Ijmrhs Vol 1 Issue 1

DOI: 10.5958/2319-5886.2015.00001.
International Journal of Medical Research

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Received: 5 June 2014
Research article
Coden: IJMRHS
Revised: 9th July 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 11th Oct 2014
HISTOLOGICAL CHANGES IN KIDNEYS OF ADULT RATS TREATED WITH MONOSODIUM

GLUTAMATE: A LIGHT MICROSCOPIC STUDY
Singh BR, Ujwal Gajbe, *Anil Kumar Reddy, Vandana Kumbhare
Department of Anatomy, J.N.M.C, Sawangi (Meghe), Wardha, Maharashtra, India
*Corresponding author email: kumarlucky48@gmail.com
ABSTRACT
Introduction: Monosodium Glutamate (MSG), which is chemically known as AJI-NO-MOTO also familiar as
MSG in routine life. MSG is always considered to be a controversial food additive used in the world. It is a
natural excitatory neurotransmitter, helps in transmitting the fast synaptic signals in one third of CNS. Liver and
kidney play a crucial role in metabolism as well as elimination of MSG from the body. Present study is to detect
structural changes in adult rat kidney tissue treated with MSG; observations are done with a light microscope.
Materials & Methods: The study was conducted in the department of Anatomy, J.N.M.C, Sawangi (M) Wardha.
Thirty (30) adult Wistar rats (2-3 months old) weighing about (200 20g) were used in the current study, animals
were divided into three groups (Group A, B, C). Group A: Control, Group B: 3 mg /gm body weight, Group C:
6 mg /gm body weight, MSG were administered orally daily for 45 days along with the regular diet.
Observations & Results: The Mean values of animals weight at the end of experiment (46th day) respectively
were 251.2 13, 244.4 19.9 and 320 31.1. Early degenerative changes like, Glomerular shrinkage (GSr), loss
of brush border in proximal convoluted tubules and Cloudy degeneration was observed in sections of kidney
treated with 3 mg/gm body weight of MSG. Animals treated with 6 mg/gm body weight of MSG showed rare
changes like interstitial chronic inflammatory infiltrate with vacuolation in some of the glomeruli, and much
glomerular shrinkage invaginated by fatty lobules. Conclusion: The effects of MSG on kidney tissues of adult
rats revealed that the revelatory changes are directly proportional to the doses of MSG.
Key words: Monosodium Glutamate, Kidney, Rats, Cloudy degeneration
INTRODUCTION
Monosodium Glutamate (MSG), which is chemically
known as AJI-NO-MOTO 1, 2 also familiar as MSG in
routine life. MSG is always considered to be a
controversial food additive used in the world. It exists
naturally in many products made by fermented
proteins, such as soy sauce and hydrolyzed vegetable
protein and it is also prepared commercially by the
fermentation of molasses.3 MSG is a natural
excitatory neurotransmitter; it helps for mediating fast
synaptic transmission in one third of all CNS
Anil et al.,
synapses.1, 4 Liver and kidney plays a crucial role in

metabolism as well as elimination of MSG from the
body.5
Monosodium glutamate (MSG) is a common example
of one of the synthetic chemical used in newer
generation foods. Detailed look at the literature shows
that Kikunae Ikeda (1908) was the first person found
glutamic acid in seaweed Laminaria Japonica; he
extracted glutamic acid and discovered its unique
flavour enhancing property. Schaumburg H.H. and R.
Int J Med Res Health Sci. 2015;4(1):1-6
Byck in 1968 3, they were the first people to draw

attention to the Chinese restaurant syndrome
characterized by headache, chest discomfort and
facial flushing while taking the Chinese meal.3, 7
Various studies have been conducted on the
physiological role of MSG; indicated that kidney,
liver, brain, and heart weight were significantly
increased in weight in rats treated with MSG 3. One
of the most common effects of MSG is asthma
attacks; the usage of MSG increases the chances of an
asthma attack and it is exacerbating migraine
headaches also6, 7. Subsequently, it was documented
that MSG produces oxygen-derived free radicals. It is
also reported that Monosodium Glutamate causes
disturbances of central endocrine axis affecting wide
areas of the body, causing learning difficulties8, its
neurotoxicity, obesity and gonadal dysfunction was
established by many workers. MSG is also linked to
disease such as obesity, Type 2 diabetes and
Alzheimers disease.9
The diversity in manifestation of toxic effects and
susceptibility of different species of animals to MSG
was such that till date no specific dietary limitations
have been recommended. On the contrary, U.S. Food
and Drug Administration FDA lists it as a GRAS
(generally recognize as safe) and limits its use only in
baby food.8, 11 Despite of its use as a taste stimulator
and improved appetite enhancer, many reports
indicated that Monosodium Glutamate is toxic to
human and experimental animals. It may be
considered that, Monosodium Glutamate may have
some deleterious effect on the Kidney of adult rats at
higher dose.12 Present study is to detect histological
changes in adult rat kidney tissue treated with MSG;
observations are done with a light microscope.
Aim and objectives: 1. Study of morphology and
microscopic structure of adult rat kidneys treated with
Monosodium Glutamate (3mg and 6mg/gm body
weight). 2. Comparison of microscopic structural
changes of experimental animal with control.
MATERIALS AND METHODS
The present animal interventional study conducted in
department of Anatomy, Jawaharlal Nehru Medical
College, Sawangi (M) Wardha. Thirty (30) adult
Wistar rats (2-3 months old) weighing about (200
20g) were used in the current study, which were
obtained from animal house, Jawaharlal Nehru
Anil et al.,
Medical College. Before conducting the study, the

experimental rats were kept in the department
research laboratory for one week in normal
environment (24 2 0 C) and supplemented by a
standard diet and water.
The study was approved by the Institutional Ethical
Committee, which has duly authorized by CPCSEA
for animal experiments.
Grouping of Animals
The rats were divided into three groups, 10 rats in
each group and treated orally as follows:
Group A: The control group in which rats were
administrated orally with distilled water daily for 45
days along with regular diet.
Group B: The experimental group in which rats were
administrated orally the therapeutic dose of
monosodium glutamate (3 mg /gm body weight) daily
for 45 days along with regular diet.
Group C: The experimental group in which rats were
administrated orally the therapeutic dose of
monosodium glutamate (6 mg /gm body weight) daily
for 45 days along with regular diet.
All three experimental animal groups were sacrificed
according to CPCSEA guidelines immediately after
completion of study period (on 46th days), before
sacrificing; rats were weighed with the digital
weighing machine. Rats were dissected and kidney
samples were taken for morphological and
histological examination. Kidney samples were fixed
in 10% buffered formalin (pH 7.2) and dehydrated
through a series of ethanol solutions, embedded in
paraffin wax, and paraffin blocks were prepared.
Sections of 5m thicknesses were cut by using a
rotary microtome. Sections are stained with
Haematoxyline-Eosin (H&E) and then examined
under light microscope.
RESULTS
The mean values of animals weight on the day of
commencement of experiment (1st day) for group A
(the control group), B and C (the Study group)
respectively were 187.2 20.5, 183.6 22.3, and
182.4 19.3. The Mean values of animals weight at
the end of experiment (46th day) respectively were
251.2 13, 244.4 19.9 and 320 31.1. (Table 1).
.
Table 1: Weight records of animals in study and

experimental groups before and after Monosodium
Glutamate administration
Weight in gm on
Weight in gm on
day 0
46th day
Group A
B
C
A
B
C
164
156
150
236
278
220
MIN
212
210
210
272
268
350
MAX
MEAN 187.2 183.6 182.4 251.2 244.4 320
20.5
22.3
19.3
13
19.9
31.1
SD
*P value
0.14
0.11
0.04$
*P values compared with their respective group 0
day values
Histological observations: Group A: kidney
sections of control rats showed normal histological
structures of the glomeruli, Bowmans capsule,
proximal tubules and distal tubule (Fig. 1).
Group B: The rats which were treated with a dose of
3 mg/gm body weight of MSG for 45 days showed
variable pathological changes in glomeruli and some
parts of the urinary tubules. Cross section at the
cortex of kidney shows dilatation of Bowmans
capsule, shrinkage of glomerulus and dilatation of the
proximal and distal convoluted tubules (Fig. 2.a).
Early degenerative changes like, Glomerular
shrinkage (GSr), loss of brush border in proximal
convoluted tubules and Cloudy degeneration was
observed in a few sections of the kidney (Fig. 2.b).
Group
Fig. 1: Cross section of control rat (Group A) kidney

showing normal histological structures of Malpighian
corpuscles with its glomerulus (G) Bowmans capsule
(BC) proximal convoluted tubule (P) and distal
convoluted tubule (D). (H&E, 100 X)
Anil et al.,
Fig. 2.a: Cross section of Study Group B kidney (3

mg / gm body weight) showing dilatation of some
Bowmans capsule (BC), shrinkage of glomerulus
(GSr), dilatation of the proximal (PCT) and distal
convoluted tubules (DCT). (H&E, 100 X)
Fig. 2.b: Tubular dilatation (PCT & DCT) with loss

of brush border in proximal convoluted tubule (PCT).
(H&E, 450 X)
Fig. 3.a: Cross section of Study Group C kidney (6

mg / gm body weight) showing dilated Interlobular
blood vessels (DBV) and cloudy degeneration in PCT
and DCT. (H&E, 100 X)
Fig. 3.b: Showing Vascular congestion (VC) (H&E,

