f 2014-15 7 1 19 9 36 (27.5%) 2015-16 6 1 20 10 37 (28.2%) 2016-17 1 0 5 7 13 (9.9%) 2017-18 5 3 11 8 27 (20.6%) 2018-19 2 2 6 8 18 (13.7%) total 21 7 61 42 131 (100%) 28 (21.4%) 103 (78.6%) panda, nanda and dhar / panacea journal of medical sciences 2020;10(3):216–221 219 table 5: outcome of the leprosy cases (old and new): year wise diagnosed cases (new + old) cured defaulters relapse non-traceablepb mb total pb mb total 2013-14 8 10 18 4 9 13 4 1 0 2014-15 14 16 30 5 7 12 8 6 4 2015-16 13 20 33 11 13 24 5 3 1 2016-17 2 9 11 1 5 6 4 0 1 2017-18 10 13 23 7 8 15 6 2 0 2018-19 8 8 16 6 5 11(68.7%) 5 (31.2%) 0 0 total 55 76 131 100% 34 47 81 (61.8%) 32 (24.4%) 12 (9.1%) 6 (4.6%) table 6: defaulter cases among urban vs rural population urban rural diagnosed defaulted diagnosed defaulted pb mb total pb mb total pb mb total pb mb total 14 14 28 5 4 9 41 62 103 10 13 23 fig. 2: distribution of leprosy cases according to sex fig. 3: distribution of cases according to place of residence fig. 4: comparison of point prevalence of leprosy in rural and urban area. 4. discussion table 1 depicts that a total of 47pauci-bacillary (pb) adult leprosy cases (age >=15 years) have been detected over a period of 5 years, out of which majority of the cases i.e., 29.8% and 27.7% were registered in the year 2014-15 and 2015-16 respectively. among the 47 adult pb cases, 26 were males 21 were females. among the males, 8 belonged to urban area and 18 from rural villages. similarly out of 21 females, only 4 were from urban & 17 from rural area. a total of 8 children were registered as pb (child) leprosy over the above said study period and 6 out of 8 (75%) cases were from rural area. as revealed fromtable 2 a total of 66 adult mb cases were registered during this study period out of which 24.2% and 30.3% mb cases were registered during 2014-15 and 220 panda, nanda and dhar / panacea journal of medical sciences 2020;10(3):216–221 2015-16 respectively. majority i.e., 45(68.2%) were males. 37 out of the 45 males were from rural places, only 8 were from urban areas. similarly 2 among the 21 female cases were from urban area and the rest were from rural areas. so over all, 56 out of 66 (84.8%) adult cases were having residence in the rural areas, again showing rural predominance of the leprosy burden. similarly 6 out of the 10 (60%) mb leprosy children had residence in rural areas. from tables 1 and 2 it was found that a total of 18 out of 131 leprosy cases i.e., about 14% of cases were children and majority of the affected children i.e., 66.6% (12 out of 18) were having residence in rural area. so major focus should be directed towards the rural areas as well as the children affected with leprosy as it is well known that the proportion of child leprosy cases is an indicator of continued transmission of infection in the community while the percentage of patients with grade 2 deformity reflects a delay in the diagnosis. according to the available data of nlepprogress report for the year 201415, child cases which at present constitute about 9% of global and indian new cases detected annually, showed no appreciable decline over the last decade. what is worrisome for india is that the proportion of new child cases detected was 12% or higher in eight states/union territories with lakshadweep reporting as a proportion of child cases as high as 75%; with 245 new child cases presenting with grade 2 disabilities for the year 2014–2015. 11 in case of children i.e., under the age of 15 years old leprosy is common in countries where leprosy continues to be endemic. as per the global data 2012; 21,349 new child cases(i.e.,9%of all the new leprosy cases)were detected; amongst which 76.5% belonged to south-east asia region. in india, 10 states had proportion of child leprosy cases more than 10%, out of them in daman and diu it was 30%. based on different study reports; much higher proportion of cases were found in active population surveysi.e., 35% in maharashtra and 32.5% in agra. 12 from tables 1 and 2 it is found that majority of the leprosy cases i.e., (58%) 76 out of total 131 are of mb category which are also the major source of transmission of infection in the community. similar results were found in a study conducted by giri vc et al(2017); where 60.8% of cases were mb category and rest 39.2% were pb leprosy cases. 13 table 3 shows that, a total of 22 out of 76 mb (28.9%) cases were detected with grade-i & grade ii deformity. majority i.e., 18 out of 62(29%) cases were documented from rural area, out of which 7 cases were having visible deformity i.e., grade-ii deformity. however only a single case with grade-ii deformity was detected from urban area, showing delay in the diagnosis and treatment of the leprosy cases in rural area; may be because of social stigma for which special emphasis needs to be given over the rural areas. in the study conducted by giri vc et al(2017); it was found that a total of 6 out of 166 newly detected leprosy cases had either gr-i or gr-ii deformity. 13 table 4 shows 28 out of total 131 leprosy cases belonged to urban areas where as majority i.e., 103 (78.6%) cases were from rural areas. overall male predominance of leprosy cases were found both in urban as well as in rural areas. more numbers of cases were registered during 201415 & 2015-16 which was declined in the subsequent year i.e., 2016-17, but again increased in 2017-18 and 2018-19 which may be due to more active case finding by door to door screening campaign by the grass root level workers like asha in leprosy case detection campaign (lcdc). however table nos-2 & 4 showed that the number of new cases detected among the children age group was found to decrease in both pb & mb category similar results were found in a study conducted by mohite et al(2013) showed that the number of new cases of leprosy decreased from 543 to 95, the percentage of child cases among the new cases decreased from 44% to 4.7% due to effective implementation of nlep services. however the proportion of mb cases among the new cases was increased from 17% to 32.6%. 14 figure 1 showed that proportionately higher numbers of male leprosy cases in the urban area were registered in comparison to that in rural area and the reverse was noticed for female cases. figure 2 depicts amongst the registered leprosy cases males were proportionately much higher in number which may be due to more exposure of the males to the infection sources. figure 3 shows about 80% cases were registered from the rural area, which indicates that more stringent screening campaigns & monitoring of the cases under treatment to be undertaken in the rural areas. figure 4 shows the comparative analysis of overall point prevalence (by 31st march of respective years) of leprosy cases based on residence which is much higher in rural area in comparison to urban. rural prevalence was found above the target for elimination of leprosy except for the year 2017 which was 0.9/10,000 population. however a huge improvement in the prevalence of leprosy in rural area was noticed from 3.2/10,000 in 2015 to 0.9/10,000 over a period of only 2 years. whereas there was little bit increase in the prevalence towards 2018 and 2019 which may be a result of increase new case detection which may be due to more active case finding lcdc. whereas in the urban area though the prevalence was below the cutoff line, a gross increase was noticed in 2018 & in 2019 it exceeded the cutoff target for elimination. this may be due to gathering of hidden cases, more number of resistant patients or relapse cases due to defaulter to mdt. from table 5, it was found that 81 out of total 131(61.8%) diagnosed leprosy cases were successfully panda, nanda and dhar / panacea journal of medical sciences 2020;10(3):216–221 221 undergone treatment and got cured. 34 out of 55 (61.8%) pb cases got cured from leprosy and 47 out of 76 (62%) mb cases also got cured. however a total of 32 under both pb & mb cases out of 131 (24.4%) cases were found to be defaulters to treatment. incomplete treatment or defaulters to treatment are the major challenge for leprosy eradication since they are the continuous source of disease transmission in the community. table 6 shows that, (15 out of 32) i.e., 46.8% of the defaulters belong to pb category, rest 53.2% however proportion of leprosy patients defaulted in pb category was found to be more in comparison to that of mb category i.e., 15 out of 55 (27.3%) diagnosed pb cases were defaulted from treatment whereas 17 out of 76 (22.4%) diagnosed mb cases were the defaulters. similarly a higher proportion i.e., 32.1% (9 out of 28) of the defaulters was found amongst the urban patients in comparison to (22.3%) 23 out of 103 enrolled rural patients. 5. conclusion majority of the cases (80%) were registered from the rural area, which indicates that more stringent screening campaigns & monitoring of the cases under treatment to be undertaken in rural area. similarly percentage of children affected with leprosy indicates the continued transmission of infection in the community; hence major focus should be directed towards the children affected with leprosy. defaulters to mdt are also the major source of continuous infection for the community. hence more effective measures need to be taken for reduction of default rate. and strict adherence to mdt should be ensured through regular follow-up by the frontline workers as well as by the supervisory teams is of utmost importance to achieve the success. active surveillance for leprosy can be strengthened in above areas with special focus on iec and bcc activities. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. sengupta u. elimination of leprosy in india: an analysis. indian j dermatol venereol leprol. 2018;84:131–6. 2. panigrahi sk, galhotra a, pal a. leprosy–a raging persistent enigma. j family med prim care . 2019;8(6):1863–6. doi:10.4103/jfmpc.jfmpc_245_19. 3. world health organization.global leprosy update. wkly epidemiol rec. 2014;89:389–400. 4. singh sk, mishra mn, kumar a, nath g, singh tb. resistance to anti leprosy drugs in multi-bacillary leprosy: a cross sectional study from a tertiary care centre in eastern uttar pradesh, india. indian j dermatol venereol leprol. 2018;84(3):275–9. doi:10.4103/ijdvl.ijdvl_34_16. 5. singal a, sonthalia s. leprosy in post-elimination era in india: difficult journey ahead. indian j dermatol. 2013;58(6):443–6. doi:10.4103/0019-5154.119952. 6. rao pn, suneetha s. current situation of leprosy in india and its future implications. indian dermatol online j. 2018;9(2):83–9. doi:10.4103/idoj.idoj_282_17. 7. weekly epidemiological record no. 35; 2017. 8. global leprosy update2014; need for early case detection. wkly epidemiol rec. 2015;90:461–74. 9. pescarini jm. socioeconomic risk markers of leprosy in high-burden countries: a systematic review and meta-analysis. plos negl trop dis. 2018;12(7):e6622. 10. leprosy stages a return in odisha after ten years-2056351; 2019. available from: https://www.newindianexpress.. 11. nlep – progress report for the year 2014-15, central leprosy division. new delhi. directorate general of health services, . new delhi: nirman bhawan; 2015. 12. butlin cr, saunderson p. children with leprosy; dblm hospital,. bangladesh: notkhana, nilphamari 5300;. 13. giri vc. achieving integration through leprosy case detection campaign (lcdc). ijbr. 2017;8(1). 14. mohite rv, mohite vr, durgawale pm. differential trend of leprosy in rural and urban area of western maharashtra. indian j lepr. 2013;85:11–8. author biography mayadhar panda, tutor sikata nanda, associate professor rabi narayan dhar, associate professor cite this article: panda m, nanda s, dhar rn. evaluation of impact of national leprosy eradication programme in a community health centre in eastern india. panacea j med sci 2020;10(3):216-221. http://dx.doi.org/10.4103/jfmpc.jfmpc_245_19 http://dx.doi.org/10.4103/ijdvl.ijdvl_34_16 http://dx.doi.org/10.4103/0019-5154.119952 http://dx.doi.org/10.4103/idoj.idoj_282_17 https://www.newindianexpress. introduction materials and methods results discussion conclusion source of funding conflict of interest panacea journal of medical sciences 2021;11(1):158–160 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article lone urethral injury following sexual intercoursea rare case report abstract narendar tiramdas1,*, sadhan kumar1, pvln. murthy1, vinay kumar1 1dept. of urology, kamineni institute of medical sciences, narkatpally, nalgonda, telangana, india a r t i c l e i n f o article history: received 24-08-2020 accepted 20-09-2020 available online 29-04-2021 keywords: penile fractures corpus spongiosum urethral trauma coitus related penile trauma a b s t r a c t penile fracture after coitus present with excrusiating pain, detumescence, swelling , deformation and ecchymosis. penile fracture associated with urethral rupture occurs only in 10% to 20% cases. isolated corpus spongiosum and urethral injury without corpus cavernosum injury is extremily rare with five male patients described in the literature. we report a patient, who presented with typical features of penile fracture, was found to have an isolated penile urethral injury on surgical exploration and underwent primary repair. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction penile fracture is defined as rupture of corpus cavernosum because of trauma to the erect penis. penile fracture with or without urethral injury is an uncommon urological emergency. 1 it often occurs by unusual sexual intercourse or masturbation. penile fracture usually associated with snapping sound, severe pain and rapid detumesence. gross hematuria or voiding difficulty symptoms suggest associated urethra injury. isolated urethral and spongiosum injury are very rare and might occur without any symptoms. it is usually diagnosed on the basis of clinical findings and surgical exploration. we report a case of isolated penile urethral injury following sexual intercourse. 2. case report a 35year-old male presented to the emergency department complaining of pain, progressive penile swelling and deformity with 6 hours duration. the penile trauma occurred while doing sexual intercourse with his wife after taking alcohol. he forcefully tried to insert penis into the vagina and hit the pubic symphysis of the wife in normal (supine) * corresponding author. e-mail address: narendaruro@gmail.com (n. tiramdas). position. he felt rapid detumescence and bleeding per urethra. he presented to causality 6hrs after the incident. he passed blood stained urine mainly at the beginning of the stream, after that penile swelling was gradually increasing in size. physical examination revealed a swollen, deformed, dusky coloured flaccid phallus with blood at the tip of the meatus (figure 1). the ultrasound showed breach in the corpus spongiosum with haematoma in the distal penile region. with the provisional diagnosis of penile fracture, patient agreed for emergency surgical exploration under spinal anaesthesia. after giving prophylactic antibiotic intravenously, a subcornal circumferential incision was made and degloved upto the base of the penis. a small hematoma was found on the ventral surface of the penis. the tunica albugenia over the corpus cavernosum found to be intact. on further debridement of haematoma revealed a vertical full thickness. tear of size 3*2 cm noted over the ventral surface of penile urethra (figure 2). primary urethral repair was done using 4-0 vicryl in two layers over 14f foleys catheter (figure 3). the circumcisional incision was closed with interrupted sutures. penile dressings applied in penis elevated position. post op period was uneventful. patient https://doi.org/10.18231/j.pjms.2021.034 2249-8176/© 2021 innovative publication, all rights reserved. 158 https://doi.org/10.18231/j.pjms.2021.034 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.034&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:narendaruro@gmail.com https://doi.org/10.18231/j.pjms.2021.034 tiramdas et al. / panacea journal of medical sciences 2021;11(1):158–160 159 was discharged with foley catheter on postoperative day 8. fig. 1: gross image of penile fracture fig. 2: per operative image of isolated urethral defect the foley catheter was removed after 28days, and patient was able to void to completion without difficulty. on recent follow-up after 6weeks, his erectile function was preserved without any urinary complaints. 3. discussion antomically the penis is composed of three columns of tissues, dorsally two columns of corpus cavernosum and ventrally corpus spongiosum. the two columns of copus cavernosum covered by tunica albugenia. these corpus cavernosal strctures composed of sinusoids, which contributes to penile rigidity. the corpus spongiosum contains the urethra and does not contributes for penile rigidity. 2 penile fractures are mostly due to abnormal sexual postions like female superior position (reverse). because of sudden blunt trauma to the penis, tear in the tunica albuginea will occur. 3 penile fractures most commonly occurs on fig. 3: peropearative image of isolated urethral defect the ventrolateral aspect of the penis. usually concomitant urethral injury is greatly associated with bilateral corporal injury than unilateral corporal injury. the clinical diagnosis of penile fracture mainly made by a “pop” sound, followed by rapid detumescence, pain, swelling and “egg-plant” penile deformity. ulltasonography, cavernosography, magnetic resonace imaging can be used for diagnosis in equivocal cases for assessing the degree of injury. 4 retrograde urethrography or urethroscopy can be used to demonstrate urethral injury, which has been described in the literature. 5 emergency surgical exploration is the definitive diagnostic procedure for penile factures. immediate exploration yields few complications and better long-term results than conservative treatment. the main principles of repair include degloving of penile skin, evacuation of hematoma, repair of tunica albuginea tear, urethral injury repair and urethral catherisation. 5 usually one month absentice from sex is advised following penile fracture. erectile dysfunction, painful erection, penile deviation, wound infection, urethral stricture and urethrocutaneous fistula formation are the usual complication following penile fractures with or without surgical repair. 6 in our case, isolated urethral injury was properly diagnosed and repaired on emergency surgical exploration. we have not observed any complications after surgery in our patient till now. 4. conclusion this case highlights the high index of suspicion for isolated penile urethral and corpus spongiosum injury during sexual intercourse. based on clinical findings and 160 tiramdas et al. / panacea journal of medical sciences 2021;11(1):158–160 following the management principles of penile fractures and urethral injury , this rare entity of isolated urethral injury can be diagnosed and managed successfully without any complications. 5. source of funding no financial support was received for the work within this manuscript. 6. conflict of interest the authors declare they have no conflict of interest. references 1. eke n. fracture of the penis. br j surg. 2002;89(5):555–65. doi:10.1046/j.1365-2168.2002.02075.x. 2. maharaj d, naraynsingh v. fracture of the penis with urethral rupture. injury. 1998;29:483. doi:10.1016/s0020-1383(98)00089-8. 3. mohanpatra tp, kumar s. reverse coitus: mechanism of urethral injury in the male partner. j urol. 1990;144:1467–8. 4. patel a, kotkin l. isolated urethral injury after coitusrelated penile trauma. j trauma. 2010;68(4):e89–e90. doi:10.1097/ta.0b013e31818d0e2d. 5. mendonca rd, bicudo mc, sakuramoto pk, bezerra ca, pompeoa ac, wroclawski er, et al. isolated anterior urethral trauma in man after coitus: a case report. einstein. 2009;7(4):503–5. 6. mcardle j, wille ma, courtney m. isolated spongy urethral rupture from abrupt coital distractive force brian . hollowell j radiol case rep. 2017;11(2):23–7. author biography narendar tiramdas, assistant professor sadhan kumar, post graduate pvln. murthy, professor vinay kumar, assistant professor cite this article: tiramdas n, kumar s, murthy pvln, kumar v. lone urethral injury following sexual intercoursea rare case report abstract. panacea j med sci 2021;11(1):158-160. http://dx.doi.org/10.1046/j.1365-2168.2002.02075.x http://dx.doi.org/10.1016/s0020-1383(98)00089-8 http://dx.doi.org/10.1097/ta.0b013e31818d0e2d introduction case report discussion conclusion source of funding conflict of interest original research article http://doi.org/10.18231/j.pjms.2020.006 panacea journal of medical sciences, january-april, 2020;10(1):21-25 21 clinical study of visual field defects (vfd) in traumatic brain injury (tbi) tanushree v 1 , sanjana singh r 2* 1assistant professor, 2junior resident, dept. of ophthalmology, bangalore medical college hospital and research institute, bangalore, karnataka, india *corresponding author: sanjana singh r email: singh11sanjana@gmail.com abstract purpose: to determine the frequency of occurrence of visual field defect in a visually symptomatic patients with traumatic brain injury. materials and methods: a study was conducted at our institution on 40 patients with history of traumatic brain injury. study was for a duration of one year from june-2018 to may-2019. patients with detailed clinical information were included and was subjected to visual field analysis. results: out of 40 cases, 32(80%) were males and 8(20%) were females. age distribution varied from 10–62 years, with 18-45 years being most common. 