100 X)
portion and distortion in the renal architecture. On the

other hand, few sections showed interstitial chronic
inflammatory infiltrate with vacuolation in some of
the glomeruli, and much glomerular shrinkage
invaginated by fatty lobules, In addition, there was a
focal mononuclear leukocytes inflammatory cell that
infiltrate between the tubules at the cortico medullary
portion (Fig. 3.c). Necrosis of lining cells in tubules,
inflammatory cells infiltrating renal tubules, a focal
haemorrhagic area in between the renal tubules and
chronic inflammation replaced urinary tubules were
evident in all rats treated with MSG in this group
(Fig. 3.d).
DISCUSSION
Fig. 3.c: Interstitial chronic inflammatory infiltrates

(IF) with vacuolation of glomeruli (vc) and
glomerular shrinkage (GSr) (H&E, 100 X)
Fig. 3.d: Renal tubules showing Tubular Necrosis (TN)

(H&E, 450 X)
C: The rats, which were treated with a dose of 6
mg/gm body weight of MSG for 45 days manifested
more intensive deterioration in comparison to those
observed in group A. Dilatation, hyperemia in the
interlobular cortical blood vessels and vascular
congestion were seen clearly in figure 3.a and 3.b.
There was an increase in the incidence of marked
severe vascular degenerative changes in the lining
epithelial cells of the renal tubules at the cortical
Anil et al.,
The findings on weight and histological changes in

rat kidney are mostly in conformity with the findings
of previous studies. Albino rats are the commonest
laboratory animals to be used for experimental work.
They have greater sensitivity to most of the drugs.
They are the most standardized (pure and uniform
strain) of all laboratory animals. Since they are small
in size, they are easy to handle. They do not have
their vomiting centre, they cannot vomit. These
albino rats withstands long period of experimentation
also. Therefore, it would be worthwhile to examine
the effects of Monosodium glutamate on the kidney
of adult Albino rats. 13
In the present study, some of the sections of kidney
tissue show that dilatation of PCT and DCT, swelling
in Bowmans capsule, injured brush border of
proximal convoluted tubules and necrotic lesions of
the urinary tubules. Similar findings observed in
studies done by Contini MDC et al., (2012); 14
Onaolapo A Y et al., (2013) 15. Swelling of lining
epithelium in kidney tissues treated with MSG was
because of decreased O2 levels which lead to an
aerobic respiration. The cells of lining epithelium
depend on glycolysis to maintain their ATP levels.
Glycolysis results production of lactic acid, which
causes the intracellular pH to drop. Dysfunction of
the Na+/K+ ATP as has been observed in an acidic
environment in the cell and further more influx of
Na+ and H2O into the cells leads to swelling. Long
term ischaemia can lead to more influx of ca++,
which causes mitochondrial, lysosomal damage, and
membrane damage (Allen DH et al., 1987).7
Findings, which are observed in sections of rat

kidneys, treated with 3mg/gm per body weight of
MSG like early degenerative changes like Glomerular
shrinkage, cloudy degeneration and loss of brush
border in PCT are in conformity with the studies
reported by Nagata M et al (2006) 9, Scher W. and
Scher BM. (1992) 10, Schiffman, S.S. (1998) 11.
Dilatation, hyperaemia with vascular congestion was
observed in sections of kidney treated with 6mg/gm
per body weight of MSG, similar results reported by
Schaumburg HH (1969) 3, Schiffman SS (2000) 12.
Some of the sections showed that shrunken
glomerulus with swollen Bowmans capsule,
vacuolation in glomerulus and Necrotic changes in
urinary tubules. Similar findings are reported by
Kwok, R. H. M. (1968)8, Onaolapo A Y et al., (2013).
15
In the present study, Infiltrated cells are identified in

some sections of kidney were confirmed with studies
done by Inuwa H M et al., (2011) 16 and Tawfik MS
et al., (2012) 17, these infiltrated cells lead to
production of chronic inflammatory disease after long
use of MSG. Amal A. Afeefy (2012) 18 reported that
the supplementation of honey reduces the cellular
changes induced by MSG, it indicates that honey
protects the kidney tissues against the toxic effects of
MSG, however, such observations are not done in our
study.
CONCLUSION
The findings of the current experimental study to
assess the effect of monosodium Glutamate on
kidneys of adult rats with the light microscope,
disclose that there are significant histo - pathological
changes in the kidney tissue of rats. The changes are
directly proportional to the doses of MSG. It is also
observed that higher the dose of MSG, more will be
the weight gain.
Conflict of interest: None declared by authors
Source of funding: Nil
REFERENCES
1. Adrienne S. The toxicity of MSG, a study in
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3. Schaumburg HH, Byck R, Gerstl R, Mashman
JH. Monosodium L-Glutamate: Its pharmacology
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1969; 16(3): 826- 28
4. Singh K, Ahluwalia P. Studies on the effect of
Monosodium Glutamate administration on some
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5. Bhattacharya T, Bhakta A and Ghosh SK. Long
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6. Stevenson DD. Monosodium glutamate and
asthma. Journal of Nutrition. 2000; 13(1): 106773.
7. Allen DH, Delohery J, Baker G. Monosodium
L-glutamate-induced
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8. Kwok, R. H. M. Chinese-restaurant syndrome.
New England Journal of Medicine. 1968: 72 (3):
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9. Nagata M, Suzuki W, Iizuka S, Tabuchi M,
Maruyama H, Takeda S, Aburada M, Miyamoto
K.: Type 2 diabetes mellitus in obese mouse
model induced by monosodium glutamate. Exp.
Anim. 2006; 55 (2): 109-115.
10. Scher W. and Scher BM. A possible role for
nitric oxide in glutamate (MSG)-induced Chinese
restaurant syndrome, glutamate-induced asthma,
hotdog headache, pugilistic Alzheimers
disease, and other disorders. Med Hypotheses.
1992; 38 (3): 185-188.
11. Schiffman, S.S. Sensory enhancement of foods
for the elderly with monosodium glutamate and
flavors. Food Reviews International. 1998;
14(2): 321-333.
12. Schiffman, S. S. Intensification of sensory
properties of foods for the elderly. Journal of
Nutrition. 2000 13(3): 927-930.
13. Mosaibih Mai A AL. Effects of monosodium
glutamate and acrylamide on the liver tissue of
adult Wistar rats. Life Sci J. 2013; 10(2): 35-32.
14. Contini MDC, Millen N, Riera L, Mahieu S.
Kidney and Liver Functions and Stress Oxidative
Markers of Monosodium Glutamate Induced
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Obese Rats. Food and Public Health. 2012; 2(5):

168-177.
Onaolapo A Y, Onaolapo O J, Mosaku T J,
Akanji O & Abiodun O. A Histological Study of
the Hepatic and Renal Effects of Subchronic Low
Dose Oral Monosodium Glutamate in Swiss
Albino Mice. British Journal of Medicine &
Medical Research. 2013; 3(2): 294-306.
Inuwa H M, Aina V O, Baba Gabi, Aim ola I &
Leehman
Jaafaru.
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of
Nephrotoxicity and Hepatoxicity of Monosodium
Glutamate (MSG) Consumption, British Journal
of Pharmacology and Toxicology. 2011; 2(3):
148-153
Tawfik MS, Manal Said & Badr NA. Adverse
effects of monosodium glutamate on liver and
kidney functions in adult rats and potential
protective effect of vitamins C and E Food and
Nutrition Sciences. 2012; 12(3), 651-659.
Amal A. Afeefy Marwa S.Mahmoud and Mona
A.A. Arafa. Effect of Honey on Monosodium
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Anil et al.,
DOI: 10.5958/2319-5886.2015.00002.8