16(40%) patients had one of the targeted defect. of which, 8(50%) had scattered scotomas, 3(18%) had right & 3(18%) had left homonymous hemianopia, 2(12%) had bi-temporal hemianopia with chiasmal injury. most frequent defects in the tbi were scattered scotomas next to homonymous hemianopia conclusion: uniqueness of this study is that, it reports frequency of visual field defect in traumatic brain injury. most were motor vehicle‐ related, younger male patients. findings should alert and make one aware of the adverse effects on quality of life and rehabilitation. keywords: visual field defects (vfd), traumatic brain injury (tbi). introduction visual field deficits may commonly follow head trauma. the afferent and efferent visual systems are susceptible to injury from a variety of mechanisms. these patients can be a diagnostic and therapeutic challenge, in large part secondary to the frequently vague nature of their visual complaints and their coexistent neurologic deficits.1 traumatic brain injury is frequently associated with ophthalmic manifestations and consequent morbidity. many of the ophthalmic findings are often ignored and hence present much later to specialist neuro-ophthalmic clinics.2 homonymous hemianopia coupled with visual neglect is generally accepted as the most common type of visual field defect following traumatic brain injury. this study emphasize the clinical correlation of ophthalmic finding in early localization of the site of injury, ongoing assessment, management, rehabilitation and further prognosis of the patient with traumatic brain injury. materials and methods a prospective study of 40patients with history of traumatic brain injury seen between april 2018 to may 2019 in the out patient department at bangalore medical college and research institute. this study was performed after obtaining ‘permitted to study’ by ethical committee. all patients after taking an informed consent, underwent a standardized neuro-ophthalmic history and examination with detailed clinical information, which included age, sex of the patient, time of injury, types of visual field defects, location of lesion were recorded. visual acuity recorded with snellens chart, refraction done, detailed anterior segment evaluation under slit lamp and detailed posterior segment evaluated to look for any pathology. in our study visually symptomatic patients with history of traumatic brain injury was included. patients with space occupying lesions, optic neuropathy due to other causes like infectious, inflammatory, toxic, vascular, dietary and neoplastic, glaucomatous field defect were excluded. visual fields were tested by confrontation test and humphrey automated perimeter. the association between the visual field defect and ocular findings, neuro-deficit and the final outcome of the patient was evaluated. results the total number of cases in our study were 40 individuals with history of traumatic brain injury, out of which 32 (80%) were males and 8 patients (20%) were females.age distribution in our study varied from 10-62 years, with most number of cases were reported from the age group of 18 -45 years being the most common. in this sample of 40 patients, 16patients (40%) patients had one of the targeted defect. out of which, 8 patients (50%) had scattered scotomas, 3 patients (18%) had right & 3 patients (18%) had left homonymous hemianopia (hhm), 2 patients (12%) had bi-temporal hemianopia with chiasmal injury. the most frequently affected visual field defect in tbi was found to be scattered scotomas followed by homonymous hemianopia. various mode of injury presented to us were: motor vehicle accident which accounts to nearly 75% of all cases being the most common type of injury. followed by blunt trauma (15%), self fall and projectile object injury accounted to 5%each in our study. the data regarding the numeric and percentage distribution of the age (fig. 1), sex distribution (fig. 2) and targeted visual field defects for all subjects are presented in fig. 3. tanushree v et al. clinical study of visual field defects (vfd) in traumatic brain injury (tbi) panacea journal of medical sciences, january-april, 2020;10(1):21-25 22 fig. 1: age distribution fig. 2: sex distribution in percentage fig. 3: visual field defects in percentage case 1: 48yr old male patient with left sided homonymous hemianopia tanushree v et al. clinical study of visual field defects (vfd) in traumatic brain injury (tbi) panacea journal of medical sciences, january-april, 2020;10(1):21-25 23 case 2: 26yr old male patient with right sided homonymous hemianopia case 3: 16 years old male patient with bitemporal hemianopia extending into bilateral infero-nasal quadrant tanushree v et al. clinical study of visual field defects (vfd) in traumatic brain injury (tbi) panacea journal of medical sciences, january-april, 2020;10(1):21-25 24 case 4: 40 years old male patient with bitemporal hemianopia case 5: right eye superior arcuate scotoma extending into inferior arcuate. left eye early superior arcuate scotoma tanushree v et al. clinical study of visual field defects (vfd) in traumatic brain injury (tbi) panacea journal of medical sciences, january-april, 2020;10(1):21-25 25 table 1: percentage of patients with visual field defect frequency of occurrence of vfd in the total sample of tbi patients no of subjects with vfd % of subjects with vfd tbi (n= 40) 16 40% table 2: 16 patients (40%) patients had one of the targeted defect represented in the table total no of patients type of visual field defect 8 scattered scotomas 3 right homonymous hemianopia 3 left homonymous hemianopia 2 bi-temporal hemianopia with chiasmal injury discussion various presentations of visual field defects may occur following tbi as a result of damage to any portion of the visual pathway from the visual cortex of the brain onward to the retina. defects may include constriction of the fields and either isolated or multiple scattered defects throughout the fields, with or without a generalized decrease in sensitivity. lateralized field defects such as homonymous hemianopias may also occur with or without neglect, in which patients are fully unaware of objects located in space within the visual field defects.5 symptoms of visual field defects include mobility issues (e.g., patients bumping into objects), reading diiculties and trouble locating items in tasks of daily living such as eating. homonymous hemianopias create significant safety challenges, especially when associated with neglect and any activities that require an accurate awareness of one’s surroundings.5 screening for gross field defects by confrontation testing is useful, but more detailed evaluation with automated or goldmann perimetry is essential to accurately localize and quantify any suspected defects.5 visual field testing is critical in these populations, as well as ensuring visual fields are in consideration when evaluating quality of life and developing rehabilitation programs. homonymous hemianopias have a major legal and financial impact because of their effects on driving, additionally, these deficits affect patient's quality of life such as reading and other tasks.4 neuro vision rehabilitation can be carried out by the following methods: 1. lenses: plus lenses to stabilise the vestibular ocular systems 2. peli prisms: to locate objects outside the patient’s visual field. prisim is placed on the lens of the temporal field defect. upper and lower are 40-57d press on prisms. these expand the field by 22 degree. 3. binasals: eliminates binocular confusion.6 conclusion uniqueness of this study reports frequency of visual field defects in traumatic brain injury. the most commonest was motor vehicle‐related injury especially in the younger individuals who were predominantly male patients. all these findings should alert and make one aware of the adverse effects on quality of life and rehabilitation.7 this study emphasises the importance of early, systematic evaluation of all patients with traumatic head injury for homonymous hemianopia, as it is important for the functioning and rehabilitation of the patient. source of funding none. conflict of interest none. references 1. van stavern gp, biousse v, lynn mj, simon dj, newman nj. neuro-ophthalmic manifestations of head trauma. j neuro-ophthalmol. 2001;21(2):112-7. 2. kulkarni ar, aggarwal sp, kulkarni rr, deshpande md, walimbe pb, labhsetwar as. ocular manifestations of head injury: a clinical study. eye (lond). 2005;19(12):1257-63. 3. suchoff ib, kapoor n, ciuffreda kj, rutner d, han e, craig s. the frequency of occurrence, types, and characteristics of visual field defects in acquired brain injury: a retrospective analysis. optometry. 2008;79(5):259-65. 4. bruce bb, zhang x, kedar s, newman nj, biousse v. traumatic homonymous hemianopia. j neurol neurosurg psychiatry. 2006;77(8):986-8. 5. suhr cl, shust m, prasad r, wilcox dt, chronister c. recognizing tbi-related vision disorders; 2015. 6. kapoor n, suchoff ib, ciuffreda kj, han e, rutner d, craig s. characteristics of visual field defects in acquired brain injury: a retrospective analysis. investig ophthalmol vis sci. 2008;49:451. how to cite: tanushree v, singh sr. clinical study of visual field defects (vfd) in traumatic brain injury (tbi). panacea j med sci. 2020;10(1):21-5. https://www.ncbi.nlm.nih.gov/pubmed/?term=van%20stavern%20gp%5bauthor%5d&cauthor=true&cauthor_uid=11450900 https://www.ncbi.nlm.nih.gov/pubmed/?term=biousse%20v%5bauthor%5d&cauthor=true&cauthor_uid=11450900 https://www.ncbi.nlm.nih.gov/pubmed/?term=lynn%20mj%5bauthor%5d&cauthor=true&cauthor_uid=11450900 https://www.ncbi.nlm.nih.gov/pubmed/?term=simon%20dj%5bauthor%5d&cauthor=true&cauthor_uid=11450900 https://www.ncbi.nlm.nih.gov/pubmed/?term=newman%20nj%5bauthor%5d&cauthor=true&cauthor_uid=11450900 https://www.ncbi.nlm.nih.gov/pubmed/?term=newman%20nj%5bauthor%5d&cauthor=true&cauthor_uid=11450900 https://www.ncbi.nlm.nih.gov/pubmed/?term=suchoff%20ib%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/?term=kapoor%20n%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/?term=ciuffreda%20kj%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/?term=rutner%20d%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/?term=han%20e%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/?term=craig%20s%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/?term=craig%20s%5bauthor%5d&cauthor=true&cauthor_uid=18436166 https://www.ncbi.nlm.nih.gov/pubmed/18436166 https://iovs.arvojournals.org/solr/searchresults.aspx?author=n.+kapoor https://iovs.arvojournals.org/solr/searchresults.aspx?author=i.+b.+suchoff https://iovs.arvojournals.org/solr/searchresults.aspx?author=k.+j.+ciuffreda https://iovs.arvojournals.org/solr/searchresults.aspx?author=e.+han https://iovs.arvojournals.org/solr/searchresults.aspx?author=d.+rutner https://iovs.arvojournals.org/solr/searchresults.aspx?author=s.+craig 429 too many requests you have sent too many requests in a given amount of time. panacea journal of medical sciences 2020;10(3):245–249 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article detection of vancomycin susceptibility among methicillin resistant staphylococcus aureus in a tertiary care hospital dimple raina1,*, sakeena2, iva chandola1, reshmi roy1 1dept. of microbiology, shri guru ram rai institute of medical and health sciences, dehradun, uttarakhand, india 2dept. of microbiology, muzaffarnagar medical college and hospital, muzaffarnagar, uttar pradesh, india a r t i c l e i n f o article history: received 19-06-2020 accepted 01-07-2020 available online 29-12-2020 keywords: staphylococcus aureus mrsa vancomycin e-test agar dilution clsi a b s t r a c t introduction: staphylococcus aureus infections in current times have become challenging to treat because of advent of methicillin resistant staphylococcus aureus (mrsa) strains which are concurrently resistant to a wide panel of drugs and posing a threat to clinicians and microbiologists globally. the optimal drug for treatment of such mrsa infections is vancomycin but strains with augmented minimum inhibitory concentration (mic) for this drug also have surfaced. objectives: to know the frequency of mrsa isolates in various clinical samples with their antimicrobial sensitivity patterns and to equate agar dilution and e-test methods for mic determination of vancomycin to mrsa strains. materials and methods: a total of 50 non repeat clinical isolates of staphylococcus aureus isolates were collected from various clinical specimens and were tested for methicillin resistance using the cefoxitin disc diffusion test (30µ g). all mrsa isolates were tested for specific mic by agar dilution and e-test methods. results: 29 (58%) isolates were resistant to cefoxitin (mrsa). 13.8% isolates had mic of 4µ g/ml for vancomycin (visa) by both agar dilution and e-test methods. however by agar dilution method 25 (86.2%) isolates exhibited vancomycin mic of ≤ 2 µ g/ml and by e-test 68.9% of the isolates showed mic ≤ 2 µ g/ml. conclusion: multidrug resistant mrsa strains are on the rise and alternate drug of choice for these infections; vancomycin also is showing increased mic so prudent use of this drug is advocated. e-test can detect mrsa strains with intermediate mic values useful for detection of mic creep so that vancomycin can be used rationally. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction staphylococcus aureus has become a huge concern because of its high morbidity, high mortality attributes and both community-acquired and nosocomial infections are associated with it. 1 the advent of methicillin-resistant staphylococcus aureus (mrsa) strains has further made it challenging to treat staphylococcus aureus infections. the only therapeutic alternatives in many cases are limited to glycopeptides such as vancomycin or teicoplanin. however, in recent times treatment failures for even vancomycin * corresponding author. e-mail address: dr.dimpleraina@gmail.com (d. raina). have been reported. now there is an increasing body of evidence which suggests that a relationship exists between vancomycin mic and clinical vancomycin failure, despite the fact that in vitro mrsa strains are absolutely susceptible (mic 2 g/ml) to vancomycin. 2 although majority of these strains have a vancomycin mic within the susceptible limits, yet a gradual and progressive upsurge in vancomycin mic which is also acknowledged as the "mic creep" has been on the rise in recent years. 3 as a matter of fact, after arbitrating on the incessant rise in the cases of failed vancomycin therapy clsi thereupon abridged the breakpoints of vancomycin from 4 mg/l to 2 mg/l for susceptible strains of staphylococcus aureus https://doi.org/10.18231/j.pjms.2020.051 2249-8176/© 2020 innovative publication, all rights reserved. 245 https://doi.org/10.18231/j.pjms.2020.051 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:dr.dimpleraina@gmail.com https://doi.org/10.18231/j.pjms.2020.051 246 raina et al. / panacea journal of medical sciences 2020;10(3):245–249 and for the resistant strains from 32 mg/l to 16 mg/l. infections with mrsa isolates that reveal mic creep can lead to poor prognostic outcomes, deferred therapeutic responses, amplified relapse rates, protracted hospital stay with consequent increased hospitalization costs and greater mortality rates. 4 this awareness of data of infections with mrsa strains that have increased vancomycin mics can help in the early identification of patients who are at perils of vancomycin treatment failure so that alternate treatment options can be explored at the right time. 5 therefore, the present study aims to approximate the vancomycin susceptibility patterns amongst methicillin resistant staphylococcus aureus isolates in a tertiary care hospital. 2. materials and methods the study was conducted in the department of microbiology & immunology, at shri guru ram rai institute of medical and health sciences & affiliated shri mahant indiresh hospital, dehradun from november 2016 to april 2017. the study was approved by the institutional research board and ethics committee. a total of 50 non repeat clinical isolates of staphylococcus aureus were collected from diverse clinical specimens like pus, wound swab, blood culture, sputum, broncho-alveolar lavage, pleural fluid and urine. various attributes like colony characteristics, microscopic morphology, and biochemical reactions were used for preliminary detection of staphylococcus aureus as per the standard protocol. automated method; vitek-2 (biomerieux) was used for both identification and for determining the antibiotic susceptibility patterns. however manual method i.e. disc diffusion method based on mec a mediated oxacillin resistance and 30 µ g cefoxitin disk as a surrogate marker for oxacillin was also utilized for detecting mrsa strains. reference staphylococcus aureus strains; staphylococcus aureus atcc 25923 was used as negative and atcc 43300 was used as positive control for quality maintenance and consistency of results. isolates showing inhibition zone size ≥ 22 were considered as sensitive (mssa) and ≤ 21 mm were considered as resistant (mrsa) as per clsi criteria for zone diameter breakpoints of staphylococcus aureus for cefoxitin.[6] clsi guidelines were used to determine mic of vancomycin by agar dilution method and by e-test method. atcc strains; 25923 and atcc 700698 of staphylococcus aureus were incorporated within in all the test plates for quality and standardization. the least concentration of vancomycin that inhibited the visible growth of bacteria was considered as mic of drug for that organism. interpretation of mic of vancomycin was done as per the clsi guidelines for both agar dilution method and e-test strip method. vancomycin mic of ≤ 2 µ g/ml was considered as the breakpoint for vancomycin susceptible (vssa) mrsa strains, 4-8 µ g/ml for vancomycin intermediate (visa) strains and ≥16 µ g/ml for vancomycin resistant (vrsa) strains. 6 3. results over-all 50 staphylococcus aureus strains were isolated from various clinical specimens of which pus specimens contributed for bulk of the isolates (78%). 29 (58%) isolates were resistant (zone diameter <21mm) to cefoxitin while 21 (42%) were sensitive (zone diameter >22 mm) to cefoxitin. maximum number of mrsa isolates were recovered from pus (75.8%) followed by 6.9 % each from blood, suction tip and tissue (table 1). allocation of patients on the basis of different sites from where mrsa was isolated is given in (table 2). majority of these isolates were recovered from the surgery wards (31%) followed by patients admitted in orthopedic wards (24.1%). maximum number of isolates showed increased resistance to amoxicillin/clavulanic acid (89.7%) (apart from penicillin and cefoxitin for which 100% resistance was seen) (table 3). however, linezolid sensitivity was observed in all mrsa isolates. by agar dilution method for determining vancomycin susceptibility among mrsa isolates, a total of 25 (86.2%) isolates were having mic for vancomycin in the range of 0.52 µ g /ml (≤ 2 µ g/ml) i.e. vssa. by e-test method method 68.9% of the isolates had mic ≤ 2 µ g/ml. 31% isolates reported a vancomycin mic of >2 µ g/ml but <4 µ g/ml. 13.8% visa isolates with mic of 4µ g/ml were observed by both the methods. (table 4). the concentrations of vancomycin that inhibited growth of 50% and 90% of the isolates were defined as mic50 and mic90 respectively. mic50 and mic90 of the study isolates were found to be 1 µ g /ml and 4 µ g /ml by both the methods respectively. table 1: distribution of mrsa isolates according to specimens (n=29) clinical specimen mrsa n percentage (%) pus 22 75.8% blood 2 6.9% suction tip 2 6.9% tissue 2 6.9% urine 1 3.5% total 29 100% 4. discussion in the current study isolation of methicillin resistant staphylococcus aureus was maximum from pus 22(75.8%) followed by 2(6.9%) from blood. similar observations have been reported by chaudhri cn et al in their study wherein maximum number of isolates were isolated from pus raina et al. / panacea journal of medical sciences 2020;10(3):245–249 247 table 2: distribution of mrsa isolates according to location/ site (n=29) location/site mrsa n percentage (%) surgery ward 9 31% orthopaedic ward 7 24.1% opd 5 17.2% medicine ward 2 6.9% medicine hdu 2 6.9% dermatology 1 3.5% surgical icu 2 6.9% gynaecology/ obstetrics 1 3.5% total 29 100% table 3: trends of antibiotic resistance among mrsa isolates (n=29) antibiotic sensitive intermediate resistant n percentage % n percentage % n percentage % penicillin 0 0 0 0 29 100% cefoxitin 0 0 0 0 29 100% amoxycillin/clavulanic acid 3 10.30% 0 0 26 89.70% ciprofloxacin 6 20.6% 3 10.3% 20 68.9% erythromycin 12 41.3% 0 0 17 58.6% trimethoprim/sulfamethoxazole 10 34.4% 2 6.8% 17 58.6% clindamycin 16 55.1% 0 0 13 44.8% tetracycline 12 41.3% 6 20.6% 11 37.9% gentamycin 13 44.80% 6 20.70% 10 34.50% linezolid 29 100% 0 0 0 0 table 4: comparative analysis of vancomycin mic by agar dilution and e-test methods (n=29) vancomycin mic µ g/ml agar dilution n (%) e-test n (%) 0.25 0.5 3(10.3) 4(13.8) 0.75 3(10.3) 1 13(44.8) 8(27.6) 1.5 3(10.3) 2 9(31.0) 2(6.9) 2.5 2(6.9) 3 2(6.9) 3.5 1(3.4) 4 4(13.8) 4(13.8) total 29 29 (76.7%) followed by blood (3.9%) and also by sreenivasulu reddy p et al wherein most of the isolates were also isolated from pus (69%) followed by blood (9%). 7,8 cutaneous and sub cutaneous infections caused by staphylococcus aureus often manifest in the form of abscesses and are formed to restrain the focus of infection. 9 maximum isolates were from the ipd (82.8%) whereas only 17.2% isolates were from opd. this is in concurrence with suryadevara vd who in her research work has reported 70% of the isolates from ipd and 30% isolates from opd. 10 the reasons can be attributed to healthcare workers who are chronic carriers for these isolates, emergence of strains with amplified resistance sequences and extended hospital stay especially in icus. 58% isolates were resistant to cefoxitin which is in concurrence with other studies as by sanjana et al in which the isolation rate of mrsa was 39.6%, juayang et al (40.6%) and arora et al (46%). 11–13 in a tertiary care center, the incidence of mrsa may be higher since the probability of the patient being put on antimicrobial drugs beforehand is quite elevated and thus onset of selective pressure may negotiate a critical role in acquisition of resistance to most of the frequently used drugs. 14 100% resistance was seen for penicillin and cefoxitin and similar observations have also been reported by ramakrishna n. 15 frequently prescribed antibiotics such 248 raina et al. / panacea journal of medical sciences 2020;10(3):245–249 as ciprofloxacin erythromycin, clindamycin, gentamicin, tetracycline and co-trimoxazole all showed increased levels of resistance in our study as has also been reported from many parts of india particularly in association with mrsa. 10 linezolid is one of the well-recognized alternative drugs for vancomycin and can be safely used for cutaneous and sub cutaneous infections, pneumonia, urinary tract infections and bacteremia caused by mrsa strains. 7 the current study shows that 68.9% of isolates had an mic of 0.5 2µ g/ml whereas 31% isolates had an mic >2µ g/ml by the e.-test method. similar observations have been made by sreenivasulu reddy p et al wherein 82% isolates showed mic between 0.5-2µ g/ml and 17% of isolates had an mic of >2µ g/ml. 8 tandel et al however reported 60.3% strains with an mic of >2µ g/ml. 16 by the agar dilution method 86.2% isolates demonstrated mic of 0.5 2µ g/ml. however, by both the methods 4 (13.8%) strains exhibited a vancomycin mic of 4 µ g/ml and were therefore categorized as vancomycin intermediate (visa). kumari j et al have also reported 4.1% isolates with mic >2 µ g/ml by both methods. 17 there are several researches that have established a correlation for mrsa strains with increased vancomycin mics (>1 µ g/ml) and still within the context of susceptibility (≤ 2 µ g/ml) but unfortunately with proven clinical letdowns. 18,19 determination of mic of vancomycin by e-test method was constantly higher by a range of 0.5-1 µ g/ml than that worked out by agar dilution method. such high mics by e test as equated to agar dilution method have also been reported from other studies. 16 the important contributing factor could be the variances in the concentration gradient of vancomycin prepared in these tests. in agar dilution method the concentration of vancomycin is prepared in doubling dilutions or in geometric progression, whereas dilution of vancomycin concentrations is used in arithmetic progression in the e-test method so that the mics for intermediate concentrations of the drug can also be determined. 20 area under the vancomycin concentration curve-tomic ratio (auc/mic) is also a significant factor to establish the effectiveness of vancomycin therapy in mrsa infection therapeutics. 21 the odds of attaining this ratio is nearly 100% if mic of vancomycin is ≤0.5 µ g/ml; and the likelihood reduces to practically 0% if the mic of vancomycin is 2 µ g/ml. 22,23 mic/auc ratio can be considerably prejudiced by even a sole dilution alteration in the mic which in turn can significantly influence the outcome of therapy. 21 if just one dilution difference is pertinent to envisage the clinical consequences of mrsa infections, then the mic method is a vital component of this reckoning. 19 5. conclusion for mrsa infections vancomycin still is the drug of choice and therefore should be judiciously used in treatment of such resistant infections as also observed in our study that mrsa continue to be multi drug resistant leaving clinicians with limited therapeutic options. however, a silver lining in our study is that efficacy of linezolid still incites hope for visa and vrsa cases. mic creep needs further evaluation to optimize treatment modalities hence early detection of such strains in high susceptibility range could minimize the risk of emergence of more aggressive visa and vrsa infections. for determination of vancomycin mic dilution methods still are the gold standard, yet e-tests could be considered to establish vancomycin mic in the intermediary zones and for observing trivial mic changes. 6. acknowledgement we would like to express our heartfelt thanks to the central laboratory staff, department of microbiology sgrrim&hs for their unflinching support during the period of this study. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. abdulgader sm, rijswijk a, whitelaw a, newton-foot m. the association between pathogen factors and clinical outcomes in patients with staphylococcus aureus bacteraemia in a tertiary hospital, cape town. int j infect dis. 2020;91:111–8. doi:10.1016/j.ijid.2019.11.032. 2. lina yc, wangb jh, lina kh, hoc yl, ho cm, m c. methicillin-resistant staphylococcus aureus with reduced vancomycin susceptibility in taiwan. tzu chi med j. 2018;30(3):135–40. 3. chang w, ma x, gao p, lv x, lu h, chen f. vancomycin mic creep in methicillin-resistant staphylococcus aureus (mrsa) isolates from 2006 to 2010 in a hospital in china. indian j med microbiol. 2015;33(2):262–6. doi:10.4103/0255-0857.148837. 4. diaz r, afreixo v, ramalheira e, rodrigues c, gago b. evaluation of vancomycin mic creep in methicillin-resistant staphylococcus aureus infections—a systematic review and meta-analysis. clin microbiol infect. 2018;24(2):97–104. doi:10.1016/j.cmi.2017.06.017. 5. manthan s, geeta v, summaiya m. retrospective analysis of the distribution of vancomycin mic values among clinical isolates of methicillin-resistant staphylococcus aureus in a tertiary care hospital, surat. njirm. 2017;8(2):5–8. 6. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing; twenty – seventh informational supplement. clsi document m100-s27. wayne: clsi; 2017. 7. chaudhari cn. in vitro vancomycin susceptibility amongst methicillin resistant staphylococcus aureus. med j armed forces india. 2014;70:215–9. 8. reddy sp, john ms, devi vp, reddy spb. detection of vancomycin susceptibility among clinical isolates of mrsa by using minimum http://dx.doi.org/10.1016/j.ijid.2019.11.032 http://dx.doi.org/10.4103/0255-0857.148837 http://dx.doi.org/10.1016/j.cmi.2017.06.017 raina et al. / panacea journal of medical sciences 2020;10(3):245–249 249 inhibitory concentration method. int j res med sci. 2015;3(6):1378– 82. doi:10.18203/2320-6012.ijrms20150151. 9. kobayashi sd, malachowa n, deleo fr. pathogenesis of staphylococcus aureus abscesses. am j pathol. 2015;185:1518–21. doi:10.1016/j.ajpath.2014.11.030. 10. suryadevara vd, basavaraju a, vasireddy k. prevalence of mrsa among clinical isolates and their antibiogram in a tertiary care hospital. j evol med dent sci. 2017;6(21):1667–9. doi:10.14260/jemds/2017/367. 11. sanjana rk, shah r, chaudhary n, singh yi. prevalence and antimicrobial susceptibility pattern of methicillin-resistant staphylococcus aureus (mrsa) in cms-teaching hospital: a preliminary report. j coll med sci nepal. 2010;6:1–6. 12. juayang ac, de los reyes gb, de la rama ajg, gallega ct. antibiotic resistance profiling ofstaphylococcus aureusisolated from clinical specimens in a tertiary hospital from 2010 to 2012. interdiscip perspect infect dis. 2014;2014:898–909. doi:10.1155/2014/898457. 13. arora s, devi p, arora u, devi b. prevalence of methicillinresistant staphylococcus aureus (mrsa) in a tertiary care hospital in northern india. j lab physicians. 2010;2(02):78–81. doi:10.4103/0974-2727.72154. 14. pant nd, sharma m. carriage of methicillin resistant staphylococcus aureus and awareness of infection control among health care workers working in intensive care unit of a hospital in nepal. braz j infect dis. 2016;20(2):218–9. doi:10.1016/j.bjid.2015.11.009. 15. ramakrishna n, murty ds, reddy bk. detection of methicillin resistance and vancomycin resistance among clinical isolates of staphylococcus aureus in a tertiary care hospital at tirupati. sch j app med sci. 2016;4(7b):2396–9. doi:10.21276/sjams.2016.4.7.19. 16. tandel k, praharaj ak, kumar s. differences in vancomycin mic among mrsa isolates by agar dilution and e test method. indian j med microbiol. 2012;30(4):453–5. doi:10.4103/0255-0857.103768. 17. kumari j, shenoy ms, chakrapani m, vidyalakshmi k, gopalkrishna bk. comparison of e-test and agar dilution for determining minimum inhibitory concentration of vancomycin to healthcare-associated methicillin-resistant staphylococcus aureus. asian j pharm clin res. 2016;9(4):189–91. 18. aguado jm. high vancomycin mic and complicated methicillin susceptible staphylococcus aureus bacteremia. emerg infect dis. 2011;17(6):1099–102. 19. wilcox m. reporting elevated vancomycin minimum inhibitory concentration in methicillin-resistant staphylococcus aureus: consensus by an international working group. future microbiol. 2019;14(4):345–52. 20. kruzel mc, lewis ct, welsh kj, lewis em, dundas ne, mohr jf, et al. determination of vancomycin and daptomycin mics by different testing methods for methicillin-resistant staphylococcus aureus. j clin microbiol. 2011;49(6):2272–3. doi:10.1128/jcm.0221510. 21. prakash v, lewis js, jorgensen jh. vancomycin mics for methicillin-resistant staphylococcus aureus isolates differ based upon the susceptibility test method used. antimicrob agents chemoth. 2008;52(12):4528. doi:10.1128/aac.00904-08. 22. dhand a, sakoulas g. reduced vancomycin susceptibility among clinical staphylococcus aureus isolates (‘the mic creep’): implications for therapy. f1000 med rep. 2012;4:4–4. doi:10.3410/m4-4. 23. mohr jf, murray be. point: vancomycin is not obsolete for the treatment of infection caused by methicillin-resistant staphylococcus aureus. clin infect dis. 2007;44(12):1536–42. doi:10.1086/518451. author biography dimple raina, associate professor sakeena, tutor iva chandola, associate professor reshmi roy, assistant professor cite this article: raina d, sakeena, chandola i, roy r. detection of vancomycin susceptibility among methicillin resistant staphylococcus aureus in a tertiary care hospital. panacea j med sci 2020;10(3):245-249. http://dx.doi.org/10.18203/2320-6012.ijrms20150151 http://dx.doi.org/10.1016/j.ajpath.2014.11.030 http://dx.doi.org/10.14260/jemds/2017/367 http://dx.doi.org/10.1155/2014/898457 http://dx.doi.org/10.4103/0974-2727.72154 http://dx.doi.org/10.1016/j.bjid.2015.11.009 http://dx.doi.org/10.21276/sjams.2016.4.7.19 http://dx.doi.org/10.4103/0255-0857.103768 http://dx.doi.org/10.1128/jcm.02215-10 http://dx.doi.org/10.1128/jcm.02215-10 http://dx.doi.org/10.1128/aac.00904-08 http://dx.doi.org/10.3410/m4-4 http://dx.doi.org/10.1086/518451 introduction materials and methods results discussion conclusion acknowledgement source of funding conflict of interest panacea journal of medical sciences 2020;10(2):104–107 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article dry eyes in patients with pseudoexfoliation –a descriptive study a sivaraja gowthaman1, elfride farokh sanjana2, hannah ranjee prasanth2,* 1dept. of ophthalmology, melmaruvathur adhiparasakthi institute of medical sciences and research, melmaruvathur, tamil nadu, india 2dept. of ophthalmology, pondicherry institute of medical sciences, puducherry, india a r t i c l e i n f o article history: received 13-04-2020 accepted 06-05-2020 available online 26-08-2020 keywords: pseudoexfoliation dry eye syndrome a b s t r a c t introduction: pseudoexfoliation syndrome is seen commonly above 60 years of age. it can lead to various complications such as poor dilatation of pupil, increased iop and intraoperative complications such as zonular dehiscence or capsular rupture, vitreous loss and subluxation of intraocular lens. pseudoexfoliative glaucoma is one of the common types of secondary open angle glaucoma. pseudoexfoliation syndrome can also cause ocular surface disorders due to tear film instability. hence this study was done to assess the prevalence of dry eyes in patients with pseudoexfoliation. materials and methods: this was a descriptive study which involved 150 eyes with pseudoexfoliation syndrome. tear secretion assessment was done using schirmer’s test i. then the tear film stability was evaluated using tear break-up time(tbut). ocular surface damage was assessed using fluorescein staining and lissamine green staining. result: schirmer’s test i, 144 eyes out of 150 eyes had schirmer’s test value more than 15 mm (96%). 4 eyes (2.6%) had value between 10-15 mm .2 eyes (1.4%) had value between 5-10 mm. six eyes with dry eye syndrome were identified by schirmer’s test i. tear breakup time was decreased in 3 eyes (between 7-9 seconds). three eyes with dry eye syndrome were identified by tbut test. fluorescein staining was positive in one eye. lissamine staining was positive in 2 eyes with score of 2 and 3. in this study of pseudoexfoliation patients, there were 9 eyes(6%) with dry eye syndrome. conclusion: early recognition of dry eye syndrome in patients with pseudoexfoliation syndrome can reduce ocular morbidity and prevent a significant compromise in their quality of life. © 2020 published by innovative publication. this is an open access article under the cc by-nc license (https://creativecommons.org/licenses/by-nc/4.0/) 1. introduction pseudoexfoliation syndrome is a systemic connective tissue disorder usually present in 10% population over 60 years of age. 1 it is characterized by accumulation and deposition of white fluffy amyloid like proteinaceous material which is not degraded in vivo. in eyes it is present in anterior chamber and its angle, trabecular meshwork, epithelium of ciliary body, iris and lens. 2 apart from eyes, pseudoexfoliative material is also seen in other organs such as heart, lung, kidney, brain and vessels using electron microscopy or specific histochemical markers. 3 ocular manifestations * corresponding author. e-mail address: drranjee@hotmail.com (h. r. prasanth). such as dry eye syndrome, open angle glaucoma, central retinal vein occlusion and cataract are well known in pseudoexfoliation. it affects the dilatation of pupil, causes increased iop and intraoperative complications such as zonular or capsular rupture, vitreous loss and subluxation of intraocular lens. dry eye syndrome is an ocular surface disorder due to tear film deficiency or its excessive evaporation. dry eye syndrome affects about 6.9-10.6% of the adult population. pseudoexfoliation is accompanied by an increase in the osmolarity of the tear film and inflammation of the ocular surface. damage occurs because of tear deficiency or tear film instability. 4 in pseudoexfoliation dry eye syndrome is due to instability of tear film. 5 few recent studies have https://doi.org/10.18231/j.pjms.2020.024 2249-8176/© 2020 innovative publication, all rights reserved. 104 https://doi.org/10.18231/j.pjms.2020.024 https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by-nc/4.0/ mailto:drranjee@hotmail.com https://doi.org/10.18231/j.pjms.2020.024 gowthaman, sanjana and prasanth / panacea journal of medical sciences 2020;10(2):104–107 105 shown prevalence of dry eye syndrome in patients with pseudoexfoliation. 1,5 in this study we aim to establish the ocular surface changes in patients with pseudoexfoliation with the use of schirmer-1 test, tbut test, lissamine green staining and fluorescein staining. 2. materials and methods 150 eyes of patients with pseudoexfoliation in department of ophthalmology opd were recruited in the study after obtaining informed consent. a comprehensive assessment of patients was undertaken including patients age, gender, medical, ocular history, visual acuity assessment and slit lamp examination. the descriptive study was done from november 2015 to april 2017. patients over age 40 and belonging to either sex with pseudoexfoliation were included in the study. patients with sjogren’s syndrome, lacrimal gland and drainage disorders, previous ocular surgeries, patients using any topical eye drops such as timolol, known diabetic patients, pseudoexfoliative glaucoma were excluded. data entry was done using ms excel 2013 and analyzed using epi info and spss version 20. mean and standard deviation for continuous variables, number and percentage for categorical variables were used to represent the data. chi square test, yate’s corrected chi-square test and fisher’s exact test were used to assess the prevalence of dry eyes among pseudoexfoliation patients. z test was used to assess the difference between two means. p value <0.05 was considered statistically significant. tear secretion assessment was done using schirmer’s test i. then the tear film stability was evaluated using tear break-up time(tbut). ocular surface damage was assessed using fluorescein staining and lissamine green staining. 3. results and discussion in this study 150 eyes with pseudoexfoliation were recruited from ophthalmology out patient department and were assessed for the prevalence of dry eye syndrome. four dry eye syndrome tests were performed in all 150 eyes with pseudoexfoliation to assess ocular surface changes. tear secretion was assessed by doing schirmer’s i test. tear film stability was assessed by tear breakup time test and ocular surface damage was assessed by lissamine green staining and fluorescein staining. the age distribution were minimum of 50 years and maximum of 90 years. mean age in this study group was 65.76 years. out of 150 sample size studied, 130 eyes were above 60 years in this study. many studies have shown that pseudoexfoliation was seen in more than 60 years of age. in a study by skegro et al, approximately 10% of population above 60 years had pseudoexfoliation. 1 a study conducted by aravind et al in south indian population stated that the prevalence of pseudoexfoliation increases over 50 years. 6 among the population studied males were 100 and females were 50. in some studies female population were most affected and in some males were affected. aravind et al showed no gender based predisposition to pseudoexfoliation. 6 in this study of 150 eyes, 56 (74.5%) patients had pseudoexfoliation in both eyes. 38 people(25.5%) had unilateral involvement. in a study by subhashini et al.56.6% were unilateral and 43.4% were bilateral. 6 a study by parekh et al states that 81% of uninvolved eyes in unilateral pseudoexfoliation syndrome patients had ultra structural involvement detected with electron microscopy. 7 in this study of 150 eyes, symptoms of dry eye syndrome such as grittiness was seen in 2 eyes (1.3%) and burning sensation was seen in 14 eyes(9.33%). table 1: tear secretion assessment using schirmer’s 1 test schirmer’s test grading frequency percent normal 144 96.0 mild 4 2.7 moderate 2 1.3 severe 0 0 total 150 100 table 2: tear film stability evaluation using tear break-up time(tbut) tbut grading frequency percent normal 147 98.0 mild 3 2.0 moderate 0 0 severe 0 0 total 150 100 table 3: ocular surface damage assessment using lissamine green staining lissaminegreen staining score frequency percent 0 148 98.7 1 0 0 2 1 0.7 3 1 0.7 total 150 100.0 table 4: ocular surface damage assessment using fluoresce in staining fluorescein staining frequency percent nil 149 99.3 positive 1 0.7 total 150 100.0 in our study all 150 eyes had cataract with varying grades. immature cataract with various nucleus sclerosis 106 gowthaman, sanjana and prasanth / panacea journal of medical sciences 2020;10(2):104–107 table 5: prevelance of dry eyes among pseudoexfoliation patients distribution prevelance frequency percent normal 141 94.0 dry eye 9 6.0 total 150 100.0 grading was seen in 114 eyes(76%), mature cataract was seen in 32 eyes (21.3%), hypermature cataract in 4 eyes(2.7%). all patients underwent cataract surgery. there were many studies which explain intraoperative complications 8,9 and its management during cataract surgery. 2 in our study complications during cataract surgery were not assessed, but most of the patients underwent small incision cataract surgery and few extracapsular cataract extraction due to poor pupillary dilatation. one eye out of 150 eyes had phacodonesis. in our study tear secretion was assessed using schirmer’s test i, 144 eyes out of 150 had schirmer’s test value more than 15 mm (96%). four eyes (2.6%) had value between 10-15 mm.2 eyes (1.4%) had value between 5-10 mm.(table 1). p value was 0.6585 which was not statistically significant with regards to gender. six eyes with dry eye syndrome were identified using schirmer’s i test in this study. in a study conducted by subhashini et al at pondicherry, tear secretion value was decreased in pseudoexfoliation syndrome patients when compared to normal eyes. 5 the results showed schirmer’s test value between group 1 and group 2 were 22.05+/_4.4 mm and 10.6+/_7 mm respectively. in other studies such as erodogen et al. 10 and kozobolis et al. 11 mean values of schirmer’s test was decreased between case and control group. in kozobolis study average schirmer’s test value was 10.6mm and 13.4 mm between case and control group. in our study tear film stability was assessed using tear break up time. three eyes (2%) had value between 7-9 second (table 2). p value was 0.293 which was not statistically significant with regards to gender. 3 eyes with dry eye syndrome were identified in this study with tbut. other studies such as erodogen et al 10 also showed decreased tbut between case and controls. subhashini et al showed results of tbut were 14.75 +/_2.5s and 5.6+/_2.8s respectively between group 1 and group 2. 5 in kozobolis study tbut was 8.6 sec and 12.3s between case and control group respectively. 11 a study by cho et al revealed cataract surgery in itself can induce dry eye. 12 presence of pseudoexfoliation can cause many intraoperative complications as explained by sushil kumar et al 2 and pranithi et al. 8 so if a patient has dry eyes due to pseudoexfoliation then cataract surgery further induces dry eye syndrome in such patients. according to kuppan et al antiglaucoma medications such as timolol can cause dry eye. 13 out of 150 eyes assessed with lissamine green staining for ocular surface damage, one eye had score of 2 and one eye had score of 3)(table 3). out of 150 eyes studied, fluorescein staining was positive in one eye 0.7% (table 4) in our study 9 eyes (6%) had dry eye syndrome among 150 eyes studied (table 5). 4. conclusion the prevalence of dry eye syndrome in pseudoexfoliation patients was 6% in this study. patients with pseudoexfoliation syndrome are at higher risk for developing pseudoexfoliative glaucoma and cataract. early recognition of dry eye syndrome in susceptible population of patients with pseudoexfoliation syndrome can reduce ocular morbidity and prevent a significant compromise in their quality of life. 5. ethical consideration the study was done after obtaining approval from ethical review board of pondicherry institute of medical sciences. purpose of the study was explained to the patient. written informed consent in patient’s own language was taken from both the subjects and their nearest relatives. 6. source of funding none. 7. conflicts of interest no conflict of interest. references 1. škegro i, suić sp, kordić r, jandroković s, petriček i, kuzman t. ocular surface disease in pseudoexfoliation syndrome. coll antropol. 2015;39:43–5. 2. kar sk, bhuyan l, nanda ak. pseudoexfoliation a dreaded nightmare in cataract surgery. int j biomed adv res. 2015;6(2):159– 62. 