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1 Coden: IJMRHS
Copyright @2014
th
th
Received: 5 May 2014
Revised: 28 Oct 2014
Research article
ISSN: 2319-5886
Accepted: 31st Dec 2014
EFFECT OF PLYOMETRIC TRAINING ON VERTICAL JUMP HEIGHT IN HIGH SCHOOL

BASKETBALL PLAYERS: ARANDOMISED CONTROL TRIAL
*Chhaya Verma1, Lakshmi Subramanium2, Vijaya Krishnan3
1
Professor of Physiotherapy, Seth G.S. Medical College & KEM Hospital, Parel, Mumbai
M.P.Th, Ergonomic Consultant, Ergworks Inc, Banglore, India
3
M.P.Th (musculoskeletal sciences), LTMMC & LTMGH, Sion, Mumbai
2
*Corresponding author email:victoryv2@yahoo.co.in

ABSTRACT
Background: Plyometric involve high intensity eccentric contraction immediately after a powerful concentric
contraction. A vertical leap in basketball also involves rapid & repeated muscle contraction & stretching. Various
methods have been used to improve the vertical leap in players, but only few studies mention about plyometrics.
Aim: To determine the effect of Plyometric training on vertical jump height in high school basketball players &
compare them with their untrained counterparts. Methods and Materials: 144 students were randomly selected
& distributed in Group I (Pre-pubertal) & Group II (Pubertal) which was further divided into Group A (trained
players) & Group B (untrained students). A gender wise distribution followed this. Plyometric training of 6 weeks
was conducted & the vertical jump height pre & post training were recorded & compared. Results: Vertical jump
height improved significantly post Plyometric in Group Bcompared to Group A. Boys showed improvement in
Group B, however girls were better in Group A. Correlation of BMI with vertical jump height was negative &
significant in Group B. Conclusion: Plyometric training brought significant change in untrained students. Boys
gained more jump height while girls showed significant increase in jump height during pubertal growth spurt.
Also, increased BMI reduced jump height.
Keywords: Basketball, Vertical jump height, Plyometric training, Body mass index.
INTRODUCTION
Basketball is one of the most popular team based
sport played and watched throughout the world. The
aim of the game is for each team to defend a goal area
while trying to score goals at the opposing end of the
court. The on court team of 5 players consists of 2
forwards, 2 guards and a centre with each player
having to play in attack and defence. Basketball
requires speed, explosive power and sustenance of
maximum performance throughout the game.1
Vertical Jump: is the act of raising ones centre of
gravity higher in the vertical plane solely with the use
of ones own muscles. The vertical jump is divided
into 2 types:
Chhaya et al.,
Standing vertical jump: refers to vertical jump

done from a standstill with no steps involved
Running Vertical jump: refers to vertical jump
after an approach or run to help add energy to the
jump in an effort to improve on the standing
vertical jump.2
Plyometric Training: Is an essential tool for
improving explosive force. Plyometric exercises are
defined as eccentric loading immediately followed by
a concentric contraction. 3
Neurophysiology:These
exercises
induce
neuromuscular adaptations to the stretch reflex,
elasticity of the muscle and golgi tendon organs. This
7
muscle action of eccentric to concentric or

deceleration to rapid acceleration is known as
Stretch-Shortening Cycle (SSC).4The conversion
from the negative (eccentric) to positive (concentric)
work is known as Amortization Phase. This begins at
the onset of eccentric contraction and continues to the
initiation of Concentric Contraction.5,6 Wilt suggested
that muscular performance gains after Plyometric
training are attributed to these neural adaptations and
it may enhance neuromuscular function.6,7
The shorter the duration of all the 3 phases, greater
will be the exploratory power of the muscles
exercised.Plyometric training is a training strategy
designed to improve the performance by
incorporating the basic needs of agility & power,
allows muscle to reach exponential increase in the
maximum strength & speed of movement inthe
shortest duration.8-11
Researchers have suggested that Plyometric exercises
were initially utilized to enhance sport performance
and more recently used in the rehabilitation of injured
athletes to help in preparation for a return to sport
participation.12 Santos et al in their study concluded
that Plyometric training showed positive effects on
upper & lower body explosive strength in adolescent
male basketball players.13Saggital plane Plyometric
program showed significant improvement in vertical
jump height in a study conducted by King & Cipriani,
on high-school basketball players. 14 A study done by
Mondal & Wondirad, to assess the effect of 6-week
Plyometric training on vertical jump performance
demonstrated a significant improvement in the
vertical jump performance of an athlete. 12 Also,
Abbas Asadi, in his study concluded that a 6-week inseason Plyometric training program had positive
effects for improving power & agility, performance in
young male basketball players & his study further
provides support for coaches & players to use this
training method during competitive phase. 15
The purpose of this study, thus, was to determine the
effect of Plyometric training on vertical jump height
in high school basketball players compared to their
untrained counterparts around puberty. The effect of
training on boys & girls were also separately noted.
Aim: To determine the effect of 6-weeks of
Plyometric training on vertical jump height in high
school basketball players and untrained students
around puberty.
Objectives: 1. To compare the effect of Plyometric

training on vertical jump height between high school
basketball players and untrained students. 2. To
observe the effect of training on pre pubertal &
pubertal boys & girls. 3. To observe the effect of
Body Mass Index on vertical jump height.
MATERIAL AND METHODS
Study design: A randomized control trial
Study duration: 6 weeks
Sample size: 144
Location: Mumbai, Maharashtra, India
Inclusion criteria: Basketball players - boys and
girls from different schools in Mumbai who have
been playing the sport at a competitive level. 2 groups
of Pre-pubertal (10-11 yrs) and Pubertal (14-15 yrs)
were taken. Healthy active students (non basketball
players) of the same age and sex were included.
Exclusion criteria: Previous history of lower limb
injuries. Ligament and muscle injuries, boys and girls
who were unable to cope up with the training sessions
Subjects
(n=144)
Group I
(72) (1011 Years)
A
(Trained 36)
(i) Girls
(22)
(ii) Boys
(14)
Group II
(72) (1415 Years)
B
(Untrained
36)
(Trained
36)
(Untraine
d 36)
(i) Girls
(22)
(i) Girls
(22)
(i) Girls
(22)
(ii) Boys
(14)
(ii) Boys
(14)
(ii) Boys
(14)
Fig. 1: Randomised distribution of subjects

Procedure: An institutional ethics committee
approval was obtained. A written consent from all the
participants along with prior permission from the
school principals was obtained. A musculoskeletal
screening of all the subjects was done. Measurement
of the height and weight was done and the Body Mass
Index was calculated.
Explosive power is the ability to exert a maximal
force in as short time as possible. Speed is the ability
to reproduce these explosive movements one after the
with minimal fatigue. Running speed is very
important in basketball players and it can be assessed
by sprint tests, shuttle tests etc.7
8
Chhaya et al.,
Vertical jump height was measured pre and post

training. 16-18 The athlete stands on to a wall and
reaches up with the hand closest to the wall. The
point of the fingertips is marked keeping feet flat on
the ground. The athlete then jumps vertically as high
as possible and attempts to touch the wall at the
highest point of jump. The difference in the distance
between the reach height and jump height is the
score. The best of three attempts is recorded. Biceps
and triceps, as all major muscle groups in the body
are important for basketball. There are compound
movements that can be done to integrate an isolated
bicep or tricep exercise within other movements e.g.
Pull up, press ups. The pushing exercises incorporate
triceps while pulling exercises will incorporate the
biceps.
The subjects were put on a Plyometric training

program of 6 weeks, constituting the lower body19
and upper body20 Plyometric exercise.
Duration of a session: 40 minutes.
Frequency: 3 days/week (alternate days)
The training session consisted of: Warm up exercises:
10-15 minutes including stretching of hamstrings,
tendoachilles, illiopsoas, adductors and mobility
exercises of the lower limb. Also, stretching of
biceps, triceps, shoulder, pectorals, trunks were done.
Slow skipping and marching were included too.
Plyometric training: 20-25 minutes including arm
Plyometric and lower body Plyometric. Cool down:
10 minutes including slow jogging, walking, lying
down back stretch, deep breathing, and relaxation
Training program:
The untrained group was asked to perform the general
warm up prior to the vertical jump. Cool down
exercises were performed by them after the jump
height was recorded.
For trained group: the exercises included wereUpper body Plyometric: Press-ups, Chest Pass, Power
Drop
Lower body Plyometric: Two-legged hops or Bunny
hops, Depth jumps, Short sprints or Bounds
Fig 2: Vertical Jump Test