3. ritch r, schlötzer-schrehardt u. exfoliation syndrome. surv ophthalmol. 2001;45(4):265–315. 4. hashemi h, khabazkhoob m, kheirkhah a, emamian mh, mehravaran s, shariati m, et al. prevalence of dry eye syndrome in an adult population. clin exp ophthalmol. 2014;42(3):242–8. 5. kaliaperumal s, rao v, govindaraj i. abnormalities of tear function in patients with pseudoexfoliation. int j clin exp physiol. 2014;1(1):34– 8. 6. arvind h, raju p, paul pg, baskaran m, ramesh sv, george rj. pseudoexfoliation in south india. br j ophthalmol. 2003;87:1321– 3. 7. parekh p, green wr, stark wj, akpek ek. electron microscopic investigation of the lens capsule and conjunctival tissues in individuals with clinically unilateral pseudoexfoliation syndrome. ophthalmol. 2008;115(4):614–9. 8. magdum rm, maheshgauri r, patel k, patra s, pranathi k. a study of complications during cataract surgery in patients with pseudoexfoliation syndrome. j clin ophthalmol res. 2014;2(1):7–11. 9. al-saleh s, al-dabbagh n, al-shamrani s, khan n, arfin m, tariq m, et al. prevalence of ocular pseudoexfoliation syndrome and associated complications in riyadh, saudi arabia. saudi med j. 2015;36(1):108–12. gowthaman, sanjana and prasanth / panacea journal of medical sciences 2020;10(2):104–107 107 10. erdogan h, arici ds, toker mi, arici mk, fariz g, topalkara a. conjunctival impression cytology in pseudoexfoliative glaucoma and pseudoexfoliation syndrome. clin exp ophthalmol. 2006;34(2):108– 12. 11. kozobolis vp, detorakis et, tsopakis gm, pallikaris ig. evaluation of tear secretion and tear film stability in pseudoexfoliation syndrome. acta ophthalmologica scandinavica. 1999;77(4):406–9. 12. cho yk, kim ms. dry eye after cataract surgery and associated intraoperative risk factors. korean j ophthalmol. 2009;23:65–73. 13. kuppens ev, de jong ca, stolwijk tr, de keizer rj, van best ja. effect of timolol with and without preservative on the basal tear turnover in glaucoma. br j ophthalmol. 1995;79(4):339–42. author biography a sivaraja gowthaman assistant professor elfride farokh sanjana professor hannah ranjee prasanth associate professor cite this article: gowthaman as, sanjana ef, prasanth hr. dry eyes in patients with pseudoexfoliation –a descriptive study. panacea j med sci 2020;10(2):104-107. introduction materials and methods results and discussion conclusion ethical consideration source of funding conflicts of interest panacea journal of medical sciences 2020;10(3):295–298 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article a randomized study to determine the efficacy of pregabalin for the treatment of moderate or severe baseline neuropathic pain at a tertiary care centre in ganjam, odisha sambit kumar panda1,*, pradyut kumar pradhan2, sanjay kumar behera1, chinmaya debasis panda2 1dept. of orthopaedic surgery, m.k.c.g. medical college, berhampur, odisha, india 2dept. of pharmacology, m.k.c.g. medical college, berhampur, odisha, india a r t i c l e i n f o article history: received 01-06-2020 accepted 04-07-2020 available online 29-12-2020 keywords: neuropathic pain pregabalin placebo a b s t r a c t background: neuropathic pain (nep) is caused by a disease like lesion; it is the disease of the somatosensory nervous system. nep also caused some severe health disorders such as diabetic peripheral neuropathy (dpn), postherpetic neuralgia (phn), and spinal cord injury (sci). along with the severe health issues, nep adversely affects the quality of life (qol) as well as an economic burden on the infected persons and their family plus society. aim: the aim of the study is to define the efficiency of pregabalin for the treatment of moderate or severe baseline neuropathic pain at a tertiary care centre in ganjam, odisha. materials and methods: it was a randomized study conducted between august 2019 and january 2020 at the mkcg medical college berhampur, ganjam, odisha on 700 patients. simple randomization technique was employed to give patients either pregabalin or placebo. all the patients aged >18 years were selected for the study. the pain was assessed for all the patients using the 11-point numeric rating scale, where 0 = no pain and 10 = worst possible pain. all the patients having pain score >4 were involved in the study. patients who were below 18 years of age were omitted from the study. further, the patients whose pain score was below four were also omitted from the study. results: it was observed that there were 455 patients in the pregabalin group, and in the placebo group, there were 245 patients. the patients were also bifurcated as per the severity of their discomfort, in which 513 patients were comprised in the moderate section, whereas 187 patients were encompassed in the severe section. 63-71 years was the median age. in the moderate and severe pain group, standard mean pain scores were equivalent among the pregabalin and placebo treatment groups. there was a statistically significant difference among both the groups with respect to the change in pain score. this implies that pregabalin reduced pain more significantly as compared to the placebo group. the above table also depicted the improvement in mean sleep scores as well. there was a statistically significant difference among both the groups with respect to the sleep scores. the sleep score in the pregabalin group improved from the baseline to endpoint more significantly as compared to the placebo group. in the moderate to severe pregabalin group, 90% of the patients experienced at least one treatment-emergent as compared to 70% in the placebo group. the most common side effects of the ae were weight gain, dizziness, and peripheral edema. the highest discontinuation from the study was observed in the pregabalin group. conclusion: it was found that the pregabalin was effective in terms of reducing pain and had greater tolerability with the patients. it was also identified that the patients in the severe pain segment shifted to mild segment with the use of pregabalin dosage. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. https://doi.org/10.18231/j.pjms.2020.060 2249-8176/© 2020 innovative publication, all rights reserved. 295 https://doi.org/10.18231/j.pjms.2020.060 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ https://doi.org/10.18231/j.pjms.2020.060 296 panda et al. / panacea journal of medical sciences 2020;10(3):295–298 1. introduction neuropathic pain (nep) is caused by the disease of the somatosensory nervous system like lesion. severe health disorders like diabetic peripheral neuropathy (dpn), postherpetic neuralgia (phn), and spinal cord injury (sci) are related with nep. 1 from the studies, it has also been found that chronic nep harmfully affects the quality of life (qol) along with putting a monetary load on the patients, their family and the society. 2 furthermore, nep affects the brain neurons, which further impacts the various regions of the body like sensation, integrative processing, pain modulation, emotions and cognition. 3 this, in turn, results in the changes in the behavioural pattern of the patient and might also lead to depression. 4 it has been reported that there is a prevalence of nearly 29% in the india of nep. 5 however, it has been established that nep is often under-diagnosed in the developing as well as developed countries. this results in the delay of treatment. also, there are discrepancies regarding the treatment regime as well. multiple studies have been conducted on analyzing the effect of the nep over the rising economic burden on the patients, which was found to be positively associated. 6 this implies that the regular visits to the doctor and the treatment regime decreases the productivity of the patients along with overlaying them with an economic burden. 7 however, pregabalin is considered to be a reliable treatment drug for the nep. it is an α 2-δ ligand having analgesic properties. it has also been found beneficial in the controlling of anxiety and neuropathic pain related to spinal cord injury. 2. aim to determine the usefulness of pregabalin for the treatment of moderate or severe baseline neuropathic pain at a tertiary care centre in ganjam, odisha 3. material and methods it was a randomized study conducted between august 2019 and january 2020 at the mkcg medical college berhampur, ganjam, odisha on 700 patients. simple randomization technique was employed to give patients either pregabalin or placebo. all the patients aged >18 years were selected for the study. the pain was assessed for all the patients using the 11-point numeric rating scale, where 0=no pain and 10=worst possible pain. all the patients having pain score >4 were included in the study. all the patients below 18 years of age and the patients whose pain score was below four were excluded from the study. * corresponding author. e-mail address: drsambitpanda@gmail.com (s. k. panda). 4. results the above table depicts that there were 455 patients in the pregabalin group, and 245 individual was found in the placebo group. the patients were also separated based on the severity of their pain, according to which in the moderate group, 513 patients were included, although in the severe group, there were 187 patients included. 63-71 years was the median age. within the moderate and severe pain cohorts, the standard mean pain scores were comparable between both the group of pregabalin and placebo treatment sections. out of 330 patients in moderate and 125 in severe pregabalin group, only 297 in moderate and 106 in severe group reported on follow-up. similarly, out of 183 patients in moderate and 62 in severe placebo group, only 142 in moderate and 48 in severe group reported on follow-up. thus, overall, 52 and 55 patients were lost on follow-up in pregabalin and placebo group respectively. further, the above table depicts changes in the pain score of the patients in the pregabalin and placebo group on follow-up. there was a statistically significant difference among both the groups with respect to the change in pain score. this implies that pregabalin reduced pain more significantly as compared to the placebo group. the above table also depicted the improvement in mean sleep scores as well. there was a statistically significant difference among both the groups with respect to the sleep scores. the sleep score in the pregabalin group improved from the baseline to endpoint more significantly as compared to the placebo group. furthermore, it was observed in the study that nearly 90% of the patients in the moderate to severe pregabalin section go through at least one treatment-emergent as compared to 70% in the placebo group. the most common side effects of the ae were weight gain, dizziness, and peripheral edema. the highest discontinuation from the study was observed in the pregabalin group. 5. discussion in the present study, it was found that patients treated with pregabalin were able to tolerate the drug in a better manner. it was also found in the study that the efficacy of pregabalin was found to be more effective in reducing the pain and sleep score of the patients as compared to that of the patients receiving placebo in their treatment regime. similar results were obtained in the study of parsons et al., (2019). 8 as per the current study, it was found that the dosage of pregabalin was positively related to the reduction of the pain score and the sleep score. furthermore, similarly as per the study of the freeman et al., (2008) 9 it was studied that pregabalin was positively equated with the reduction of sleep score and pain score. nearly 20% of the patients shifted to mild from severe pain in the pregabalin group related to the 10% in the placebo group; it was identified in the present study. the results were consistent with that of mailto:drsambitpanda@gmail.com panda et al. / panacea journal of medical sciences 2020;10(3):295–298 297 table 1: summary of neuropathic pain studies included in the analysis condition (study number/ clinical trials.gov identifier) total treatment phase/main tenance phase (weeks) pregabalin maintenance dose (mg/day) administration no. of participants placebo pregabalin total phn (a0081120/nct00394901) 13/12 150, 300, 600b bid fixed dose 97 272 369 dpn (a0081163/nct00553475) 13/12 300, 600b bid fixed dose 135 179 314 sci (a0081107/nct00407745) 16/12 150-600 bid fixed dose 27 32 59 table 2: baseline demographic and clinical characteristics nep population: baseline pain moderate severe pregabalin placebo pregabalin placebo n 330 183 125 62 age, years, median (range) 64 (25-90) 63 (30-90) 71 (26-90) 68 (28-88) sex, n female 120 50 55 22 male 210 133 70 40 duration of nep-related pain, months, mean (sd) 45.7 (51.5) 50.2 (44.8) 54.9 (66.8) 50.1 (49.8) pain score, mean (sd) 5.6 (1.9) 5.5 (1.5) 9.4 (0.5) 9.0 (0.8) sleep score, mean (sd) 3.7 (1.9) 3.6 (1.7) 5.4 (2.9) 5.6 (3.1) table 3: change in mean pain and sleep scores from baseline to endpoint (locf analysis) pregabalin placebo difference from placebo n ls mean change n ls mean change (se) ls mean difference (se) p-value change in pain score nep moderate 297 -1.65 (0.15) 142 -0.81(0.25) -0.84 (0.1) <0.05 severe 106 -1.65(0.25) 48 -1.15(0.26) -0.5 (0.01) <0.05 change in sleep score nep moderate 297 -1.56 (0.13) 142 -0.56(0.16) -1.0 (0.03) <0.05 severe 106 -1.36(0.20) 48 -0.20(0.21) -1.16 (0.01) <0.05 yamashita et al. (2014). 10 the most common side-effects in the current study were found to be weight gain, dizziness, and peripheral edema. supporting the current study farrar et al., (2001) 11 found similar results. 6. conclusion in light of the above results, it was found that the pregabalin was effective in terms of reducing pain and had greater tolerability with the patients. it was also identified that the patients in the severe pain segment shifted to mild segment with the use of pregabalin dosage. however, in both severe and moderate groups, the efficacy and tolerability was optimal and helped in achieving pain reduction and sleep improvement. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. cohen sp, mao j. neuropathic pain: mechanisms and their clinical implications. bmj. 2014;348(6):f7656. doi:10.1136/bmj.f7656. 2. costigan m, scholz j, woolf cj. neuropathic pain: a maladaptive response of the nervous system to damage. annu rev neurosci . 2009;32(1):1–32. doi:10.1146/annurev.neuro.051508.135531. 3. mccarberg bh, nicholson bd, todd kh, palmer t, penles l. the impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an internet survey. am j ther . 2008;15(4):312–20. http://dx.doi.org/10.1136/bmj.f7656 http://dx.doi.org/10.1146/annurev.neuro.051508.135531 298 panda et al. / panacea journal of medical sciences 2020;10(3):295–298 doi:10.1097/mjt.0b013e31818164f2. 4. jensen mp, chodroff mj, dworkin rh. the impact of neuropathic pain on health-related quality of life: review and implications. neurol. 2007;68(15):1178–82. doi:10.1212/01.wnl.0000259085.61898.9e. 5. saxena ak. pharmacological management of neuropathic pain in india: a consensus statement from indian experts. pharmacological management of neuropathic pain in india: a consensus statement from indian experts. indian j pain. 2018;32:132–44. 6. schaefer c, chandran a, hufstader m, baik r, mcnett m, goldenberg d, et al. the comparative burden of mild, moderate and severe fibromyalgia: results from a cross-sectional survey in the united states. health quality life outcomes. 2011;9:71. doi:10.1186/1477-7525-9-71. 7. mann r, schaefer c, sadosky a, bergstrom f, baik r, parsons b, et al. burden of spinal cord injury-related neuropathic pain in the united states: retrospective chart review and cross-sectional survey. spinal cord. 2013;51(7):564–70. doi:10.1038/sc.2013.34. 8. parsons b. the efficacy of pregabalin for the treatment of neuropathic pain in japanese subjects with moderate or severe baseline pain. j pain res. 2019;12:1061–8. 9. freeman r. efficacy, safety, and tolerability of pregabalin treatment for painful diabetic peripheral neuropathy. diabetes care. 2008;31:1448–54. 10. yamashita t, takahashi k, yonenobu k, kikuchi s. prevalence of neuropathic pain in cases with chronic pain related to spinal disorders. j orthop sci. 2014;19(1):15–21. doi:10.1007/s00776-013-0496-9. 11. farrar jt, young jp, lamoreaux l, werth jl, poole mr. clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. pain. 2001;94(2):149–58. doi:10.1016/s0304-3959(01)00349-9. author biography sambit kumar panda, assistant professor pradyut kumar pradhan, assistant professor sanjay kumar behera, assistant professor chinmaya debasis panda, assistant professor cite this article: panda sk, pradhan pk, behera sk, panda cd. a randomized study to determine the efficacy of pregabalin for the treatment of moderate or severe baseline neuropathic pain at a tertiary care centre in ganjam, odisha. panacea j med sci 2020;10(3):295-298. http://dx.doi.org/10.1097/mjt.0b013e31818164f2 http://dx.doi.org/10.1212/01.wnl.0000259085.61898.9e http://dx.doi.org/10.1186/1477-7525-9-71 http://dx.doi.org/10.1038/sc.2013.34 http://dx.doi.org/10.1007/s00776-013-0496-9 http://dx.doi.org/10.1016/s0304-3959(01)00349-9 introduction aim material and methods results discussion conclusion source of funding conflict of interest panacea journal of medical sciences 2021;11(2):173–176 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article a retrospective study on management of bell’s palsy in a tertiary care hospital dhanyan harshidan1, p.k purushothaman1,*, priyangha elangovan1 1dept. of otorhinolayngology, srm medical college, hospital & research centre, srm nagar, chennai, tamil nadu, india a r t i c l e i n f o article history: received 25-09-2020 accepted 24-12-2020 available online 25-08-2021 keywords: bell’s palsy housebrackman scale corticosteroids paralysis a b s t r a c t introduction: bell’s palsy is the most common facial nerve disorder. the clinical symptoms of bell’s palsy include facial muscle paralysis, difficulty in eating, drinking and talking. bell’s palsy management is still controversial. many patients recover spontaneously; some require medicines like corticosteroids, antiviral drugs and other managements. aim: to study the effectiveness of bell’s palsy management that has been followed in our institution. materials and methods: this analysis had carried out from june 2016 to june 2019at srm medical college hospital and research institute, chennai. total of 30 patients with bell’s palsy who had admitted in the department of otorhinolaryngology had enrolled in this study. all the patients underwent thorough clinical examination and laboratory investigation, and the results were statistically analyzed and discussed. results: out of 30 patients, 16(53%) patients were males, and 14(47%) patients were females. 53.3% of patients had onset of symptoms after 48 hours. there was a statistical significant improvement in housebrackman scale on 6 months follow-up. conclusion: the therapeutic measures for bell’s palsy if initiated within 72 hours of onset aids in bringing better outcome and improves the quality of life in patients. this is an open access (oa) journal, and articles are distributed under the terms of the creative commons attribution-noncommercial-sharealike 4.0 license, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. for reprints contact: reprint@ipinnovative.com 1. introduction bell’s paralysis is characterized by a sudden onset of paralysis or muscle weakness on one side of the facial nerve supplies. it is also known as facial paralysis of the acute idiopathic lower motor neurons. various etiological factor contributes to facial nerve paralysis include trauma, infection, neoplasm, autoimmune reaction, ischemia and by birth, but still, the causing factor of bell’s palsy is unknown. 1–5 many viruses like hiv, ebv and hbv had reported as triggering organism, but hsv is the most involved. 6 the early signs of bell’s palsy are inability to close the mouth and the eye on the affected side causing dryness of mouth and eye, reduced taste on the affected side; altered * corresponding author. e-mail address: dr.dhanyan@gmail.com (p. k. purushothaman). taste on the anterior two-thirds of the tongue and late signs will be ear pain, synkinesis, facial spasm and contracture, peripheral dysfunction of the facial nerve, dysfunctional lacrimation, noise intolerance, hyperacusis and abrupt onset (over hours), with maximal facial weakness at 24 to 72 hours. the resulting impairment can contribute to significant emotional distress during bell palsy. bell’s palsy incidence is about 20 to 30 cases for 100,000. either sex is equally affected and may occur at any age, the median age is 40 years, and the incidence is lowest under 10 years of age and highest in people over the age of 70. left and right sides are equally affected. most of the patients do not need any laboratory investigation, thorough history taking, and clinical examination is more than enough. if the symptoms persist and paralysis is present, and there is no improvement, then https://doi.org/10.18231/j.pjms.2021.038 2249-8176/© 2021 innovative publication, all rights reserved. 173 174 harshidan, purushothaman and elangovan / panacea journal of medical sciences 2021;11(2):173–176 the laboratory investigation is much needed. however, diagnosis and early prediction of the course of the disease are essential to avoid irreversible axonal damage. in determining the degree of nerve damage and potential subsequent dysfunction, electrophysiological tests can give useful information. the results of the topo diagnostic test and electrophysiological test like an emg, enog, nct also aid in the prognosis. therapeutic management of bell’s palsy is still controversial. corticosteroids considered to be the most commonly accepted bell palsy medication with or without antiviral medicine. 7–9 if the pain has been present for more than ten days, then no medical treatment is needed. most widely used corticosteroids include prednisone 1mg/kg bd weight in divided doses for five days and then tapered, iv methylprednisolone 500mg single dose. the leading cause of bell’s palsy is inflammation and oedema, inducing irritation of the facial nerve as it passes through the fallopian canal. potent anti-inflammatory agents such as oral corticosteroids target the inflammatory processes, presumably decreasing nerve oedema and thereby results in the normal facial nerve function. protection of eyes is necessary. surgical treatment includes surgical nerve decompression. other treatment modalities include electrotherapy, facial exercise, botulinum toxin injection. therefore, we conducted a retrospective study to evaluate systematically the effects of treatment method that has followed in our institution for our patients with bell’s palsy. 