RESULTS
Table 1: vertical jump height pre & post training
Vertical jump height (cms)
Trained/
Age
untrained Gender
girls
PreTrained
boys
Pubertal
group I
girls
Untrained
(10-11yrs)
boys
girls
Trained
Pubertal
boys
group II
girls
(14-15yrs)
Untrained
boys
Inference: There is an improvement seen in post
all groups.
Pre
Post
Postmean
mean
Premean
32.95
34.18 1.23
32.14
33.78 1.64
32.77
34.09 1.32
28.14
31.07 2.93
31.45
33.36 1.91
35.17
35.57 1.21
31.36
32.09 0.73
31.78
35.21 3.43
training vertical jump height
n
mean + sd
22 34.18 +1.38
14 33.78 +1.28
22 34.09 +1.46
14 31.07 +1.49
22 33.36 +1.38
14 35.57 +2.19
22 32.09 +3.51
14 35.21 +1.99
as compared to the pre-training in
9
Chhaya et al.,
Table 2: Comparison of effect of Plyometric

training on vertical jump height (in cms) of
trained players & untrained students.
Girls
Boys
10-11 yrs
14-15 yrs
10-11 yrs
14-15 yrs
Trained
1.23
1.9
1.64
1.21
Untrained
1.32
0.73
2.93
p-value
0.83
0.15
0.02
3.43
*
0.009*
Inference: Improvement in vertical jump height was

significantly greater in untrained boyscompared to
trained boys.
Table 3: Mean improvement between Boys &
Girls in Vertical Jump Height(in cms)
Gender
Trained
Untrained
10-11 yrs
14-15 yrs
10-11 yrs
14-15 yrs
girls
1.23
1.9
1.32
0.73
boys
1.64
1.21
2.93
p-value
0.37
0.25
0.003
3.42
*
0.013*
Inference: Improvement in jump height is significant

in boys compared to girls in untrained group while in
the trained group girls are better than boys.
Table 4: Mean difference in Vertical Jump Height
between Pre Pubertal & Pubertal ages
Age
Girls
pre-pubertal
(10-11 yrs)
pubertal
(14-15 yrs+a55)
p-value
boys
trained
untrained
trained
untrained
1.22
1.32
1.64
2.92
1.9
0.73
1.21
3.42
0.1
0.47
0.5
0.45
Inference: There is no significant difference in the

pre-pubertal and pubertal age groups in vertical jump
height.
Table 5:Body Mass Index in Pre Pubertal &
Pubertal boys and girls
Girls
Age
Trained
Pre-pubertal
_0.4(0.06)
(10-11 yrs)
Pubertal
0.113(0.6)
(14-15 yrs+a55)
Boys
Untrained
Trained
_0.49(0.02) _0.12(0.49)
Untrained
_0.5(0.05)
_0.490(0.02) _0.172(0.55) _0.32(0.2)
Inference: A significant negative correlation is seen

in the untrained boys and girls of both age groups
suggesting that as the BMI increases, the vertical
jump height decreases.
DISCUSSION
Vertical jump measurements are used primarily in
athletics to measure performance. The most common
sports in which this is measured are field and track
events, basketball, football, volleyball etc. This study

was conducted to evaluate the effects of 6 weeks
plyometric training on vertical jump height in high
school basketball players. It was also aimed at
determining the effect of the pre-training status,
gender and pubertal age on the difference in vertical
jump post plyometric training.
Kinetic forces involved during a vertical jump are61. Contact time: Period of time for which the foot
/feet are in contact with the ground during an
activity. This phase is important, as the body
cannot generate force to increase velocity or
change directions without foot contact.
2. Ground reaction force (GRF): is the force exerted
by the ground on a body in contact with it.
3. Impulse: is the rate of change of momentum.
These above factors mentioned collectively
contribute to the quality of both the types of the
vertical jump: standing and running which are
enhanced during a plyometric training programme.
Table 1 demonstrates the significant improvement in
the jump height post plyometrics. The training effect
was seen to be enhanced in untrained students as
compared to trained players (Table 2). Neural
adaptations after training among initially untrained
individuals include earlier activation and increases in
maximal discharge rates of single motor
neuron.21But,
in
individuals
with
training
background, these neuromuscular adaptations have
already occurred. Therefore, the players showed
lesser improvements as compared to untrained
students.
The jump height is usually recorded as a distance
score. It can be affected by the angle of knee bending,
effective use of hands, co-ordination etc. hence, to
minimise these factors the students were given three
attempts to perform the test and the average of the
scores were recorded for analysis purpose.
Boys demonstrated increased vertical jump height
than Girls (Table3). This was due to the fact that
Boys demonstrated a neuromuscular spurt evidenced
by an increased vertical jump height and increased
ability to attenuate the landing force. 22 Also,
eccentric exercises are performed differently by girls
as compared to boys as they have different activation
pattern. Eccentric contractions induce a significant
post-exercise force deficit. It was observed that girls
showed greater loss of strength immediately after a
bout of maximal eccentric contraction due to muscle
10
Chhaya et al.,
thawing. 23 Since, plyometric exercises involve this

effect; the difference in activation patterns might also
have affected the final outcome in girls. There are
many ways to improve vertical jump, but the most
effective exercises include plyometrics along with
exercises that build both strength and power. For e.g.
Full squats, weighted step ups, overhead walking
lunges sprints, agility drills etc. the students can build
strength by performing basic weight training exercise
and build power with faster dynamic movements.
Also, practising maximum vertical jump will increase
the vertical jump.1,6
During and following puberty, boys have a significant
increase neuromuscular performance, while most
girls do not (Table 4).24 But specialized
neuromuscular training introduced at the onset of
puberty can influence these neuromuscular responses
in girls. These improved neuromuscular adaptations
due to our plyometric training could probably have
resulted in an enhanced improvement in pubertal
aged girls compared to boys.
An improvement in vertical jump is said to be
enhanced in the pubertal age group due to physiologic
growth spurt.23, 24 But in our study this effect was
seen only in trained pubertal aged girls. On an
average, girls begin the process of puberty about 1- 2
yrs earlier than boys.25Girls, therefore, attain their
adult height and growth spurt earlier than boys. All
girls in our study in the age group of 14 15 yrs had
attained their menarche at least a year prior to the
start of the study and thus would be at the peak of
their growth spurt. This difference in the pubertal age
between boys and girls explains the absence of
significant improvement in vertical jump height in
pubertal aged boys.
It is easier for ones propulsive muscles to carry one
faster and further if ones body is lighter.26 Also,
greater the body mass, greater the ground reaction
force and lesser will be the velocity of the vertical
jump.2 This reasons the negative correlation of BMI
with the jump height. In our study, a significantly
negative correlation is present in untrained students
as compared to trained players (Table 5). As the BMI
calculated from the weight would include both
muscle and fat mass, some individuals may have a
high BMI because of increased muscularity rather
than increased body fat.27-32
Increased muscularity especially in the lower limbs
would enhance power production and hence increase
vertical jump. This might be the cause of a significant

negative correlation seen in untrained subjects.
Pearsons Correlation test was used for calculation
and is depicted in table 5.
CONCLUSION
This study concludes that plyometric training of 6
weeks brought a significant change in the vertical
jump height in untrained students as compared to
basketball players. Boys gained more jump height
compared to girls with training, however, during
pubertal growth spurt girls showed significant
increase in jump height. As Body Mass Index of a
person increases, vertical jump height decreases. This
correlation is however not significant for trained
individuals who have a higher BMI due to muscle
mass and not fat.
ACKNOWLEDGEMENT
We thank god almighty, the college dean, the prof &
head of physiotherapy department, the school
principals and all the students who participated in the
study.
Conflict of Interest: Nil
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DOI: 10.5958/2319-5886.2015.00003.X

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Received: 27 Aug 2014
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 28th Nov 2014
A RANDOMIZED CONTROLLED STUDY OF RISK FACTORS AND ROLE OF PROPHYLACTIC

ANTIBIOTICS IN PREVENTION OF SURGICAL SITE INFECTIONS
*Avijeet Mukherjee1, Naveen N2
1
Associate Professor, Department of General Surgery, College of Medicine and JNM Hospital, WBUHS, Kalyani,
West Bengal, India
2
MCh Resident, Department of Plastic Surgery, Rajarajeswari Medical College and Hospital, Bangalore,
Karnataka, India.
*Corresponding author email: Naveen_uno1@yahoo.co.in
ABSTRACT
Background and Objectives: Surgical site infection (SSI) is the most common nosocomial infection encountered
in post operative surgical wards. The use of prophylactic antibiotic in clean elective surgical cases is still a subject
of controversy to surgeons. The objective of the study is to identify the need for using prophylactic antibiotics in
clean surgeries, prevalence of organisms in patients who are not given prophylactic antibiotics and to study
whether the presence of risk factors increase the incidence of surgical site infection. Methodology: The
comparative study consists of 100 cases admitted under two groups of 50 each: Group A was given prophylactic
antibiotic and Group B didnt receive any. All surgeries other than clean surgical cases were excluded from the
study. Results: Out of 50 patients in group B who were not given prophylactic antibiotic, 2 patients had more
than one risk factor for development of SSI and both of them developed SSI. Of the 50 patients who received
prophylactic antibiotic, none developed SSI. The rate of infection in group A was nil and in Group B was 4%.
Conclusion: Prophylactic antibiotics are not recommended for clean elective surgical cases as there is no
statistically significant change in the infection rate seen in patients not receiving prophylactic
antibiotic(P=0.4952). Meticulous surgical technique and correcting risk factors prior to surgery is a must for
reducing incidence of SSI.
Keywords: Cephalosporins; Noscomial infection; Prophylactic antibiotics; Surgical site infection.
INTRODUCTION
Surgical site infection (SSI) is one of the most
frequent causes of post-operative morbidity. SSI is
the most common nosocomial infection in our
population, reaching 38% of all infections in surgical
patients. Incisional infections are the most common
accounting for 60% to 80% of all SSIs1.They present
with redness, delayed healing, fever, pain, tenderness,
warmth or swelling. Additionally, they may also
produce pus discharge. The emergence of
prophylactic antibiotics has made a huge contribution
towards extending range and complexity of surgical

procedures. The antibiotic era which began more than
5 decades ago has revolutionized the treatment of
surgical infection, particularly during post operative
period. It has led to reduction in surgical site
infections, which complicate the clinical management
of surgical patients often lengthening the hospital stay
and increasing the cost of providing medical care.
The explanations for this continuing problem with
infection is obviously multifactorial, but the wide
13
Avijeet et al.,
Int J Med Res Heath Sci. 2015;4(1):13-21
spread use of antibiotic has frequently resulted in an

unrealistic over dependence on their effectiveness in
treating disease with consequent violation of
established surgical principles and the breakdown of
isolation procedures. The concept of pre operative
antibiotic was mooted by Stranchan in 1977, where
he compared a single preoperative dose of Cefazolin
with a regime of Cefazolin given for a period of 5
days post operatively. The infection rate seen in
single dose was 3% and in multiple postoperative
dose was 5%2. Prophylactic antibiotic therapy is
clearly more effective where began preoperatively
and continued through the intra operative period, with
the aim of achieving therapeutic blood levels
throughout the operative period3. In the current study,
we want to emphasize on the risk factors that increase
the SSI and role of prophylactic antibiotic
administration to clean surgical cases in this
institution.
Objectives
1. To evaluate the need for using antibiotics in clean
surgeries
2. To determine whether prophylactic antibiotic is
itself sufficient to minimize surgical site infection
3. To study the patient response to prophylactic
antibiotic with respect to age, nutrition and general
physical status
4. To scrutinize whether presence of risk factors
increases the incidence of surgical site infection
The study was done over the duration of one year and
100 cases were selected for our study purpose.
Patients those presented in surgery OPD, a complete
clinical history was taken, and clinical examination
was done and underwent relevant investigations. This
randomized controlled trial was done at
Adichunchanagiri Institute of Medical Sciences,
Mandya. For sample size calculation because of lack
of evidence and in view of need for a large sample we
chose 50 patients in each group. After explaining the
purpose of the study and taking informed written
consent, patients were enrolled in the study. We
followed the pair wise randomization method, where
we recruited 2 participants at a time and then
randomized them to intervention and control group,
by asking them to pick chit. This was done to ensure
equal number in both the arms. Duration of the study
was for 12 months. All of the cases considered for the
Avijeet et al.,
study were clean surgical cases and underwent

surgery in an utmost sterile environment.
Methods
This study involved only clean cases of elective
surgeries. The study group involved 100 clean
(uncontaminated) surgeries done in our hospital. Only
cases with Type 1 surgical wound (Clean cases) were
included in the study. Pregnant women and very
elderly (>60 yr) were excluded. The group was split
into group A and group B of 50 cases each. Group A
comprised of patients who received a pre-operative
single dose of Cefotaxime a broad spectrum
cephalosporin. Group B received no such
prophylactic antibiotic. The groups were split into
two, taking consideration the type of surgeries, the
age of the patient, the presence or absence of risk
factors for development of SSI, and associated
medical conditions, all of which were represented in
both the groups almost equally and a comparative
clinical study was made. Ethical committee clearance
was obtained.
On admission to the hospital, a detailed proforma was
completed, which includes the diagnosis, preoperative investigations and meticulous pre-operative
patient preparation. All the patients were followed
unto ten days post operatively. Wound swabs were
sent for culture and sensitivity in infected cases and
the results were compared and studied. Patients were
admitted on our out-patient days. Patients were
categorized as clean cases, depending on their
complaints, clinical examination and diagnosis.
Patients with remote infections like respiratory tract
infections or urinary tract infections were treated on
out-patient basis and taken up for surgery after 2
weeks. Patients were informed regarding the study
and informed consent was taken. All patients were
admitted a day prior to surgery after getting
thoroughly investigated and also some special
investigations in selected cases to clinch the diagnosis
was performed. The preoperative hospital stay was
minimized to prevent the patient from getting the
access to hospital infections.
Patients with diabetes mellitus were treated
appropriately. Preoperative skin preparation was done
meticulously. Night before patients were allowed to
take a thorough scrub after which parts were prepared
with povidone iodine on table and surgical site was
isolated from the surrounding by covering operative
site by sterile gauze. A single dose of IV Cefotaxime
14
1 gm half an hour before surgery was administered.

Patients were anesthetized suitably under aseptic
precaution. Sterile gauze was removed and patients
skin was painted with povidone iodine solution and
sprit and allowed to dry. Surgical site was draped.
Movement in the operating room was restricted.
Whenever necessary, closed suction drain was
preferred. Patients were isolated in the postoperative
ward for at least 3 days.
Drains, when present, were removed on second
postoperative day. Wound was inspected on third
day for signs of inflammation and infection. If
infected, wound swab was taken and sent for culture
and sensitivity and antibiotic was started immediately
in all infected cases.
Sutures were removed on the eighth postoperative
day. Patients were followed up to tenth postoperative
day. The available results and outcomes in both
groups were studied and analyzed and compared with
the available previous study and final conclusion was
drawn.
Statistical Analysis: Descriptive statistical analysis
has been carried out in the present study. Statistical
software SPSS 15.0 and MedCalc 9.0.1 have been
used
RESULTS
Infection Rate: Group A had 50 clean surgical cases
out of which none of them were infected. In group B
out of 50 clean cases, 2 cases were infected. (Table 1)
Age of the patients: The age varied from 6 to 60
years, but the maximum number of patients belonged
to 31 to 40 yrs age group. Two patients in group B
were infected. One belonged to the 31-40 yrs age
group and other in the 41-50 yrs age group. (Table 2
& 3)
Sex Distribution: In both groups, both sexes were
distributed almost equally, male percentage 56% and
female percentage 44% in both groups. Both the
infected cases were females in the present study.
Risk Factors: Out of 100 cases taken up for the study
21 patients were identified to have risk factors for
development of surgical site infection. In the present
study 2 patients in group B with obesity were found
to have a prolonged duration of surgery contributing
to more than one risk factor for development of SSI.
Both the patients who had a prolonged duration of
surgery and obesity developed surgical site
infections. The patients with diabetes mellitus (4
patients) were corrected of their diabetic status prior