2. aim to study the effectiveness of bell’s palsy management that has been followed in our institution. 3. materials and methods this retrospective study had conducted in srm medical college hospital and research institute, chennai, from june 2016 to june 2019. thirty patients diagnosed with bell’s palsy who had admitted in the department of otorhinolaryngology had enrolled in this study. cases with indications of the steroid treatment were selected. exclusion criteria including patients with paralysis of other cranial nerves, passing more than three days of onset of symptoms, patients with age below 18 years and above 60 years, suspected ramsay hunt syndrome, meningitis, myelitis or vasculopathy, uncontrolled diabetes, hypertension, neuropsychiatric disease and refusal to participate in the study. all the cases underwent thorough history taking and a detailed clinical examination, topo diagnostic tests like schirmer’s test and electrodiagnostic test like emg, enog and nerve conduction time test. all the patients were graded by house-brackman grading system according to their severity of the facial palsy. all patients received prednisone 1mg/kg/body wt. in divided doses for five days and then tapered, antiviral consisted of valacyclovir 1 gram, three times a day for five days, gingiko biloba 120mg, oral vitamin b-complex and multi oral vitamin, vitamin c and facial physiotherapy is given according to the strengthduration curve and eye care. steroids had given as guideline development group, ten days’ course of oral steroids with at least five days at a high dose (prednisone 60mg for five days and then five days’ taper) within 72hours of onset. the nerve conduction time was performed on the eighth and 14 days’ post-onset using electromyography machine. the facial nerve was percutaneously stimulated just below the ear by a bipolar electrode and anterior to the mastoid process. a pulse current of 0.2 milliseconds was then applied with an intensity greater than that needed for maximum response to be achieved. the time of nerve conduction was either read directly from the cathode tube or a photograph. the mean facial nerve conduction time for an unaffected side was 3.53 milliseconds, and the maximum time for the normal facial nerve is 4.3 milliseconds. after two weeks of the onset of facial palsy electromyography test had conducted. the following six muscles had examined orbicularis oculi, zygomaticus major, orbicularis oris, levator labia superior and depressor angular oris. the presence or absence of blink reflux was analyzed simultaneously and classified as favourable or unfavourable. for follow up, patients had instructed to visit the hospital assessment on 3rd week, 3rd and 6th month of treatment. according to house-brackman grading system, the response was graded as complete recovery (grade 1), a partial recovery (grade 2-5), and no response (grade 6) and also depending on the duration of onset of bell’s palsy. 4. results out of 30 patients, 16(53%) patients were males, and 14(47%) patients were females. out of 30 patients, 16(53%) patients were males, and 14(47%) patients were females. based on age group 6(20%) patients had age less than 30 years, 9(30%) patients between 31-40 years, 7(23.3%) patients between 41-50 years and 8(26.7%) patients greater than 51 years. out of 30 patients, 16(53%) patients were males, and 14(47%) patients were females. based on the onset of symptoms, 4(13.3%) patients had symptoms within 24 hours, 10(33.3%) patients had 24-48 hours, and 16(53.3%) patients had 48-7 hours. out of 30 patients, 16(53%) patients were males, and 14(47%) patients were females. based on housebrackman grading in baseline category four patients had grade 2, eleven patients had grade 3; twelve patients had grade 4, three patients had grade 5. by the end of 3rd-week, four patients had grade 0, six patients had grade 1, five patients had grade 2, twelve patients had grade 3, two patients had grade 4, one patient had grade 5. and at 3rd-month eight harshidan, purushothaman and elangovan / panacea journal of medical sciences 2021;11(2):173–176 175 table 1: cross-tabulation between house-brackman grading scale. house-brackman grading grade 0 grade 1 grade 2 grade 3 grade 4 grade 5 grade 6 p-value baseline 0 0 4 11 12 3 0 <0.0001 3rd week 4 6 5 12 2 1 0 3rd month 8 7 7 6 1 1 0 6th month 14 5 7 3 1 0 0 fig. 1: gender distribution. fig. 2: age distribution. fig. 3: onset of symptoms. patients had grade 0, seven patients had grade 1, seven patients had grade 2, six patients had grade 3, one patient had grade 4, one patient had a grade . at 6th-month 14 patients had grade 0, five patients had grade 1, seven patients had grade 2, three patients had grade 3, one patient had grade 4. 5. discussion among 30 patients who underwent treatment, we graded the facial nerve paralysis with house brackman grading. in our study, the rate of complete recovery is in 90 percent of the patients, and around 10 percent of the patient had partial recovery due to the delay in the start of treatment especially if the therapy had started after 72 hours’ onset. in our study male and females had equal proportion and age distribution suggest that mostly it affects the younger age compared to older age and majority had onset of symptoms within 72 hours. a study done by mathews wb et al 10 showed that the path of the disease could be badly affected by older age. in his study, heath et al 11 found that the mean age of patients with rapid and full recovery was 35.8 ± 15.9 years, while patients with incomplete recovery were 55.4 ± 18.8 years, respectively. gordana djordjević, stojanka djurić et al. have shown in their clinical trials that, within the first two weeks of the disorder, a certain number of patients had a changing neurological deficit. they say that in the early phase of the disease. 12 the prognosis depending on the degree of the motor deficit was substantially reduced. may m et al 13 and hauser wa et al 14 suggest that the majority of patients with symptoms of incomplete third and fourth-degree facial paralysis had a fast and full recovery on the fourteenth day of the disease. research by yasukawa et al 15 found that 80 percent of 47 bell’s palsy patients had < 90 percent facial nerve degeneration, all of whom improved satisfactorily within 4 months. another research by wang et al 16 showed that 22 patients with full facial paralysis showed that 83.3 percent of those < 90 percent loss of enog response had a complete recovery, while 70 percent had partial recovery at 6 months after the onset of bell’s paralysis. in his study, hato et al. 17 suggested that the recovery rate was higher in patients treated with valacyclovir and prednisolone than in patients treated with prednisolone alone. a study performed by kawaguchi et al. 18 found that 34% of patients with bell 176 harshidan, purushothaman and elangovan / panacea journal of medical sciences 2021;11(2):173–176 paralysis had vzv, hsv-1 reactivation and the recovery rate was substantially higher than prednisolone in patients receiving combined prednisolone and valacyclovir. 6. conclusion various management strategies have been followed worldwide for bell’s palsy. from this study, we concluded that managing bell’s palsy in the early three days had a good recovery rate and patients had fewer symptoms alone. management of bell’s palsy followed in our institution is more successful and the therapeutic measures for bell’s palsy if initiated within 72 hours of onset aids in bringing better outcome and improves the quality of life in patients. 7. conflict of interest the authors declare that there are no conflicts of interest in this paper. 8. source of funding none. references 1. hadar t, tovi f, sidi j, sarov b, sarov i. specific igg and iga antibodies to herpes simplex virus and varicella zoster virus in acute peripheral facial palsy patients. j med virol. 1983;12(4):237–45. doi:10.1002/jmv.1890120403. 2. mccormick d. herpessimplex virus as a cause of bell’s palsy. lancet. 1972;299(7757):937–9. doi:10.1016/s0140-6736(72)91499-7. 3. adour kk, bell dn, hilsinger rl. herpes simplex virus in idiopathic facial paralysis (bell palsy). jama. 1975;233:527–30. 4. devriese pp. compression and ischaemia of the facial nerve. acta otolaryngol (stockh). 1974;77(1-6):108–18. doi:10.3109/00016487409124605. 5. abramsky o, webb c, teitelbaum d, arnon r. cellular immune response to peripheral nerve basic protein in idiopathic facial paralysis (bell’s palsy). j neurol sci. 1975;26(1):13–20. doi:10.1016/0022510x(75)90109-4. 6. murakami s. bell palsy and herpes simplex virus: identification ofviral dna in endoneurial fluid and muscle. ann intern med. 1996;124:27–30. 7. bauer ca, coker nj. update on facial nerve disorders. otolaryngol clin north am . 1996;29(3):445–54. doi:10.1016/s00306665(20)30366-2. 8. adour kk. medical management of idiopathic (bell’s) palsy. otolaryngol clin north am . 1991;24(3):663–73. doi:10.1016/s00306665(20)31121-x. 9. adour kk, ruboyianes jm, trent cs, doersten pv, quesenberry cp, byl fm, et al. bell’s palsy treatment with acyclovir and prednisone compared with prednisone alone: a double-blind, randomized, controlled trial. ann otol rhinol laryngol. 1996;105(5):371–8. doi:10.1177/000348949610500508. 10. mathews wb. prognosis in bell’s palsy. bmj. 1961;2:215–7. 11. heath jp, cull re, smith im, murray jam. the neurophysiological investigation of bell’s palsy and the predictive value of the blink reflex. clin otolaryngology all sci. 1988;13(2):85–92. doi:10.1111/j.13652273.1988.tb00747.x. 12. djordjević g. stojanka djurić early prognostic value of electrophysiological tests in bell’s palsy estimating the duration of clinical recovery. med biol. 2005;12(1):47–54. 13. may m, wette r, hardin wb, sullivan j. the use of steroids in bell’s palsy: a prospective controlled study. laryngoscope. 1976;86(8):1111–22. doi:10.1288/00005537-197608000-00003. 14. hauser wa, karnes we, annis j, kurland lt. incidence and prognosis of bell’s palsy in the population of rochester, minnesota. mayo clin proc. 1971;46:258–64. 15. yasukawa m, yasukawa k, ohnuma h. prognostic diagnosis of facial palsy with electroneurography. masui-jap j anesth. 1995;44:378–87. 16. wang y, zhang s, xu h. a report of 164 cases of bell’s palsy. chin j otorhinolaryngol. 1996;31:334–7. 17. hato n, matsumoto s, kisaki h, takahashi h, wakisaka h, honda n, et al. efficacy of early treatment of bell’s palsy with oral acyclovir and prednisolone. otol neurotol. 2003;24(6):948–51. doi:10.1097/00129492-200311000-00022. 18. kawaguchi k, inamura h, abe y. reactivation of herpes simplex virus type 1 and varicella-zoster virus and therapeutic effects of combination therapy with prednisolone and valacyclovir in patients with bell’s palsy. laryngoscope. 2007;117(1):147–56. author biography dhanyan harshidan, assistant professor p.k purushothaman, professor and hod priyangha elangovan, postgraduate scholar cite this article: harshidan d, purushothaman pk, elangovan p. a retrospective study on management of bell’s palsy in a tertiary care hospital. panacea j med sci 2021;11(2):173-176. http://dx.doi.org/10.1002/jmv.1890120403 http://dx.doi.org/10.1016/s0140-6736(72)91499-7 http://dx.doi.org/10.3109/00016487409124605 http://dx.doi.org/10.1016/0022-510x(75)90109-4 http://dx.doi.org/10.1016/0022-510x(75)90109-4 http://dx.doi.org/10.1016/s0030-6665(20)30366-2 http://dx.doi.org/10.1016/s0030-6665(20)30366-2 http://dx.doi.org/10.1016/s0030-6665(20)31121-x http://dx.doi.org/10.1016/s0030-6665(20)31121-x http://dx.doi.org/10.1177/000348949610500508 http://dx.doi.org/10.1111/j.1365-2273.1988.tb00747.x http://dx.doi.org/10.1111/j.1365-2273.1988.tb00747.x http://dx.doi.org/10.1288/00005537-197608000-00003 http://dx.doi.org/10.1097/00129492-200311000-00022 panacea journal of medical sciences 2020;10(3):269–275 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: www.ipinnovative.com original research article a study of risk factors and obstetric outcome of antepartum haemorrhage in a tertiary care hospital of eastern india subrata das1,*, ajit r. bhattacharyya2 1dept. of obstetrics & gynecology, esi pgi msr & esic medical college and esic hospital & odc (ez), kolkata, west bengal, india 2dept. of obstetrics & gynaecology, r g kar medical college and hospital, kolkata, west bengal, india a r t i c l e i n f o article history: received 20-07-2020 accepted 22-07-2020 available online 29-12-2020 keywords: antepartum haemorrhage placenta praevia abruptio placentae past uterine operation foetomaternal outcome a b s t r a c t background: antepartum haemorrhage (aph) is haemorrhage in or inside the genital tract after 28th weeks of pregnancy but before the delivery of baby. there are two main types of aph i.e. ‘placenta praevia’, ‘abruptio placentae’ and others are unexplained or extra-placental and local causes. objective: aim of our study was to know the different causes of aph along with foeto-maternal outcome. materials and methods: this observational study was carried out in a tertiary care hospital during the period of january, 2019 to december, 2019 i.e. the period of one year. women with more than 28th weeks of gestation and presenting with bleeding per vagina were our study subject. demographic data, cause of bleeding, mode of delivery and foetomaternal outcomes were tabulated. from the descriptive data, percentages, proportions and significance were calculated by using spss software of 24th version. results: 112 women were studied, which was actually 1.2% of total delivered women in the study period. study showed placenta praevia and abruptio placentae were 54.5% and 35.7% respectively as a cause of aph. it was seen that incidence of aph increased with age and parity and associated past history of uterine operations. study showed adverse foetomaternal outcome was more prevalent in aph in the form of postpartum haemorrhage, retained placenta, puerperal infection, coagulation failure and preterm birth, neonatal jaundice, foetal asphyxia, sepsis and increased perinatal and maternal mortality. conclusion: women with past history of uterine operation have an increased risk of developing aph. women with aph has to be considered as high risk pregnancy and needs institutional supervision. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction in india, every year more than 1,00,000 mother die due to pregnancy related causes. most of these deaths are preventable. haemorrhage is one of the deadly complications in obstetrics. haemorrhage accounted for nearly 30% of the maternal mortality of which antepartum haemorrhage (aph) constitutes 2-5% of the cases. 1,2 the world health authority defines antepartum haemorrhage as bleeding after 28th week of pregnancy i.e. the period of viability. 1,3,4 on an average 0.5 to 5% of all pregnancies are complicated by antepartum * corresponding author. e-mail address: drsubrata02@gmail.com (s. das). haemorrhage, 5,6 with 0.33% to 0.55% being the incidence of placenta praevia and abruption placenta being about 0.5-1%. 7 aph is commonly divided into four main types, i.e. placenta praevia, placental abruption and the rest others are undetermined and local/others causes. 5 placenta praevia is labelled when placenta implanted partially or completely in the lower uterine segments and placental abruption is the condition when normally implanted placenta is separated partially or completely from the uterine wall. 2,4 research shows risk factors for placenta praevia are, previous history of uterine scar, manual removal of placenta, uterine curettage, myomectomy, advanced maternal age https://doi.org/10.18231/j.pjms.2020.055 2249-8176/© 2020 innovative publication, all rights reserved. 269 https://doi.org/10.18231/j.pjms.2020.055 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals https://www.ipinnovative.com/journal/pjms https://creativecommons.org/licenses/by/4.0/ mailto:drsubrata02@gmail.com https://doi.org/10.18231/j.pjms.2020.055 270 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):269–275 and multiparty. exact cause of placental abruption is unknown but often were associated with preeclampsia, pre-labour rupture of membrane and abdominal trauma, cigarette smoking. 5,8 local causes such as cervical polyp and cervical carcinoma are rarely found present in aph. maternal complication of aph include malpresentation, premature labour, caesarean section, retained placenta postpartum haemorrhage, haemorrhagic shock, rarely disseminated intravascular coagulation and acute renal failure. 5 foetal complications include prematurity, neonatal jaundice, intrauterine death, still birth and perinatal mortality. 4 the developed world has already reduced maternal mortality from aph by implementing small family norms with increased family planning acceptances, availability of institutional delivery and sophisticated neonatal care units. objectives of our study was to evaluate incidences of different types of aph, mode of delivery and foetomaternal outcome of the pregnancy in our study which was complicated by antepartum haemorrhage (aph). 2. materials and methods the present study was conducted among the women admitted under the department of obstetrics and gynaecology of a tertiary care hospital in eastern india within the one-year period of january, 2019 to december, 2019. women who attended our emergency or outpatient department with a complaint of bleeding at 28th weeks of gestational age or thereafter but before the delivery of baby, were our study subject. during the study period, a total number of 9334 women were delivered among which 112 were diagnosed as third trimester bleeding per vagina. all booked and unbooked women of third trimester bleeding per vagina were included in this study. the institutional ethics committee approved the study, and the study was performed in accordance with its recommendations and that of that of helsinki declaration of 1975 that was revised in 2000. all women participating in this study gave a written informed consent. women excluded from the study subject were those having low lying placenta or retro placental haematoma detected on routine antenatal sonography or during caesarean section but remained asymptomatic throughout pregnancy. history of pre-existing coagulation disorder or women with anticoagulants were also excluded from the study subject. women ++with bleeding before 28th week of gestation and those with bleeding later due to initiation of labour with excessive show were also excluded from the study. the study was based on history and clinical examination supplemented by ultra-sonogram whenever possible. history of previous pregnancies and their outcome, whether induced or spontaneous abortion, any surgical procedures undertaken like dilatation and evacuation (d/c), caesarean section, manual removal of placenta or exploration of uterus were recorded. routine antenatal investigations and along with foetal lie, presentation, maturity was also taken. diagnosis of aph was done by antenatal sonography. as per standard guide line classifications, diagnosis and mode of delivery of placenta praevia and abruptio placentae was made. cases, where cause of bleeding was undetermined, were labelled as unexplained variety. the fundamental areas of concern in this study were as follows1. to find out the incidence of third trimester bleeding in the study period. 2. evaluation of the women were done with full medical, surgical and obstetrical history, clinical examination, relevant investigations and obstetrical management. 3. foetomaternal outcome was recorded within the study group. the age, parity, socioeconomic status, past gynaecological and obstetrics history and cause of antepartum haemorrhage were recorded in percentages and proportions. mode of delivery and associated foetomaternal complications were measured by chi-square test and significance of p value at 0.05 and 0.01 level. all of the data were calculated in spss 24th version. 3. results in this study 9334 deliveries were conducted, of which 29 cases were of multiple pregnancy, all of which were twins. during this study period, 112 women were admitted with third trimester bleeding per vagina. two of the studied subject delivered twin babies. so the number of babies in the studied subject was 114. the incidence of third trimester bleeding per vagina was 1.19% in this study group. in the present study, aph was found in four different categories i.e. placenta praevia, abruptio placentae/placental abruption, undetermined cause and other/local causes. from these 61(54.5%), 40(35.7%), 7(6.2%) and 4(3.6%) women were from placenta praevia, abruptio placentae, undetermined cause and others categories respectively. highest 43(38.4%) women of aph were from 26-30 years’ age group and the lowest 5 (4.5%) women were from below 20 years’ age group. (figure-1) in the present study, according to parity, incidences of different types of aph was classified. women with primi, second and multi gravida of placenta praevia were 8(7.1%), 20(17.8%), 33(29.5%) respectively and abruption placentae were 8(7.1%), 15(13.4%), 17 (15.2%) respectively. (table1) in the present study, according to updated kuppuswamy scale for 2007, 9 socio-economic status of the women was categorised into five groups. women with aph of 5 (4.5%), 9(8.0%), 24(21.4%), 31(27.7%) and 43(38.4%) were from ‘upper’, ‘upper middle’, ‘lower middle’,’ upper lower’ and das and bhattacharyya / panacea journal of medical sciences 2020;10(3):269–275 271 ‘lower’ group of socio-economic status respectively. (table2) in our study, past obstetrics history of caesarean section, aph, myomectomy and intra uterine foetal death (iufd) were 11(18.1%), 2(3.3%), 1(1.6%) and 1(1.6%) respectively in the women of placenta praevia. in the women of abruptio placentae, the number of caesarean section and iufd were 3(7.5%) and 2(5%) respectively. in the present study, history of induced abortion where uterine curettage was needed were, 5(8.2%) and 2(5%) women of placenta praevia and abruptio placentae respectively and in one woman of placenta praevia, there was history of abortion but in that woman uterine curettage was not needed. in the present study, only one woman of placenta praevia had a history of manual removal of placenta following vaginal delivery in previous pregnancy. (table-3) in our study, among the women of placenta praevia, delivery performed by caesarean section, spontaneous vaginal delivery and vaginal delivery after labour induction by artificial rupture of membrane (arm) with oxytocin drip were 53(47.3%), 3(4.9%) and 4(6.5%) respectively and among the women with abruptio placentae it was 16(40%), 9(22.5%) and 13(32.5%) respectively. there was 2(5%) women of abruption placentae who required instrumental delivery by using ventouse, and caesarean hysterectomy was required in one woman with central placenta praevia due to intractable postpartum haemorrhage. mode of treatment in different categories of aph were found highly significant (p <0.01). (table-4) in present study, birth asphyxia was classified into nil (apgar score 7-10), mild (apgar score 4-6) and severe (apgar score 0-3) according to apgar score after 5 minutes. in this study, nil, mild, severe form of birth asphyxia and still birth was present in 55(48.2%), 4(3.5%), 3(2.6%)), 1(0.9%) new-born of placenta praevia and in new-born of abruptio placentae it was 19(16.7%), 14(12.3%), 6(5.3%), 1(0.9%) respectively. among the seven, six (5.3%) and one (0.9%) new-born of undetermined type of aph was from nil and mild asphyxia group according to apgar score. according to apgar score, birth asphyxia within different types of aph was found highly significant (p<0.01). one maternal mortality occurred in a woman of concealed type of placental abruption who was admitted in a condition of severe haemorrhagic shock, coagulation failure and had delivered a stillborn baby vaginally. in the present study sepsis, convulsion, respiratory distress syndrome, jaundice and diarrhoea were present in 8(7%), 2(1.7%), 4(3.5%), 16(14%) and 1(0.9%) neonate respectively. there were 4(3.5%) early neonatal death during their seven days stay in hospital. in this study, maternal complications in the form of postpartum haemorrhage, retained placenta, puerperal infection, coagulation failure and renal failure were present in 11 (9.8%), 3(2.7%), 9(8%), 1(0.9%) and 1(0.9%) women respectively. (table-5) fig. 1: distribution of women in relation with no of deliveries in different age groups. fig. 2: different types of antepartumhaemorrhage according to apgar score after 5 min. 4. discussion incidence of antepartum haemorrhage (aph) varied widely with demographic profiles and different geographical areas. in our present study, majority of women 33/112(29.5%) were from to 26 to 30 years of age group. incidence of different causes of aph were 61/112(54.5%), 40/112(35.7%), 7/112(6.2%) and 4/112(3.6%) of women were from placenta praevia, abruptio placentae, undetermined and other causes respectively. maximum number of women 26/112(23.2%) with placenta praevia were from 26-30 years’ age. most commonly affected women 14/112(12.5%) with placental abruption were from 20-25 years’ age. from the literature review, yadav et al 4 reported in their study that 25-29 years’ age were commonest age group in their study which was quite similar to our study. in their study, placenta praevia, abruptio placentae and unclassified 272 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):269–275 table 1: distribution of women in relation to age (n=112) age placenta praevia (n=61) abruptio placentae ( n=40) undetermined cause (n=7) other (n=4) total (n=112) mean age ±sd (years) catagories no. percentage no. percentage no. percentage no. percentage no. percentage 27.49 ±5.09 below 20 years 3 2.7 2 1.8 0 0 0 0 5 4.5% 20-25 years 18 16.1 14 12.5 1 0.9 0 0 33 29.5% 26-30 years 26 23.2 13 11.6 3 2.7 1 0.9 43 38.4% 31-35 years 10 8.9 6 5.3 3 2.7 2 1.8 21 18.7% above 35 years 4 3.6 5 4.5 0 0 1 0.9 10 8.9% total 61 54.5 40 35.7 07 6.2 04 3.6 112 100% primigravida 8 7.1 8 7.1 2 1.8 0 0 18 16.1% second gravida 20 17.8 15 13.4 3 2.7 1 0.9 39 34.8% third gravida 18 17.1 9 8.1 0 0 3 2.7 30 26.8% fourth gravida 11 9.8 6 5.3 0 0 0 0 17 15.2% fifth gravida or more 4 3.6 2 1.8 2 1.8 0 0 8 7.1% total 61 54.5 40 35.7 7 6.2 4 3.6 112 100% table 2: socio-economic status according to modified kuppuswamy scale. socio-economic status no of women percentage upper 05 4.5% upper middle 09 8.0% lower middle 24 21.4% upper lower 31 27.7% lower 43 38.4% total 112 100% table 3: past uterine operation and obstetrics history in relation to present study cases. past obstetric history and uterine operation placenta praevia (n=61) abruptio placentae (n=40) undetermined (n=7) others (n=4) caesarean section 11 (18.1%) 3 (7.5%) 0 02(50%) ante partum haemorrhage 2 (3.3%) 0 0 01(25%) myomectomy 1 (1.6%) 0 0 0 intrauterine foetal death 1 (1.6%) 2 (5%) 0 0 abortion induced and spontaneous required uterine curettage 5 (8.2%) 2 (5%) 0 0 not required uterine curettage 1 (1.6%) 0 0 0 manual removal of placenta 1 (1.6%) 0 0 0 total 22(36.06%) 07 (6.25%) 0 03 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):269–275 273 table 4: mode of treatment given to the different types of third trimester bleeding p/v cases treatment given placenta praevia (n=61) abruptio placentae (n=40) undetermined (n=7) others (n=4) chi-squared test and p value spontaneous vaginal delivery 3(4.9%) 9(22.5%) 1(14.3%) 3(75%) χ 2: 46.3820 df: 12 p < 0.0001 vaginal delivery following arm oxytocin drip 46.5%) 13(32.5%) 4 (57.1%) 0 instrumental delivery 0 2(5%) 0 0 caesarean section 53(47.3%) 16(40%) 2(28.6%) 1(25%) hysterectomy 1(1.6%) 0 0 0 total 61 40 07 04 table 5: foeto-maternal complications according to different types of antepartum haemorrhages: categories no birth asphyxia (apgar at 5 min in between 7-10) mild asphyxia (apgar at 5 min in between 4-6) severe asphyxia (apgar at 5 min in between 0-3) still birth total χ 2 test, p value placenta praevia >> 55 (48.2%) 4 (3.5%) 3 (2.6%) 1 (0.9%) 63 (55.3%) χ 2: 29.7204 df: 9 p=0.005abruptio placentae 19 (16.7%) 14 (12.3%) 6 (5.3%) 1 (0.9%) 40 (35.1%) undetermined group 6 (5.3%) 1 (0.9%) 0 (0%) 0 (0%) 7 (6.1%) others 2 (1.7%) 1 (0.9%) 0 (0%) 1 (0.9%) 4 (3.5%) total (n=114) 82 (71.9%) 20 (17.5%) 9 (7.9%) 3 (2.6%) 114 (100%) perinatal complication n=114 maternal complication n=112 sepsis 8 (7%) post-partum haemorrhage 11 (9.8%) convulsion 2 (1.7%) retained placenta 3 (2.7%) respiratory distress syndrome 4 (3.5%) puerperal infection 9 (8%) jaundice 16 (14%) coagulation failure 1 (0.9%) diarrhoea 1 (0.9%) renal failure 1 (0.9%) early neonatal death 4 (3.5%) maternal death 1 (0.9) [¥ multiple findings of a single patient taken in this above table, >> there was two twin baby present in placenta praevia] variety were 76.8%, 20.5% and 2.7% respectively. in their study, incidences of placenta praevia was slightly more than finding of our study. in another study, conducted by majumder et al 3 it was also found that 26-30 years’ age group was most commonly affected age group of aph in their study. in the present study, according to parity most commonly affected group of antepartum haemorrhage were 39/112 (34.8%) women from second gravida of which placenta praevia and abruption placentae were 20/112 (17.8%) and 15/112 (13.4%) respectively. a study conducted by patvekar et al 10 found placenta praevia, abruptio placentae and indeterminate type were 29%, 66% and 5% respectively. in their study, incidences were differing from our study, which may be due to different geographical locations of study. a study reported by majumder et al 3 found 66% aph were placenta praevia, of which 12% were primigravida, 48% were 2-4th gravida and 6% were from 5th gravida onwards. in the same study, it was also found that 34% of aph were from abruption placentae and within these 6% were primigravida, 23% were 2-4th gravida and 5% were from 5th gravida or more. in their study, there were increased preponderance of aph of both categories towards higher parity. their findings were consistent with our study findings. in our study, according to updated kuppuswamy scale for 2007, 9 socio-economic status of the women was classified into five groups. highest number 43 (38.4%) of women were from lower socio economic status. on literature review, it was seen that there was paucity of data on socio economic status of women with aph. a 274 das and bhattacharyya / panacea journal of medical sciences 2020;10(3):269–275 study conducted by mukherjee s et al 11 found two-third of women with abruptio placentae were more in upper lower (112/318) and lower (102/318) socioeconomic status. in the present study, prior history of caesarean section, aph, myomectomy and iufd were present in 11/61 (18.1%), 2/61 (3.3%), 1/61 (1.6%) and 1/61 (1.6%) women of placenta praevia respectively and in abruptio placentae 3/40 (7.5%), and 2/40 (5%) had a history of caesarean section and iufd respectively. a study conducted by ayushma j et al 12 found 21% of women with aph had prior history of caesarean section in their study group. in another study reported by patvekar m et al, 10 17.3% and 34.7% of women with placenta praevia had a past history of caesarean section and abortion with curettage respectively. their study findings were quite similar to our study finding. in our study group, spontaneous vaginal delivery, vaginal delivery after labour induction by arm and oxytocin, instrumental delivery by using ventouse and caesarean section were 3/61(4.9%), 4/61 (6.5%), 0/61(0%), 53/61 (47.3%) respectively, and within the women with placenta praevia the corresponding figures were 9/40 (22.5%), 13/40 (32.5%), 2/40 (5%) and 16/40 (40%) respectively and in abruptio placentae and in the undetermined group of aph, the figures were 1/7(14.3%), 4/7 (57.1%), 0/7 (0%), 2/7 (28.6%) respectively. only one obstetric hysterectomy was required in a woman of central placenta praevia with severe postpartum haemorrhage. mode of treatment according to different type of aph was highly significant (p <0.01) found. in the present study, two women of twin pregnancy were associated with placenta praevia, so there was 63 new-born present among the 61 women of placenta praevia. twin gestation is associated with larger placental site for which there was more chances of placenta encroaching the lower uterine segments easily and leading to increased incidence of placenta praevia said by strong th and brar hs. 13 in their study, majority of placenta praevia (86.9%) were terminated by caesarean section and abruption placentae was mostly delivered vaginally of which spontaneous vaginal delivery 9 (22.5%) and labour induction by arm followed by oxytocin drip were 13 (32.5%). most of the women of the undetermined origin were also delivered vaginally. the study conducted by wasnik sk et al 2 found, rate of caesarean section was 90% in their aph group. in a similar study, reported by lankoande m et al, 14 it was found rate of caesarean section in placenta praevia and abruptio placentae (i.e. retro placental hematoma) were 56.9%, 43.1% and vaginal birth in placenta praevia and abruptio placentae were 66.6%, 33.4% respectively. their finding was very similar to finding of our study. another study reported by senkoro ees et al 15 found that women with placenta praevia had tenfold higher odds of caesarean delivery. these findings were also consistent with our study findings. in another study, patil y et al 16 reported that emergency caesarean section, elective caesarean section and vaginal delivery of placenta praevia were 55%, 30%,15% respectively, in abruption placentae it was 50%, 40%, 10% and undetermined type it was 58%, 35% and 7% respectively. the mode of delivery in their study was found significant (<0.05). in our study, postpartum haemorrhage, retained placenta, puerperal infection, coagulation failure following complication of disseminated coagulation (dic), acute renal failure was 11/112 (9.8%), 3/112 (2.7%), 9/112 (8%), 1(0.9%) and 1/112 (0.9%) respectively with one (0.9%) maternal death of a woman with placental abruption. another study, conducted by singhal s et al 6 reported that caesarean section, postpartum haemorrhage, coagulation failure and maternal mortality were 43.8%, 21.8%, 3.8% and 2.2% respectively in their similar study. in another study, conducted by majumder s et al 3 it was found that caesarean section, postpartum haemorrhage, retained placenta, coagulation failure due to dic were 66%, 2%, 1%, 2% respectively but without any maternal death. most of the figures were similar to our study. outcome of pregnancy with aph were considered as increased foetomaternal complications. in our study, mild asphyxia and severe asphyxia of new-born distinguished by apgar score of 4-6 and 0-3 respectively. among the women of aph, mild asphyxia was present in 20 (17.5%) of which 14 (12.3%) was from abruptio placentae and severe asphyxia was present in 9 (7.9%) women of aph in which 6 (5.3%) were from placental abruption. total 03 (2.6%) still birth was present in our study. distribution of babies according to apgar score were highly significant (p<0.01). a study conducted by wasnik sk et al 2 found birth asphyxia was 16% in their similar study, though their figure was a little lower than that of our study figure. birth asphyxia was more common in our study, may be due to our adoption of stringent diagnostic criteria to select asphyxia in new-born. in our study, perinatal complications of sepsis, convulsion, respiratory distress, jaundice and early neonatal death were found in 8 (7%), 2 (1.7%), 4(4%), 16 (14%), 1 (8.8%) and 4 (3.5%) within delivered new-born of aph respectively. a study conducted by yadav mc et al 4 found neonatal jaundice was present in 26.8% of aph but among the women of placenta praevia it was present in each (30/30) new-born. their findings were contradictory with the finding of our study, that may be due to study conducted in different geographical locations, or may be due to there was small sample size. in another study reported by sharmila g et al 1 it was found that still birth and neonatal death were 31.37% and 5.8% respectively. their neonatal death rate was almost das and bhattacharyya / panacea journal of medical sciences 2020;10(3):269–275 275 similar to our study but still birth rate of our study was relatively lower, that may be due to availability of better obstetrical care. 5. conclusion vaginal bleeding during third trimester of pregnancy may lead to grave consequences of women’s life. from our study, we found that risk of aph increased with past history of uterine operations and rate of caesarean delivery with adverse foetomaternal outcomes was also increased in the women with aph. but it may be concluded that regular antenatal care, identifying the major degree of aph to provide care in tertiary care hospital and also availability of neonatal intensive care is required for better outcome. 6. authors’ contributions all author exclusively contributed in this work and read and approved the final manuscript. 7. source of funding no financial support was received for the work within this manuscript. 8. conflict of interest the authors declare they have no conflict of interest. references 1. sharmila g, prasanna. maternal and perinatal outcome in antepartum hemorrhage. int arch integr med. 2016;3(9):148–60. 2. naiknaware sv. antepartum haemorrhage: causes & its effects on mother and child: an evaluation. obstet gynecol int j. 2015;3(1):255–8. doi:10.15406/ogij.2015.03.00072. 3. majumder s, shah p, deliwala kj, patel r, madiya a. study of foetomaternal outcome of antepartum haemorrhage in pregnancy. int j reprod contracept obstet gynecol. 2016;4(6):1936–9. doi:10.1016/j.jece.2016.08.032. 4. yadav mc, mehta k, choudhary v. a study of antepartum hemorrhage and its maternal and perinatal outcome at tertiary care hospital in western rajasthan. jmscr. 2019;7(9):80–5. 5. takai iu, sayyadi bm, galadanci hs. antepartum hemorrhage: a retrospective analysis from a northern nigerian teaching hospital. int j appl basic med res. 2017;7(2):112–6. doi:10.4103/2229516x.205819. 6. singhal s, nymphaea, nanda s. maternal and perinatal outcome in antepartum hemorrhage: a study at a tertiary care referral institute. int j gynecol obstet. 2007;9(2). available from: https://print.ispub.com/ api/0/ispub-article/3465. 7. lakshmipriya k, vijayalakshmi v, padmanaban s. a study of maternal and fetal outcome in antepartum haemorrhage. int j gynecol obstet. 2019;3(1):96–9. doi:10.33545/gynae.2019.v3.i1b.19. 8. altvorst m, chan ehy, taylor rs, kenny lc, myers je, dekker ga, et al. antepartum haemorrhage of unknown origin and maternal cigarette smoking beyond the first trimester. aus new zealand j obstet gynaecol. 2012;52(2):161–6. doi:10.1111/j.1479828x.2011.01398.x. 9. kumar n, shekhar c, kumar p, kundu as. kuppuswamy’s socioeconomic status scale-updating for. indian j paediatr. 2007;74:1131–2. 10. patvekar m, thawal y, kolate d, bhola a, bhargavi n, kh pp, et al. study of etiopathology and risk factors of antepartum haemorrhage in a tertiary care center. int j clin obstet gynaecol . 2019;3(6):74–8. doi:10.33545/gynae.2019.v3.i6b.393. 11. mukherjee s, bawa ak, sharma s, nandanwar ys, gadam m. retrospective study of risk factors and maternal and fetal outcome in patients with abruptio placentae. j nat sci biol med. 2014;5(2):425–8. doi:10.4103/0976-9668.136217. 12. ayushma j, anjali k. study of obstetric outcome in antepartum haemorrhage. panacea j med sci;2015(3):153–7. 13. strong th, brar hs. placenta previa in twin gestations. j reprod med. 1989;34(6):415–6. 14. lankoande m, bonkoungou p, ouandaogo s, dayamba m, ouedraogo a, veyckmans f, et al. incidence and outcome of severe ante-partum hemorrhage at the teaching hospital yalgado ouédraogo in burkina faso. bmc emerg med. 2016;17. doi:10.1186/s12873-017-0128-3. 15. senkoro ee, mwanamsangu ah, chuwa fs, msuya se, mnali op, brown bg, et al. frequency, risk factors, and adverse fetomaternal outcomes of placenta previa in northern tanzania. j pregnancy. 2017;2017:1–7. doi:10.1155/2017/5936309. 16. patil y, patil s, jaiswani r, kalburgi p. a study of maternal and fetal outcome in antepartum haemorrhage. crit rev. 2020;7(6):922–4. author biography subrata das, associate professor ajit r. bhattacharyya, professor cite this article: das s, bhattacharyya ar. a study of risk factors and obstetric outcome of antepartum haemorrhage in a tertiary care hospital of eastern india. panacea j med sci 2020;10(3):269-275. http://dx.doi.org/10.15406/ogij.2015.03.00072 http://dx.doi.org/10.1016/j.jece.2016.08.032 http://dx.doi.org/10.4103/2229-516x.205819 http://dx.doi.org/10.4103/2229-516x.205819 https://print.ispub.com/api/0/ispub-article/3465 https://print.ispub.com/api/0/ispub-article/3465 http://dx.doi.org/10.33545/gynae.2019.v3.i1b.19 http://dx.doi.org/10.1111/j.1479-828x.2011.01398.x http://dx.doi.org/10.1111/j.1479-828x.2011.01398.x http://dx.doi.org/10.33545/gynae.2019.v3.i6b.393 http://dx.doi.org/10.4103/0976-9668.136217 http://dx.doi.org/10.1186/s12873-017-0128-3 http://dx.doi.org/10.1155/2017/5936309 introduction materials and methods results discussion conclusion authors' contributions source of funding conflict of interest panacea journal of medical sciences 2021;11(1):27–30 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article incidence of chronic subdural haematoma in different age groups and its surgical management bhavuk kapoor1, mayank kapoor2, parul vaid3,*, bharat b kapoor4 1dept. of neurosurgery, government medical college, jammu, jammu and kashmir, india 2dept. of medicine, all india institute of medical sciences, rishikesh, uttarakhand, india 3dept. of obstetrics and gynaecology, shri maharaja gulab singh hospital, jammu, jammu and kashmir, india 4dept. of anaesthesia and icu, government medical college, jammu, jammu and kashmir, india a r t i c l e i n f o article history: received 30-07-2020 accepted 07-09-2020 available online 29-04-2021 keywords: chronic subdural haematoma burr hole drainage age related incidence bilateral chronic sdh a b s t r a c t background: chronic sdh is a condition which usually affects the elderly population. trauma is the most common cause of chronic subdural haematoma. surgical treatment of chronic subdural haematoma includes burr holes with or without drainage. in patients with membrane formation, craniotomy is considered. aims: to know the incidence of chronic subdural haematoma in different age groups, the risk factors for its occurrence and its surgical management. settings and design: the incidence of chronic sdh in different age groups and the different surgical procedures done for its management were noted. materials and methods: fifty patients of chronic sdh who underwent surgical intervention were analysed. statistical analysis: statistical evaluation was done results: mean age was 62.06 years. 54% of patients were in the age group of >62 years. mostly (56%) chronic subdural haematoma was on the right side. right side chronic subdural haematoma patients had mean age of 60.8 years, left side chronic subdural haematoma patients had mean age of 56.7 years and bilateral chronic subdural haematoma patients had mean age of 75.6 years. trauma (46%) was most commonly associated with chronic sdh formation. burr hole evacuation was the preferred surgical treatment modality (92%). conclusion: chronic sdh usually occurs in elderly population. bilateral chronic sdh is commonly seen in elderly patients. traumatic brain injury is the commonest predisposing factor for its occurrence. in some elderly patients even a trivial injury may lead to the occurrence of chronic sdh. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction chronic subdural hematoma is an encapsulated collection of blood and fluid on the surface of the brain. it is a condition which usually affects the elderly population. upto 90% of chronic subdural haematoma patients are elderly. 1 falls and motor vehicle accidents are the most common cause of chronic subdural haematoma. 