to surgery. None of them developed SSI. 10 patients
with anemia (corrected prior to surgery) and 3
patients with old age did not develop SSI. (Table 4
and Graph 1)
Culture Report: Culture was sent of both the
infected
patients.
Isolated
organism
was
staphylococcus coagulase negative, which was
hospital strain and was sensitive to cephalosporin and
ciprofloxacin and was resistant to penicillins,
ampicillin, streptomycin etc.
Duration of Surgery: All the cases in this study
were clean elective surgeries conducted by senior
consultants. The average duration of the surgery in
our study from the time of skin incision to the time of
closure was 1 hour 32 minutes. The minimum time
was 42 minutes and maximum time was 2 hours 17
minutes. One patient in our study who got infected
the duration was 1 hour 47 minutes and the other
patients who got infected the duration was 2 hours 5
minutes. (Table 5 & 6)
Time of Operations: All surgeries were conducted
between 9 am and 2 pm and the percentage of
surgical site infection in group B was 4% and zero in
group A. (Table 7)
Drains: In the present study 32 patients were
provided with closed suction drainage and none of
them got infected, contributing to the use of closed
suction drainage to prevent surgical wound infection
rather than the open drainage method. (Table 8)
Antibiotic and timing of prophylaxis: In
the
present study a third generation Cephalosporin was
administered half an hour before the incision under
aseptic precaution to all the patients in Group A and
none in Group A got infected when compared to the
Group B, where no such antibiotic was given and
there was an incidence of infection rate of 4% (2
patients were infected). When the statistical analysis
was done p-value was found to be 0.4952 which was
statistically not significant. There were no reports of
any allergy and adverse effected to the prophylactic
drug chosen. (Table 9)
Table 1: Infection rate seen in the study
Number No. of cases Rate of
of Cases infected
infection
Group A 50
0
Group B 50
2
4%
Total
100
2
2%
15
Avijeet et al.,
Table 2: Showing age distributions of patients in

present study group
Group A
Age in
No. of
No. of Patients
Years
cases
infected
0 10
2
11 20
2
21 30
6
31 40
29
41 50
10
51 60
01
Group B
No. of
No. of Patients
Age in Years
cases
infected
0 10
0
11 20
2
21 30
4
31 40
26
1
41 50
12
1
51 60
2
Table 3: Showing distribution of individual risk
factor in affected group
Risk
Group A Group B Total %
factors
Anemia
5
5
10
43.4
Diabetes
2
2
4
17.3
mellitus
Obesity
2
2
4
17.3
Prolonged
duration
0
2
2
8.6
of surgery
Old age
1
2
3
13.1
Total
10
13
23
100
12
10
8
6
4
2
0
Table 4: Duration of Surgery in the Present Study

Group
Group A
Age in Year
No. of Cases
< 1 hour
1-2 hours
< 2 hours
Group B
25
24
0
Age in Years
No. of cases
< 1 hour
1-2 hours
< 2 hours
22
26
2
Group B
Total
Graph 1: Showing distribution of individual risk

factors in affected group
% of
infection
-
No. of Cases
infected
1
1
% of
infection
3.84
50
Table 5: Showing timing operation and incidence

of surgical site infection
No. of
cases
operated
50
50
Time of
Surgery
Group A
Group B
9am-2pm
9am-2pm
No.of cases
infected
0
2
0
4
Table 6: Closed suction drain and wound infection

rate
Group
A
Group
B
Closed
suction
drainage
kept
Incidence
of wound
infection
Closed
suction
drainage
not kept
Incidence
of wound
infection
16
-Nil-
34
-Nil-
16
-Nil-
34
5.8
Table 7: Showing infection rate with and without

prophylactic antibiotics
Group A
Group B
No. of
Cases
50
50
No. of cases
infected
0
2
%
0
4%
Table 8: Infection rate in different studies

Studies
Group A
No. of cases
infected
-
1
2
3
Chowdary et al.
S.S. Gill
Agarwal
Infection rate
without risk
factors
3.00%
0.76%
1.47%
Infection
rate with
risk factors
8.95%
10.32%
38.46%
Table 9: Most common organism isolated

No. of cases
No. of cases infected
Studies
infected
with
S. aureus
Lilani et al4.
17
14
Mangram et al
124
87
Olson MM
9066
7881
%
82.3
70.1
86.9
16
Avijeet et al.,
Table 10: Types of surgeries and infection rate

Studies
Clean
contaminated
Clean
4
Lilani et al .
6
Cruse et al .
Anne etal.
3.68
%
7%
0.59
%
Present
study
2%
Contaminated
22.4%
32.45%
18%
>35%
2.6%
26%
Table 11: Comparison of wound infection rate in

relation to the duration of operation
Study
Cruise et al6.
Public health
laboratory service
report UK 1960
Lilani et al 4.
Present study
Time in Hours
0-1 Hours
1-2 Hours
1.4%
1.8%
>2 Hours
4.4%
9.9%
16.1%
20.7%
1.47%
3.84%
38.46%
50%
Table 12: Time of Operation and incidence of

wound infection
Incidence of Infection
in Clean Surgeries
7.00%
2.3%
6.8%
4%
Time
8 am to 4 pm
4 pm to Midnight
Midnight to 8 am
Present study (9am to 2pm)
Table 13: Incidence of infection with the use of

drains
Drain
placed
22.4%
30.40%
20.1%
25%
17%
Studies
Lilani et al.4.
Rao et al.5.
Cruise et al.6.
Olson MM .
Mangram AJ .
Drain
not placed
3.03%
2.5%
4.5%
3%
3.5%
Table 14: The present study is compared with that

of the similar studies conducted in the past
Study
group
Stone
et al.
Kal et
al.
Carlso
n et
al14.
Ann D
et al.
Rao et
al5.
Knight
R et al
15
.
Presen
t study
No
antibiotic
administe
red No. of
patients
% of
Infect
-ions
No. of
Prophylactic
antibiotic
administered
Patients
% of
Infect
ions
795
17.4
771
9.9
<0.05
100
12.9
65
18.5
NS
58
24.1
60
3.3
<0.01
427
0.94
414
0.2
NS
100
2.3
100
NS
511
1.21
512
0.94
NS
50
50
PValue
0.4952
(NS)
DISCUSSION
Surgical site infection though has been documented
ever since origin of surgery has not been able to be
mastered. Its incidence can be reduced by strict
asepsis, meticulous surgical techniques, prophylactic
antibiotic have drastically reduced the incidence of
SSI. The onus also lies on the patients in maintaining
wound hygiene and not to soil or meddle with the
dressing in the operated area.
Lilani et al4, analyzed 190 patients of clean and cleancontaminated surgeries and found the incidence of
SSI in patients to be 8.95%. The incidence of SSI in
clean cases was found to be 3.03% which was found
to be reduced with decrease in preoperative stay and
avoiding the use of drains.
Age Incidence: Though surgical site infection affects
all age groups, its incidence increases with age and is
seen frequently in older age groups. In our present
study the maximum numbers of cases were
represented in the age group 31-40 yrs. The age
incidence in the present study varied from 6 to 60
years, but the maximum number of patients belonged
to 31-40 yrs age group.
Though the older age group is considered a risk factor
for development of SSI, in the present study the age
group 30-50 yrs had two cases of wound infection
and 50-60 yrs were not affected. The absence of
surgical site infection in the 50-60 yrs age group was
probably due to the fact that less number of cases
where present in the 50-60 yrs group in the present
study.
Rao et al5, should in their study that SSI, incidence in
doubled in the older age group 50-70 yrs and the
incidence of severe complication following is
increased in both extremes of ages i.e., < 10 yrs and >
60 yrs.
Sex: In both groups, both sexes were distributed
equally, male percentage being 56% and female
percentage 44%. Both the infected cases were
females in the present study. There is no evidence
supporting the fact that females are at increased risk
of incidence of SSI.
Role of Risk Factors: In the present study the
patient factors when controlled prior to surgery did
not cause any infection. But 2 patients in Group B
who where obese and underwent prolonged duration
of surgery had infection. Both the cases were
infected. Four patients in the present study were
17
Avijeet et al.,
obese based on their body mass index were