2 many patients do * corresponding author. e-mail address: kapoorbhavuk14@gmail.com (p. vaid). not remember any history of trauma to the head and even if they had, it is usually trivial. in elderly patients, falls are a common precursor for chronic subdural haematoma occurrence. the other causative factors include long-term heavy alcohol use, long-term use of aspirin, anti-nflammatory drugs, anticoagulant medication and diseases associated with deranged blood clotting. 3 surgical treatment of chronic subdural haematoma includes burr holes with or without drainage. in a https://doi.org/10.18231/j.pjms.2021.008 2249-8176/© 2021 innovative publication, all rights reserved. 27 https://doi.org/10.18231/j.pjms.2021.008 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.008&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:kapoorbhavuk14@gmail.com https://doi.org/10.18231/j.pjms.2021.008 28 kapoor et al. / panacea journal of medical sciences 2021;11(1):27–30 few patients, where membrane formation is there, small craniotomy with aid of endoscopic removal or wide craniotomy with removal of the hematoma and membrane resection is warranted. 4 we did a study to know the incidence of chronic subdural haematoma in different age groups, the risk factors for its occurrence and its surgical management. 2. material and methods fifty patients were included in the study. all patients of chronic sdh who underwent surgical intervention were analysed. 2.1. inclusion criteria 1. patients of chronic sdh requiring surgical intervention. statistical evaluation was done using spss software for windows. 3. results most of the patients (38%) were in the age group of 62-75 years [table 1]. table 1: age distribution age (years) frequency percentage (%) 20 – 33 1 2 34 – 47 5 10 48 – 61 17 34 62 – 75 19 38 76 – 89 8 16 total 50 100 mean age was 62.06 years. 54% of patients were in the age group of >62 years. in 56% of patients chronic subdural haematoma was on the right side. in 28% of patients it was on left side and in 16% of patients it was bilateral [figure 1]. fig. 1: site of chronic sdh right side chronic subdural haematoma had mean age of 60.8 years, left side chronic subdural haematoma had mean age of 56.7 years and bilateral chronic subdural haematoma had mean age of 75.6 years [table 2]. table 2: chronic sdh laterality with age chronic sdh mean age (years) right 60.82 left 56.78 bilateral 75.62 trauma (46%) was most commonly associated with chronic sdh formation [table 3]. table 3: associated conditions conditions frequency percentage (%) trauma 23 46 hypertension 8 16 cerebrovascular diseases 2 4 cardiovascular diseases 2 4 diabetes 5 10 renal diseases 1 2 pulmonary diseases 1 2 liver diseases 1 2 burr hole evacuation was the preferred surgical treatment modality (92%) [table 4]. table 4: type of procedure done procedure frequency percentage (%) burr hole 46 92 craniotomy 4 8 4. discussion mean age in our study was 62.06 years. the mean age of chronic subdural haematoma patients has been reported as 60.4 years in india. 5 asaduzzaman et al. found mean age of 52.8 years in their study. 6 in a study by mekaj et al., mean age was 62.85 years. 7 ak et al. found mean age of 62.06 years. 8 sousa et al. found that 56.8% of their patents were ≥65 years. in our study 54% of patients were ≥62 years. 9 these findings confirm the notion that chronic subdural haematoma is common in elderly patients. in our study chronic subdural haematoma was on the right side mostly (56%), followed by on the left side (28%) and bilateral in 16%. in a study by kitya et al., chronic subdural haematoma was on the right side mostly (42.3%), followed by left side (36.3%) and bilateral in 21.4%. 10 in our study, right side chronic subdural haematoma patients had mean age of 60.8 years, left side chronic subdural haematoma patients had mean age of 56.7 years kapoor et al. / panacea journal of medical sciences 2021;11(1):27–30 29 and bilateral chronic subdural haematoma patients had mean age of 75.6 years. in a study by kitya et al., right side chronic subdural haematoma patients had mean age of 58.6 years, left side chronic subdural haematoma patients had mean age of 59.4 years and bilateral chronic subdural haematoma patients had mean age of 66.9 years. 10 this indicates that in elderly patients who generally have brain atrophy, there is higher chance of occurrence of bilateral chronic subdural haematoma. trauma was most commonly (46%) associated with chronic subdural haematoma formation in our study. this was similar to findings in most of the studies in which traumatic brain injury was the most common cause of chronic subdural haematoma formation. huang et al. found traumatic brain injury in 74.49% of patients they studied. 11 rovlias et al. found traumatic brain injury in 51.01% of patients they studied. 12 there were many patients with unknown etiology. chronic subdural haematoma might have developed in these patients as a delayed complication of trivial trauma which went unnoticed. in our study, hypertension was the next common associated disease, present in 16% of patients followed by diabetes (10%). cerebrovascular and cardiovascular diseases were present in 4% of patients respectively. in a study by nnadi mathias o. n. et al., hypertension as associated disease was present in 20% of patients and diabetes was present in 9% of patients. 13 as chronic sdh is more common in elderly patients, we commonly find chronic sdh in association with these ailments. in our study, burr hole drainage was performed in 92% of patients and craniotomy was done in 8% of patients. in a study by farhat neto, burr hole drainage was done in 94% of patients and craniotomy was done in 6% of patients. 14 in a study by h. toi et al., most of the patients (90.5%) underwent burr hole drainage and irrigation and only 1.5% underwent craniotomy. 15 so, burr hole remains the gold standard procedure for most of the cases of chronic sdh. 5. conclusion chronic sdh is a common neurosurgical entity. it commonly occurs in elderly population. in our study, mean age was 62.06 years. 54% of patients were in the age group of >62 years. mostly (56%) chronic subdural haematoma was on the right side. right side chronic subdural haematoma patients had mean age of 60.8 years, left side chronic subdural haematoma patients had mean age of 56.7 years and bilateral chronic subdural haematoma patients had mean age of 75.6 years. so, bilateral chronic sdh is more common in elderly. traumatic brain injury is the commonest predisposing factor for chronic sdh occurrence. some elderly patients without any known predisposing factor may have sustained a trivial injury which can later on lead to the occurrence of chronic sdh in them. burr hole drainage remains the commonest surgical procedure done for this condition. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. kerabe s, ozawa t, watanabe t, atoa t. efficacy and safety of post-operative early mobilization for chronic subdural haematoma in elderly patients. acta neurochir. 2010;152:1171–4. 2. mezue wc, ohaebgulam sc, chikani mc, erechukwu au. changing trends in chronic subdural haematoma in nigeria. afr j med med sci. 2011;40:373–6. 3. yadav yr, parihar v, namdev h, bajaj j. chronic subdural hematoma. asian j neurosurg. 2016;11(4):330–42. doi:10.4103/1793-5482.145102. 4. gelabert-gonzález m, iglesias-pais m, garcía-allut a, martínezrumbo r. chronic subdural haematoma: surgical treatment and outcome in 1000 cases. clin neurol neurosurg. 2005;107(3):223–9. doi:10.1016/j.clineuro.2004.09.015. 5. nayil k, ramzan a, sajad a, zahoor s, wani a, nizami f, et al. subdural hematomas: an analysis of 1181 kashmiri patients. world neurosurg. 2012;77(1):103–10. doi:10.1016/j.wneu.2011.06.012. 6. asaduzzaman sm, islam kmt, hossain mn, amin mr, alam mj, nath hd, et al. comparative study between single versus double burrhole drainage of unilateral chronic subdural haematoma. bangladesh med j. 2014;43(1):13–6. doi:10.3329/bmj.v43i1.21370. 7. mekaj ay, morina aa, mekaj yh, manxhuka-kerliu s, mittari ei, dug sb, et al. surgical treatment of 137 cases with chronic subdural hematoma at the university clinical center of kosovo during the period. j neurosci rural pract. 2008;6:186–90. 8. ak h, gūls, en i, yayuoǧlu s, atalay t, demir i, sōsūncū e, et al. the effects of membranous abnormalities on mortality and morbidity in chronic subdural hematomas. j neurol sci. 2015;32:154–60. 9. souse eb, brandão lfs, tavares cb, borges icb, neto ngf. epidemiology characteristics of 778 patients who underwent surgical drainage of chronic subdural hematomas in brasilia, brazil. bmc surg. 2013;13:5–5. 10. kitya d, punchak m, abdelgadir j, obiga o, harborne d, haglund mm, et al. causes, clinical presentation, management, and outcomes of chronic subdural hematoma at mbarara regional referral hospital. neurosurg focus. 2018;45:7. 11. huang yh, yang ky, lee tc, liao cc. bilateral chronic subdural hematoma: what is the clinical significance? int j surg. 2013;11:544– 8. 12. rovlias a, theodoropoulos s, papoutsakis d. chronic subdural hematoma: surgical management and outcome in 986 cases: a classification and regression tree approach. surg neurol int. 2015;6(1):127. doi:10.4103/2152-7806.161788. 13. nnadi on, bankole ob, olatosi jo. chronic subdural hematoma: wide dural window and incision of inner membrane. int j med res health sci. 2016;5:85–92. 14. neto jf, araujo jl, ferraz vr, haddad l, veiga jc. chronic subdural hematoma: epidemiological and prognostic analysis of 176 cases. rev col bras cir. 2015;42(5):283–7. doi:10.1590/0100-69912015005003. http://dx.doi.org/10.4103/1793-5482.145102 http://dx.doi.org/10.1016/j.clineuro.2004.09.015 http://dx.doi.org/10.1016/j.wneu.2011.06.012 http://dx.doi.org/10.3329/bmj.v43i1.21370 http://dx.doi.org/10.4103/2152-7806.161788 http://dx.doi.org/10.1590/0100-69912015005003 30 kapoor et al. / panacea journal of medical sciences 2021;11(1):27–30 15. toi h, kinoshita k, hirai s, takai h, hara k, matsushita n, et al. present epidemiology of chronic subdural hematoma in japan: analysis of 63,358 cases recorded in a national administrative database. j neurosurg. 2018;128(1):222–8. doi:10.3171/2016.9.jns16623. author biography bhavuk kapoor, lecturer mayank kapoor, post graduate parul vaid, senior resident bharat b kapoor, former professor and head cite this article: kapoor b, kapoor m, vaid p, kapoor bb. incidence of chronic subdural haematoma in different age groups and its surgical management. panacea j med sci 2021;11(1):27-30. http://dx.doi.org/10.3171/2016.9.jns16623 introduction material and methods inclusion criteria results discussion conclusion source of funding conflict of interest panacea journal of medical sciences 2021;11(1):50–52 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article correlation of er & pr with proto-oncogene & with proliferative marker ki-67 pooja agarwal1, dupinder kaur1,* 1dept. of pathology, shri ram murti smarak institute of medical sciences, bareilly, uttar pradesh, india a r t i c l e i n f o article history: received 01-05-2020 accepted 07-09-2020 available online 29-04-2021 keywords: er & pr protooncogene ki67 a b s t r a c t background & methods: this study was prospective and retrospective. prospective cases were selected from the patients admitted for surgery of invasive ductal carcinoma breast in medical college hospital. as regards retrospective cases, they were obtained from the histopathological records obtained from pathology department of srms-ims, bareilly. result: there was a significant relationship between the grades & ki-67 status. as the grade increases the proliferative index increases. here the value of (p<.0001) which is significant. in the study as observed, in maximum cases (69.64%) tumour size was 20-50mm followed by more than 50mm was in 13 cases (23.21%) and in only 4 cases (7.14%) size was less than 20mm. study designed: observational study. conclusion: out of 56 cases, 40 cases (71.42%) clinically presented with painless lump inbreast followed by painful lump in 9 cases (16.7%). 7 cases (12.50%) presented with axillary mass. out of 40cases presented with lump, 48.21%were with lump localized on right side while 23.21% were on right side. among 56 cases, in 39 cases (69.64%) tumor size varied between 20-50mm followed by 13 cases (23.21%) with size greater than 50mm and in only 4 cases (7.14%) size was less than 20mm. the proliferative index ki-67 was highest in grade 3 and lowest in grade 1 tumours. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction ki-67 is a mouse mono clonal antibody to nuclear component of a cell line derived from hodgkin’s lymphoma. the antibody react with a nuclear antigen expressed in proliferating cells throughout the cell cycle but which is absent from quiescent cell. 1 it has been so that there is the close correlation in breast carcinomas between the ki-67 growth fraction and s-phase fraction (spf) determined by flow cytometry, 2 the tl1 and mitotic counts. the ki-67 labelling occurs throughout the cell cycle, the percentage of the cell is consistently higher and generally about twice the proportion in s-phase. however, ki-67 positivity may not accurately reflect proliferative activity under some circumstances. ki-67 expression may be so low as to beundetectable at the * corresponding author. e-mail address: dupindercaur@gmail.com (d. kaur). outset of dna replication, particularly in cell with a long g1-phase. cell with proliferation impaired or arrested by immunohistochemically demonstrable ki-67 antigen. a statistically significant positive correlation between ki-67 positivity and the number of nucleolar organizer regions in mammary carcinoma nuclei has been reported. the mean value of ki-67positive cells (3% to 4%) in benign breast lesions is substantially lower than the mean value (16% to 17%) in mammary carcinoma. 3 the ki-67 growth fraction is significantly related to grade in most tumors, being highest in poorly differentiated carcinoma & invasive duct carcinomas with comedo feature. ki-67 detection represent a valuable tool & is a good objective substitute for mitotic counts when used in grading system. invasive lobular & mucinous carcinomas have a low to moderate growth fraction, whereas medullary carcinomas have more than 50% ki-67 positive cells. 4 estrogen & progesterone receptor negative tumors tend to have a high https://doi.org/10.18231/j.pjms.2021.013 2249-8176/© 2021 innovative publication, all rights reserved. 50 https://doi.org/10.18231/j.pjms.2021.013 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.013&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:dupindercaur@gmail.com https://doi.org/10.18231/j.pjms.2021.013 agarwal and kaur / panacea journal of medical sciences 2021;11(1):50–52 51 ki-67 positive fraction. 5 several studies have reported a significant inverse association between ki-67 staining & diseased free & overall survival. 6 a comparison of screen-detected & interval carcinoma revealed that interval carcinoma had higher ki-67 labelling & higher mitotic rates than tumor detected by screening. 2. materials and methods the present study entitled “correlation of er & pr with proto-oncogene & with proliferative marker ki-67” was conducted in dept. of pathology, at srmsims, bareilly. this case study was prospective and retrospective. prospective cases were selected from the patients admitted for surgery of invasive ductal carcinoma breast in medical college hospital. as regards retrospective cases, they were obtained from the histopathological records obtained from pathology department of srms-ims, bareilly. 1. biopsies and mastectomy specimens were fixed in 10% formalin. 2. detailed history about age, family history, clinical diagnosis and chief complaints was enquired. 3. tissue was fixed in buffered formalin for about 6 hour after adequate slicing. 4. gross appearance of mastectomy specimen/biopsy was noted. 5. paraffin blocks after thorough tissue processing were prepared. 6. sections were cut 3-4 micron thick and subjected to following: 7. routine haematoxylin and eosin staining was done for histological typing and grading of all cases. 8. immunohistochemistry was done using labelled antibodies for hormone receptor status (oestrogen receptor & progesterone status), her2/neu & proliferative index ki-67. invasive ductal carcinomas and all other invasive tumours were graded based on an assessment of tubule/gland formations, nuclear pleomorphism, and mitotic counts as per criteria of nottingham’s grading. 3. results table 1: presenting feature no. of cases percentage right breast lump 27 48.21% left breast lump 13 23.21% painful lump 09 16.07% axillary mass 07 12.50% as most common clinical presentation of breast carcinoma is palpable lump. maximum 40 cases (71.42%) presented with lump in breast followed by 9 cases (16.7%) fig. 1: er positive case fig. 2: pr positive case presented with painful lump. 7 cases (12.50%) presented with only axillary mass. no case with nipple discharge was seen. in 27 cases lump involved right breast and 13 case lump was present in left breast. table 2: relation of ki-67 with grading of tumour grade no. of cases ki-67 grade 1 07 25.42% grade 2 39 45.69% grade 3 10 69% there was a significant relationship between the grades & ki-67 status. as the grade increases the proliferative index increases. here the value of (p<.0001) which is significant. in the study as observed, in maximum cases (69.64%) tumour size was 20-50mm followed by more than 50mm was in 13 cases (23.21%) and in only 4 cases (7.14%) size 52 agarwal and kaur / panacea journal of medical sciences 2021;11(1):50–52 table 3: tumour size wise distribution of cases tumour size no. of cases percentage <20mm 04 7.14% 20-50mm 39 69.64% >50mm 13 23.21% was less than 20mm. 4. discussion out of the 56 cases studied, maximum patients were in age group 41-50 years (53.5%) followed by 21.4% patients were from 51-60 years of age group. (14.28%) patients were from above 60 years and (10.7%) patients were from 31-40 years of age group. this is in accordance with study of hussain et al, who found peak incidence between ages of 41-50 years. 7 among the 56 patients studied, all the patients were female. no single case in male was found. similar findings were found by hussain. 7 out of 56 cases maximum cases (71.42%) clinically presented with lump in breast followed by painful lump in 9 cases (16.07%). 7 cases (12.50%) presented with axillary mass. these findings are in accordance with the study of blamey, who noticed frequency of symptoms of women presenting in a breast clinic with lump 60-70% followed by pain 14-18%, nipple problems 7-9%, deformity 1% and inflammation1%. 8,9 in our study, out of 40 cases presented with breast lump, 27(48.21%) cases with lump were localized on right side while in 13 (23.21%) cases were localized on left side. this was in accordance with the study of haagensen 9 who showed that there is slight higher frequency of invasive breast cancer in the right breast with a reported right to left ratio of approximately 2.07:191. 5. conclusion out of 56 cases, 40 cases (71.42%) clinically presented with painless lump in breast followed by painful lump in 9 cases (16.7%). 7 cases (12.50%) presented with axillary mass. out of 40cases presented with lump, 48.21% were with lump localized on right side while 23.21% were on right side. among 56 cases, in 39 cases (69.64%) tumor size varied between 20-50mm followed by 13 cases (23.21%) with size greater than 50mm and in only 4 cases (7.14%) size was less than 20mm. the proliferative index ki-67 was highest in grade 3 and lowest in grade 1 tumours. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. gerdes j, lemke h, baisch h. cell cycle analysis of cell proliferationassociated human nuclear antigen defined by the monoclonal antibody ki-67. j immunol. 1984;133:1710–5. 2. sahin aa, ro jy, el-naggar ak, wilson pl, teague k, blick m, et al. tumor proliferative fraction in solid malignant neoplasms a comparative study of ki-67 immunostaining and flow cytometric determinations. am j clin pathol . 1991;96(4):512–9. doi:10.1093/ajcp/96.4.512. 3. gerdes j, lelle rj, pickartz h, heidenreich w, schwarting r, kurtsiefer l, et al. growth fractions in breast cancers determined in situ with monoclonal antibody ki-67. j clin path . 1986;39(9):977–80. doi:10.1136/jcp.39.9.977. 4. kuenen-boumeester v, kwast thvd, laarhoven hav, henzenlogmans sc. ki-67 staining in histological subtypes of breast carcinoma and fine needle aspiration smears. j clin pathol . 1991;44(3):208–10. doi:10.1136/jcp.44.3.208. 5. veronese sm, gambacorta m. detection of ki-67 proliferation rate in breast cancer: correlation with clinical and pathologic features. am j clin pathol . 1991;95(1):30–4. doi:10.1093/ajcp/95.1.30. 6. sahin aa, ro jy, el-naggar ak, ordonez ng, ayala ag, ro j, et al. ki-67 immunostaining in node-negative stage i/ii breast carcinoma. significant correlation with prognosis. cancer. 1991;68(3):549–57. doi:10.1002/1097-0142(19910801)68:3<549::aidcncr2820680318>3.0.co;2-j. 7. mccormick d, chongn h, hobbs c, dstta c, hall pa. detection of the ki-67 antigen in fixed and wax-embedded sections with the monoclonal antibody mib1. histopathology. 1993;22(4):355–60. doi:10.1111/j.1365-2559.1993.tb00135.x. 8. haagensen cd. diseases of breast . in: 3rd edn. wb saunders, philadelphia; 1986. 9. patel c, sindhu kp, shah mj, patel sm. role of mitotic countsin grading and prognosis of the breast cancer. indian j patholmicrobioljuly. 2002;45(3):247–54. author biography pooja agarwal, associate professor dupinder kaur, resident cite this article: agarwal p, kaur d. correlation of er & pr with proto-oncogene & with proliferative marker ki-67. panacea j med sci 2021;11(1):50-52. http://dx.doi.org/10.1093/ajcp/96.4.512 http://dx.doi.org/10.1136/jcp.39.9.977 http://dx.doi.org/10.1136/jcp.44.3.208 http://dx.doi.org/10.1093/ajcp/95.1.30 http://dx.doi.org/10.1002/1097-0142(19910801)68:3<549::aid-cncr2820680318>3.0.co;2-j http://dx.doi.org/10.1002/1097-0142(19910801)68:3<549::aid-cncr2820680318>3.0.co;2-j http://dx.doi.org/10.1111/j.1365-2559.1993.tb00135.x introduction materials and methods results discussion conclusion source of funding conflict of interest panacea journal of medical sciences 2021;11(1):111–115 content available at: https://www.ipinnovative.com/open-access-journals panacea journal of medical sciences journal homepage: http://www.pjms.in/ original research article aetiological pattern of surgical eye removal in a tertiary care centre in eastern india nazia imam1, rakhi kusumesh1, gyan bhaskar1, mobashir sarfraz ali1,*, bibhuti prassan sinha1 1regional institute of ophthalmology (rio), indira gandhi institute of medical sciences (igims), patna, bihar, india a r t i c l e i n f o article history: received 06-10-2020 accepted 15-12-2020 available online 29-04-2021 keywords: enucleation evisceration and exenteration a b s t r a c t background: to determine the pattern of surgical eye removal in a tertiary eye-care facility in eastern india. materials and methods: a retrospective case review was performed for all patients who had surgical removal of the eye between february 2011 and february 2017 at our tertiary care centre. data collected were age, sex, diagnosis, eye affected and type of surgery, time of presentation. results: in this study 159 eyes of 159 patients underwent eye removal surgery with total number of evisceration 101(63.52%), enucleation 57(35.85%) and exenteration 1(0.63%) noted from records. mean age was 43.71±26.45 with male:female ratio of 1.69:1. diagnosis was categorized into severe intractable infection 70(44.03%), trauma 34(21.38%), tumours 28(17.61%), painful blind eye 16(10.06%) and staphyloma 11(6.92%). conclusion: evisceration was preferred surgery in our study. males were more commonly involved than female. severe intractable infection was most common indication followed by trauma and tumour with retinoblastoma as the major indication. painful blind eye and staphyloma was remaining indication. causes are largely preventable and avoidable and with provision of adequate eye-care facilities this trend can be reversed. key messages: removal of eye has profound psychological, social and economical impact on an individual. to reduce this, major etiological factor prevalent in that region has to be known. aetiology prevalent in western country or different parts of our country may not fit in our scenario and every region has its own environmental, social, educational, financial conditions and cultural beliefs that significantly affects these outcomes. © this is an open access article distributed under the terms of the creative commons attribution license (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1. introduction surgery for removal of eye is the terminal therapeutic measure for end stage ocular disease like tumours, nonresponding endophthalmitis, panophthalmitis, severe ocular trauma, degenerative eye condition like staphyloma, painful blind eye, phthisis bulbi. 1,2 methods of surgically removing eye are enucleation, evisceration and exenteration. in first description of enucleation surgery was given by bartisch in 1583 and later in 1781, bear introduced evisceration when he removed * corresponding author. e-mail address: mobashirpmch@gmail.com (m. s. ali). the remaining intraocular contents of an eye following an expulsive hemorrhage. 3 enucleation the whole eyeball is removed, whereas in evisceration sclera and extraocular muscle are left intact, exenteration is the removal of globe, including all or part of orbital soft tissue. 4 in 1874, noyes described evisceration for the management of intraocular infection. 5 in 1884, mules described placing a hollow glass sphere into the eviscerated cavity. 6 evisceration requires less manipulation and consequently less inflammation and scarring of orbital tissues and extraocular muscles resulting in better implant motility and cosmetic outcome than enucleation. 7 unlike https://doi.org/10.18231/j.pjms.2021.024 2249-8176/© 2021 innovative publication, all rights reserved. 111 https://doi.org/10.18231/j.pjms.2021.024 https://www.ipinnovative.com/ https://www.ipinnovative.com/open-access-journals http://www.pjms.in/ https://crossmark.crossref.org/dialog/?doi=10.18231/j.pjms.2021.024&domain=pdf https://creativecommons.org/licenses/by/4.0/ mailto:mobashirpmch@gmail.com https://doi.org/10.18231/j.pjms.2021.024 112 imam et al. / panacea journal of medical sciences 2021;11(1):111–115 enucleation, evisceration potentially causes exposure of uveal antigens with associated risk of sympathetic ophthalmia. 8 though there is no solid evidence that evisceration is associated with an increased risk of sympathetic ophthalmia. 9 the causes of surgical removal of the eye vary according to location and tend to reflect the pattern of severe ocular disease, the level of development and its socio-cultural dynamics. 9,10 the main aim of this study was to determine the demographic pattern, prevalent causes, and its relative importance in surgical eye removal in our tertiary care centre in eastern india, which can help to formulate appropriate intervention strategies to reduce the incidence of those diseases and hence surgical removal of the eye. 2. materials and methods a retrospective analysis was carried out for all patients who underwent surgical removal of the eye either via enucleation, evisceration or exenteration between february 2011 to february 2017 at a tertiary care center of eastern india. data collected from our medical records were age, sex, diagnosis on admission, affected eye, type of surgery, time interval between onset of disease process and presentation to ophthalmologist and selfmedication or use of traditional medication prior to presentation. primary clinical indication was divided into five groups namely intractable infection, trauma, tumour, staphyloma and painful blind eye. cases with intractable infection were further subdivided into sloughing corneal ulcer with endophthalmitis/panophthalmitis, post-surgical infection presenting with non-responding endophthalmitis /panophthalmitis with nil visual prognosis. trauma cases were categorized into irrepairable severely disorganized globe and with associated nonresponding infection with nil visual prognosis. tumour was further categorized into retinoblastoma, melanoma and advanced ocular surface squamous neoplasia. age was subdivided into three groups of below 15 years as pediatric, 15-60 years as adult and above 60 years as elderly. time of presentation between onset of symptoms and presentation to ophthalmologist was further divided into within 2 days, within 7 days, within 2 weeks, within 1 month and beyond 1 month. 3. results in this retrospective study 159 eyes of 159 patients underwent eye removal surgery and, in all cases, written informed consent was present regarding indication of eye removal and its consequences and clearly signed by patients and its relatives and in case of minor consent was signed by guardian of patients. signature of two consultants was also required for the eye removal surgery with proper diagnosis. during our study period, total number of evisceration 101(63.52%), enucleation 57(35.85%) and exenteration one (0.63%) was noted from records. mean age of cohort was 43.71±26.45 (age range 3 months to 90 years). male 100(62.89%):female 59(37.11%) ratio was 1.69:1. diagnosis was broadly categorized into severe infection 70(44.03%) cases, trauma 34(21.38%) cases, tumours 28(17.61%), painful blind eye 16(10.06%) and staphyloma 11(6.92%) [table 1]. severe infection was further sub-categorized into, following sloughing corneal ulcer 52(74.29%) and post-surgical infection 18(25.71%) and it constitute 69.31% of all evisceration in our study. trauma was sub-categorized into those with non-responding infection 22(64.71%), badly lacerated non-repairable injury without infection 12(35.29%). tumour was sub-categorized into retinoblastoma 26(92.86%), melanoma one (3.57%), advanced squamous cell carcinoma one (3.57%)[table 1]. data was also analyzed for aetiological pattern of eye removal surgery in different age groups as depicted in table 2. in paediatric age group total 35(22.01%) eye removal surgeries were recorded with retinoblastoma being major aetiologicalfactor about 26(74.29%) cases. in children below 5 years of age 22 out of 23 cases (95.65%) and even in children between 5-10 years of age four out of eleven cases (36.36%) underwent eye removal surgery due to advanced retinoblastoma. in adult age group out of 72(45.28%) surgery, severe infection 35(48.61%) was the main cause.similarly, in elderly age group out of 52(32.70%) cases, severe infection 35(67.31%) was the main aetiological pattern. about 23(44.23%) cases presenting with severe infection due to sloughing ulcer had history of use of traditional medication and over the counter use of steroid. total 31(59.62%) severe infection cases presented more than 2weeks after onset of symptoms. similarly, in cases of trauma with associated severe infection presentation was delayed by more than two days in 12(54.55%) cases and more than seven days in nine (40.91%) cases [table 3]. in trauma cases 31(91.18%) eyes were eviscerated and three (8.82%) were enucleated [table 1]. 4. discussion evisceration was the preferred surgery in our series and wassimilar to reports from other country. 11–13 evisceration requires less manipulation and consequently less inflammation and scarring of orbital tissues and extra ocular muscles resulting in better implant motility and cosmetic outcome than nucleation and it is simple faster and associated with lower risk of bleeding so it was the preferred surgical option unless contraindicated or not feasible. 12,13 more males had their eye removal than female in ratio of 1.69:1 in our study and this is similar to study from other countries and also study from other part of india. 9,11,14–17 this may be due to male are more commonly involved in imam et al. / panacea journal of medical sciences 2021;11(1):111–115 113 table 1: distribution of aetiology and type of surgery for eye removal performed in our centre aetiology frequency percentage (%) type of surgery evisceration enucleation exenteration severe intractable infection 70/159 44.03 70 a. secondary to ulcer 52/70 74.29 i. traditional medicine/steroid exposure 23/52 44.23 b. secondary to surgery 18/70 25.71 trauma 34/159 21.38 31 3 a. irrepairable injury 12/34 35.29 b. with associated severe infection 22/34 64.71 i. traditional medicine/steroid exposure 1/22 4.54 tumours 28/159 17.61 27 1 a. retinoblastoma 26/28 92.86 b. melanoma 1/28 3.57 c. advanced ossn 1/28 3.57 painful blind eye 16/159 10.06 16 staphyloma 11/159 6.92 11 table 2: demographic and aetiological distribution in different age group paediatric age group (<15years) adult age group (15-60 years) elderly (>60 years) number of cases 35(22.01%) 72 (45.28%) 52 (32.70%) male:female ratio 26:9 42:30 32:20 aetiology severe intractable infection 0 35 (48.61%) 35 (67.31%) a. secondary to ulcer 30/35(85.71%) 22/35(62.86%) b. secondary to surgery 5/35(14.29%) 13/35(37.14%) trauma 5 (14.29%) 22 (30.56%) 7 (13.46%) a. irrepairable injury 3/5(60.00%) 8/22(36.36%) 1/7(14.29%) b. with associated severe infection 2/5(40.00%) 14/22(63.64%) 6/7(85.71%) tumours 26 (74.29%) 1 (1.39%) 1 (1.92%) a. retinoblastoma 26/26(100%) b. melanoma 1/1(100%) c. advanced ossn 1/1(100%) painful blind eye 1 (2.86%) 7 (9.72%) 8(15.38%) staphyloma 3 (8.57%) 7 (9.72%) 1 (1.92%) outdoor and high-risk activity that predispose them to ocular trauma. the mean age in our study was 43.71±26.45 (range 3 months90 years) is similar study from rural area of south-eastern nigeria (47.6±20.2 years) this is the active age group of our society and removal of eye not only had psychological impact but also severely affects social and economical development of our society. 18 intractable infection was the major indication in our study constituting 44.03% of all cases of eye removal surgery and is similar to report from other study. 11,19–21 this may due to poor socio economic environment and poverty with limited access to eye care facility. our centre being a referral centre these types of no responding cases are being referred to our hospital due to lack of basic medical and surgical facility in primary care center. moreover about 32.70% of patients with sloughing ulcer had tried 114 imam et al. / panacea journal of medical sciences 2021;11(1):111–115 table 3: distribution of cases according to duration between onset of symptoms and presentation to our centre duration <2 days 2-7 days 7-14 days <1month >1 month total number of cases 7 27 26 32 67 severe intractable infection 11 17 31 11 c. secondary to ulcer 11 10 31 11 d. secondary to surgery 7 trauma 7 16 9 1 1 c. irrepairable injury 7 4 1 d. with associated severe infection 12 9 1 tumours 28 d. retinoblastoma 26 e. melanoma 1 f. advanced ossn 1 painful blind eye 16 staphyloma 11 traditional medication and/or steroid prior to presentation, and is similar to study from rural india where 47.7% of corneal ulcer patients had used traditional medication prior to presentation leading to advanced disease and delayed presentation. 22 late presentation was also an additional contributing factor of advanced disease. more than half of severe infection due to ulcer cases presented 2 weeks after onset of symptom and was similar to study from other rural areas. 11 poverty, illiteracy, traditional medication, inaccessibility to basic eye health facility all contributed to late presentation panophthalmitis was the most common indication of evisceration in a study from north india similar to severe intractable infection being most common cause of eye removal and evisceration in our study. 20 trauma was the second most common cause of eye removal constituting 21.38%. this is similar to study from north india where 21.3% evisceration was done for irrepairable globe injury and was second most common cause of evisceration. 20 in another study from south india by sengupta et.al. 15%of enucleating was due to trauma and in study by vemuganti et.al. 13% of enucleation was due to trauma. 17,23 however trauma was the most common cause of eye removal surgery in study from both developed and developing countries. 3,12,24,25 and even in trauma cases evisceration(91.18%) is preferred over enucleation (8.82%) unless contraindicated like extensive globe disruption where removal all uveal tissue is difficult by evisceration, in cases where sclera is largely intact and intraocular content is identifiable or if there is accociated nonresponding endophthalmitis /panophthalmitis evisceration was preferred. in our study more than half of trauma cases presented with nonresponding endophthalmitis/panophthalmitis mainly due to delayed presentation. advanced ocular tumour (17%) was the 3rd most common cause of eye removal in our study and retinoblastoma alone constituted more than 90% of all tumours. so, our study varies from those of south india where tumour was predominant cause of eye removal 49% in vemuganti et al. study and more than 63% in sengupta et al study and 42% by poriccha and aurora in children.[18,23,26] 17,23 in paediatric age group nearly three-quarters of total eye removal surgery was due to retinoblastoma and in children below 5 years of age 95.65% and between 5-10 years of age 36.36%of surgery was due to retinoblastoma. high percentage retinoblastoma associated eye removal in children was due to late presentation, poor socioeconomic condition, lack of education and adequate treatment facility in primary care centre leading to delayed presentation in ourcentre with advanced stage where treatment other than enucleation is not feasible. painful blind eye constitutes 10.06% of surgical removal of eye mainly due to absolute glaucoma, higher than okoyeo et. al (5.8%)and vemugantietal (3%) but lower than ababneh et. al (19%). 11,12,17 staphyloma constitute very small percentage of eye removal surgery in our series and compared to other study vemuganti et.al (25%), okoye et. al.(13.3%) this may be due to cultural beliefs that patient does prefer to live with the defect rather than living without an eye if they are symptom free. only few patients get their eye removed for cosmetic reason. 11,17 pattern of surgical eye removal vary in different age groups.in children, retinoblastoma is the predominant cause in our study similar to study from vemuganti et.al, sengupta et.al, awe oo et.al. in adult severe infection and trauma is the most common cause. in elderly severe infection, painful blind eye and trauma is the most frequent cause of surgical eye removal in our study, though in other study trauma is the most common cause in adult and elderly. 17,23,25 5. conclusion this is a first of its kind study from eastern india however such studies have been reported from northern and southern imam et al. / panacea journal of medical sciences 2021;11(1):111–115 115 india. this study gives an insight about the prevailing eye health conditions and approach of common people towads its management which is largely dependent on socioeconomic factors, literacy level, cultural beliefs and availability of adequate primary care. the aetiological pattern seen in our scenario is largely preventable and avoidable and with intensive eye health education, like avoiding use of traditional medication and self-medication with steroids etc., consulting eye specialist on first sign of eye problem or after trauma, early diagnosis of tumour with prompt referral and with strengthening eyecare facilities this trend can be reversed. 6. source of funding no financial support was received for the work within this manuscript. 7. conflict of interest the authors declare they have no conflict of interest. references 1. moshfeghi dm, moshfeghi aa, finger pt. major review: enucleation. survey ophthalmol. 2000;44(4):277–301. 2. yousuf sj, jones ls, kidwell ed. jr enucleation and evisceration: 20 years of experience. orbit. 2012;31:211–5. doi:10.3109/01676830.2011.639477. 3. noyes hd. discusioìn of e warlomont’s paper on sympathetic ophthalmia. in: report of the fourth international congress, london; 1872. p. 27. 4. meltzer ma, schaefer dp, rocca d, evisceration rc. evisceration. in: rocca rd, nesi f, lishman r, editors. smith’s ophthalmic plastic and reconstructive surgery. vol. 2. st. louis: cv mosby; 1987. p. 1300–7. 5. mules ph. evisceration of the globe, with artificial vitreous. trans ophthalmol soc uk. 1885;5:200–6. 6. laura tp, thomas nh, timothy jm. evisceration in the modern age. middle east afr j ophthalmol. 2012;19:24–33. 7. adeoye ao, onakpoya oh. indications for eye removal in ile-ife nigeria. afr j med sci. 2007;36(4):371–5. 8. bilyk jr. enucleation, evisceration, and sympathetic ophthalmia. curr opin ophthalmol. 2000;11(5):372–86. doi:10.1097/00055735200010000-00015. 9. saeed mu, chang by, khandwala m, shivane ag, chakrabarty a. twenty year review of histopathological findings in enucleated/eviscerated eyes. j clin pathol. 2006;59(2):153–5. 10. gyasi me, amoaku wm, adjuik m. causes and incidence of destructive eye procedures in north-eastern ghana. ghana med j. 2010;43(3):153–5. doi:10.4314/gmj.v43i3.55334. 11. ababneh oh, abotaleb ea, ameerh ma, yousef ya. enucleation and evisceration at a tertiary care hospital in a developing country. bmc ophthalmol. 2015;15:120. doi:10.1186/s12886-015-0108-x. 12. hansen ab, petersen c, heegaard s, prause ju. review of 1028 bulbar eviscerations and enucleations, changes in aetiology and frequency over a 20-year period. acta ophthalmol scand. 1999;77(3):331–5. doi:10.1034/j.1600-0420.1999.770317.x. 13. migliori me. enucleation versus evisceration. curr opin ophthalmol. 2002;13(5):298–302. doi:10.1097/00055735-200210000-00002. 14. haile m, alemayehu w. causes of removal of the eye in ethiopia. east afr med j. 1995;72(11):735–8. 15. gunalp i, gunduz k, ozkan m. causes of enucleation: a clinicopathological study. eur j ophthalmol. 1997;7(3):223–8. 16. vemuganti gk, jalali s, honavar sg, shekar gc. enucleation in a tertiary eye care centre in india: prevalence, current indications and clinico-pathological correlation. eye. 2001;15(6):760–5. doi:10.1038/eye.2001.245. 17. pandey pr. a profile of destructive surgery in nepal eye hospital. kathmandu univ med j. 2006;4(1):65–9. 18. eze bi, maduka-okafor fc, okoye oi, okoye o. surgical indication for eye. nigerian j ophthalmol. 2007;15(2):44–8. 19. dada t, ray m, tandon r, vajpayee rb. a study of the indications and changing trends of evisceration in north india. clin exp ophthalmol. 2002;30(2):120–3. doi:10.1046/j.14426404.2002.00495.x. 20. dawodu oa, faal hb. enucleation and evisceration in the gambia. nigerian j ophthalmol. 2000;8(1):29–33. doi:10.4314/njo.v8i1.11926. 21. prajna nv, pillai mr, manimegalai tk, srinivasan m. use of traditional eye medicines by corneal ulcer patients presenting to a hospital in south india. indian j ophthalmol. 1999;47(1):15–8. 22. sengupta s, kumar sk, biswas j, gopal l, khetan v. fifteen-year trends in indication of enucleation from a tertiary care center in south india; original article: year. indian j ophthalmol. 2012;60(3):179– 82. 23. yousuf sj, jones ls, kidwell ed. enucleation and evisceration: 20 years of experience. orbit. 2012;31(4):211–5. doi:10.3109/01676830.2011.639477. 24. awe oo, adeoye ao, onakpoya oh. surgical eye removal in ile-ife, nigeria. nigerian j ophthalmol. 2016;24(1):31–4. doi:10.4103/01899171.179919. 25. porricha d, aurora a. causes of enucleation and eviscerationof eyeballs in children:a clinicopathological study. indian j medical sci. 1982;36:72–9. author biography nazia imam, senior resident rakhi kusumesh, additional professor gyan bhaskar, professor mobashir sarfraz ali, associate professor bibhuti prassan sinha, professor and hod cite this article: imam n, kusumesh r, bhaskar g, ali ms, sinha bp. aetiological pattern of surgical eye removal in a tertiary care centre in eastern india. panacea j med sci 2021;11(1):111-115. http://dx.doi.org/10.3109/01676830.2011.639477 http://dx.doi.org/10.1097/00055735-200010000-00015 http://dx.doi.org/10.1097/00055735-200010000-00015 http://dx.doi.org/10.4314/gmj.v43i3.55334 http://dx.doi.org/10.1186/s12886-015-0108-x http://dx.doi.org/10.1034/j.1600-0420.1999.770317.x http://dx.doi.org/10.1097/00055735-200210000-00002 http://dx.doi.org/10.1038/eye.2001.245 http://dx.doi.org/10.1046/j.1442-6404.2002.00495.x http://dx.doi.org/10.1046/j.1442-6404.2002.00495.x http://dx.doi.org/10.4314/njo.v8i1.11926 http://dx.doi.org/10.3109/01676830.2011.639477 http://dx.doi.org/10.4103/0189-9171.179919 http://dx.doi.org/10.4103/0189-9171.179919 introduction materials and methods results discussion conclusion source of funding conflict of interest