represented equally in both the group, two in each
group. None of the patient in Group A developed
infection, but both the patients in Group B developed
surgical site infections. The two obese patients
represented in the Group B also had prolonged
operating time, probably because it was difficult to
perform surgery in obese patients, the duration being
one and half hours for one patient and two hours for
another patient. Both the patients with obesity and
prolonged duration of surgery developed surgical site
infection and belonged to Group B. It can be said
from the present study that presence of more than one
risk factor has a significant impact on the
development of surgical site infection and when not
provided with adequate antibiotic coverage are at
(prophylactic antibiotic dose)definite risk of
development of surgical site infection. Cruise and
Ford have demonstrated that presence of obesity as a
single independent risk factor for development of SSI
and prolonged time of surgery also increases the
incidence of surgical site infection6.
Anemia was present in 10 patients and all were
treated preoperatively for correction of anemia. The
patients were equally distributed in both the groups
with 5 each in Group A and Group B. None of them
developed surgical site infection. Hence anemia when
corrected preoperatively does not pose a risk for
development of surgical site infection. (Table 10)
Culture report: Culture of both the infected patients
was done. Isolated organism was staphylococcus
coagulase negative, which was hospital strain and
was sensitive to cephalosporin and ciprofloxacin and
was resistant to penicillins, ampicillin, streptomycin
etc. This clearly indicates that the cause for both the
patients to get infected is nosocomial infection i.e.,
hospital acquired infection. Studies show S. aureus
as most common organism isolated from SSI. (Table
11)
Socio economic status: All the patients at our rural
hospital were from low socio economic status. Hence
all the extra expenditure for the patients was brought
down.
Diabetes mellitus : Funary AP et al. in their study
showed that when blood glucose level were kept
strictly below 200 mg/dl during the preoperative
period by continuous intravenous infusion of insulin
reduced the incidence of SSI from 24% to 6.06%
which was statistically significant7.
Richard J Ehrilchman et al, has confirmed by their

studies that diabetes mellitus is associated with poor
wound healing and high infection rates. Diabetes and
the resultant hyperglycemia lead to decreased
function of leucocytes, especially decreased
cemotaxis and phagocytosis.
In the present study, 4 patients were diabetic (Group
A - 2, Group B - 2) their blood sugar level was well
controlled before and after surgery. None of the
patients got infected so it can be said that with the
proper control of diabetic status, infection rate can be
reduced.
Preoperative hospital stay: Studies by Cruise et al,
shows that infections of the wound lengthen the
patients hospital stay and vice versa. The longer the
patient stays in the hospital before surgery more
susceptible to surgical site infection. They also
showed with 1 day preoperative stay infection rate
was 1.2% with 1 week pre operative stay infection
rate was 2.1% and more than 2 weeks stay 3.4%. In
the present study, preoperative stay was shortened for
all patients and still infection rate was 4% in Group
B.
Types of Surgery Undertaken: The type of surgery
undertaken had a significant role in the development
of SSI (Table 12). All the 100 cases were elective
clean surgeries. Of the 100 case studies, 56% of the
study group patients were inguinal hernia patients
either bilateral or unilateral 24% were multinodular
goitres. 12% were epigastric herniae patients and 8%
were lipomas all of them were equally represented in
both the groups.
The Patients Skin: Studies by Cruise et al8, and
Hamilton et al9, showed that if the patients did not
shower the infection rate was 1.3%, and if the patient
showed before operation and used soap, the infection
rate was 2.1% and if hexachlorpropane was used in
the shower the infection rate was 1.3%. Shaving at
the operation site increased the infection rate of clean
wounds. In patients who were shaved with a razor
infection rate was 2.5% in patients who were not
shaved but had their hairs clipped the infection rate
was 1.7%. In patients who neither shaved nor clipped
the infection rate was 0.9%.
In the present study all the patients were allowed to
take a scrub bath the previous night and the area was
shaved by a razor under aseptic precaution and then
immediately painted with providing iodine solution
and them sterile gauge used to prevent bacterial
18
Avijeet et al.,
multiplication. The overall infection rate when both

the groups were combined together the infection rate
was 2% and in Group A where the prophylactic
antibiotic was given the incidence of infection was
nil.
Skin drapes: Studies Cruise et al, and Parkis and
Lemer and also by Rao have showed that with the
usual cotton drapes the infection rate was 1.5% in the
present study all the patients were draped with cotton
drapes and the infection rate without antibiotics was
4% and with antibiotics it was nil.
Scrubtime and Gloves: Dineen found that there is no
difference between 5 and 10 minutes of surgical
scrubs. He studied counts of bacteria on the hands of
surgeons at the end of two hour operation and showed
no variation with use of providone iodine or
hexachlorpropane. The economics in scrub time is
obvious. The water conservation factor is rarely
considered. Galle et al10,11. State that 10 minutes
scrub used 50 gallons of water. In the present study
the scrub time was 10 minutes with chlorhexidine
soap. This factor has not been associated with the
increase in the infection rate in clean surgical
wounds.
Duration of Surgery: Cases
were
taken
to
complete the surgery as early as possible and
efficiently. Studies indicate that the more the time
taken for surgery, the more the chance of infection.
Both cases of SSIs in our study had taken more than
the average time. Various studies indicate that there is
a direct relationship between the length of the
operating time and the rate of infection of clean
wounds roughly double with every hour of operation
time and is as shows in the various studies done
previously in the Table 13.
There is a direct relationship between the length of
the operating time and infection rate, the rate of
infection of clean wounds roughly double with every
hour of operating time. The explanation of high
infection rate in > 2 hrs group in the present study is
probably because of the small number of cases in that
group.
Possible explanation for the increase in the infection
rate with the duration of the operation is
1. Dosage of bacterial contamination increase with
time.
2. Wound cells are damaged by drying and by
exposure to air retractors.
3. Increase amount of suture and electro coagulation

may reduce the local resistance of the wound.
4. Longer procedures are more liable to be associated
with blood loss and shock, thereby reducing the
general resistance of the patients.
In the present study two cases in group B got infected
and their surgery took nearly hours contributing the
incidence of infection to the duration of surgery.
With antibiotic prophylaxis the incidence of infection
even in such operations is lessened. (Table 13)
Time of Operation: When the operative procedure is
done between midnight and 8 am the infection rate in
clean cases were almost double. The reason is most
likely due to loss of perfect operative techniques
because of weakness. Public health laboratory
service of United Kingdom has given a correlation of
incidence of infection with that of time of surgery.
Since all our surgeries were elective clean surgeries,
they were conducted during the morning hours and
were top of the theatre list. (Table 14)
Theatre and Surgical wards aerobiology of the
operating room12,13.
In the present study the operating room was equipped
with a circulator and air conditioner the movement
between the outdoor and the room was restricted for
all the surgeries, only two patients got infected and
their wound swab culture reports showed presence of
staphylococcus coagulase negative in both the
patients contributing to the cause of infection may be
at the operating room or post operative ward.
The source of airborne bacteria in the operating room
is the skin of the people present in the room, like
surgeons, assistants, anaesthetist and paramedical
staff. The occurrence of staphylococcus aureus and
staphylococcus coagulase negative in the air is
dependent on the presence of a disperser. A person
may be disperser if he has a skin disorder or a septic
lesion. So as far as possible such persons should not
be left into the ward or operating room.
The proportion of anaerobes in air counts from the
operating room is about 30% of the total number of
bacteria. The anaerobic species most commonly
found in the air are propionobacteria and anaerobic
cocci.
Airborne bacteria reach the wound by sedimentation
into the wound. These also settle to all other surfaces
that are exposed to the air such as instrument and the
surgeon's glove and are therefore transferred to the
wound by an indirect route as well.
19
Avijeet et al.,
The bacteriological requirement of ventilation is to

provide the operating room with clean air so that
airborne bacteria from outdoor air or from other
points of the hospital and the adjacent room do not
reach the theatre. The ventilation should also remove
the airborne contamination produced inside the
theatre.
Surgical techniques: All the surgeries were
conducted by senior staff and assisted by the training
post graduates, thorough scrubbing was done under
aseptic precautions. Group A patients received pre
operative single dose prophylaxis half an hour before
surgery in the form of 1 gm cefotaxime. In all the
cases, disposable blades and sterile cotton drapes
were used. Coagulation of the bleeders was not done
instead they were ligated to prevent excess damage to
the tissue. Meticulous surgical techniques were
practiced, as far as possible non braided
monofilament sutures were used. Skin was sutured
by linen or silk, under minimal tension, drains were
brought out through a separate opening. Wound was
cleaned with spirit and sterile dressings were applied.
Patients were shifted to the post operative ward,
where they were taken care of by the resident doctors
and senior nursing staff.
Drains: In the present study 32 patients were
provided with closed suction drainage and none of
them got infected, contributing to the use of closed
suction drainage to prevent surgical wound infection
rather than the open drainage method.
Cruise et al14,15 have shown experimentally that
bacteria can gain entry into the depth from the skin
via open drains when compared to closed suction
drain. Closed suction drainage provides an answer to
the problem, although closed suction drainage using
tube of smaller diameter appears to be effective one
would caution against the use of larger tubes,
especially in patients with poor wound healing,
because the defect caused by the larger tube may
provide a passage way for retrograde entrance of
bacteria into the wound.
Following an operation blood and plasma in small
quantities are found in the layers of the wound, they
are beneficial in the prevention of multiplication of
bacteria as this collection contains opsonin, which
prevent bacterial invasion. With time the
concentration of opsonin decreases and this collection
now acts as a nidus for infection, therefore it is
logical to use drains in a situation where one expects
Avijeet et al.,
a collection of large quantities of exudates in the

layers of the wound. However, drains are double
edged weapon as they can form a tract for entry of the
exogenous organism into the depth of the wound.
Antibiotic and timing of antibiotic prophylaxis: In
the present study the use of third generation
cephalosporin is justified as it is used as a single dose
and is having a prolonged half life up to 8 to 12 hours
which will take case of the wound in its initial crucial
phase. It was administered half an hour before the
incision under aseptic precaution to all the patients in
group A and no patients in group A got infected when
compared to the group B, where no such antibiotic
was given and there was an incidence of infection
rate of 4% (2 patients were infected). When the
statistical analysis was done p value was found to be
0.0694 (statistically insignificant). In the present
study the incidence of infection in the study Group B
was 4% compared to be nil in study Group A this
difference in the occurrence of postoperative
infection between the two study groups however was
found to be nonsignificant statistically that is p 0.4952.
CONCLUSION
This study is one of the most important facets of
general surgery. SSI is a condition that may present
with minimal morbidity but in severe cases may lead
to loss of hospital resources, emergence of resistant
bacteria, or may even lead to death of patients due to
sepsis. Local and microbial factors should be borne in
surgeons mind and appropriate steps taken to avoid
them. Meticulous surgical techniques should be
practiced and undue delay in the procedure should be
avoided to prevent postoperative wound infection. To
prevent surgical infection logical investigations of the
underlying source of infection, anticipation and
adherence to sound principles governing antibiotic
prophylaxis and treatment should be employed.
Single dose preoperative prophylactic antibiotic is a
powerful tool to fight post operative surgical site
infection when used in selected appropriate cases.
The use of prophylactic antibiotic in all clean cases is
not justified as the available data show no statistical
significance in the group with prophylactic antibiotic
and the group without prophylactic antibiotics.
Lastly, misuse of antibiotics should be avoided as it
will lead to increased cost burden on patients, and
increase the emergence of resistant microorganisms
20
and also increase side effects seen with antibiotic

usage. This aptly applies to the rural population,
which this study primarily involves.
ACKNOWLEDGEMENT
We Acknowledge Department of Microbiology,
Adichunchanagiri Institute of Medical Sciences,
Mandya, for their support.
REFERENCES
1. Lewis RT, Klein H. Risk factors and post
operative sepsis: Significance of pre-operative
lymphocytopenia. J Surg Res 1975; 26: 365-71
2. Strachan CJ, Black JP. Prophylactic use of
cefazolin against sepsis after cholecystectomy.
British Journal of Medicine 1977; 1: 1254-7
3. Page CP, Bohen JM, Fletcher JR et al.
Antimicrobial prophylaxis for surgical wounds:
Guidelines for clinical case. Arch Surg 1993;
128: 79-88
4. Lilani, Jangale N. Surgical site infection in clean
and clean-contaminated cases Indian J Med
Microbial, 2005; 23(4):249-52
5. Rao AS, Harsha M. Post operative wound
infection. J India Med Assoc 1975; 44: 90-3
6. Cruise PJE and Ford R. A five year prospective
study of 23,649 surgical wounds Archives of
surgery 1973; 107: 206
7. Funary AP, Aerr KJ, Grunkemeier GC, Starr A.
Continuous intravenous insulin infusion reduces
the incidence of deep sterna wound infection in
diabetic patients after cardiac surgical
procedures. Ann Thorac Surg 1999; 67: 352-60
8. Hamilton HW, Hamilton KR, Lone FJ.
Preoperative hair removal. The Canadian Journal
of Surgery 1997; 20: 269-75
9. Bull Lowburg, Lilly. Methods of disinfection of
hands and operative site. British Journal of
Medicine 1964: 2:531
10. Laufman H. Current status of special air handling
systems in operating rooms. Med Instrum 1973;
7:7
11. Carlson GE, Gonnlanakis C, Tsatsakis A. Preincisional single dose ceftriaxone for prophylaxis
of surgical wound infection, American Journal of
Surgery 1995; 170(4): 353-5
12. Knight R, Charbonneau P, Zeren F, Ratzer E.

Prophylactic antibiotics are not indicated in clean
general surgery cases, AM J Surg 2001;182(6):
682-6
13. Chowdary A, Jangale N. Surgical site infections
A clinical study. Ind J Surg,1997; 59(4): 110-13
14. Mangram AJ, Horan TC. The hospital infection
control practices advisory committee Guideline
for prevention of SSI, Infect control Hosp
Epidemol 1999; 20: 247-78
15. Olson MM, Lee JT. Continuous 10 year wound
infection surveillance results advantages and
unanswered questions Arch Surg 1990; 125: 79403
21
Avijeet et al.,
DOI: 10.5958/2319-5886.2015.00004.1

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 28 Sep 2014
DETECTION OF BIOFILM PRODUCTION IN BLOOD CULTURE ISOLATES OF STAPHYLOCOCCI
Gupta Puja1, Gupta Pratima2, *Mittal Garima3, Agarwal RK4, Goyal Rohit5
1
Postgraduate student, 3Assistant Professor, 4Professor & Head Department of Microbiology, HIMS, Dehradun,
Uttarakhand, India
2
Professor and Head, Department of Microbiology, AIIMS, Rishikesh, Uttarakhand, India
5
Assistant Professor, Department of Anaesthesiology, HIMS, Dehradun, Uttarakhand, India
*Corresponding author email: garimamittal80@gmail.com
ABSTRACT
Background: Biofilm producing bacteria which are inherently resistant to antibiotics and disinfectants are widely
associated with implant associated infections. Staphylococcus is the most commonly associated pathogens with
bloodstream infection. Aims: The current study was conducted to detect biofilm production in Staphylococci
isolated from blood culture specimens. Materials and Methods: 70 clinically significant staphylococcal isolates
from blood culture were screened for biofilm production by Tissue culture plate (TCP) method, Tube method
(TM) and Congo red agar (CRA) method and their antibiotic susceptibility profile was studied. Results: 59 out of
70 staphylococcal isolates were positive by TCP, out of these 21.4% staphylococci were high biofilm producers,
62.8% staphylococci were moderate biofilm producers and 15.8% were non-biofilm producers. Maximum
resistance was observed in biofilm producers to cotrimoxazole (74.5%) and erythromycin (62.7%) and none were
resistant to vancomycin and linezolid. Out of total 59 biofilm producers, 20.3 % (12) were methicillin resistant
and all these were S. aureus isolates. 19% (1) out of total 11 biofilm non-producers were methicillin resistant.
Conclusion: Biofilm production was seen to be a major virulence factor in most of the staphylococcal isolates
obtained from patients with signs and symptoms of septicaemia. S. aureus was found to be the major pathogen
and timely detection of biofilm producing phenotype should be carried out using a simple and reproducible
method, TCP which is both qualitative and quantitative.
Keywords: Biofilm, Blood culture, Staphylococci
INTRODUCTION
Staphylococcus epidermidis and S. aureus are

common causes of nosocomial infections and
infections on indwelling medical devices, which
characteristically
involve
biofilms1.
Staphylococcus is the most commonly associated
pathogens with blood stream infection (38%) 2,3.
S. epidermidis is a part of the normal bacterial
flora of the human skin and mucous membranes
and cause infection only after penetration of the
skin or mucous membranes, usually by trauma,
Garima etal.,
inoculation, or implantation of medical devices

and subsequently causing septicemia or
endocarditis .Some strains of Staphylococcus
epidermidis produce slime, a complete glycoprotein
which helps them to colonize foreign bodies like
vascular catheters or indwelling prosthesis4,5. S.
aureus biofilm-associated infections are difficult

to treat with antibiotics and devices need to be
replaced more frequently than those infected
with S. epidermidis. In addition, they represent a
22
reservoir of dissemination of S. aureus infection

to other sites in the human body6,7.
Research performed has revealed that the
production of a biofilm is a two-step process
involving an initial attachment and a subsequent
maturation phase, which are physiologically
different from each other and require phasespecific factors. A final detachment (or dispersal)
phase involves the detachment of single cells or
cell clusters by various mechanisms and is
believed to be crucial for the dissemination of the
bacteria, in the case of pathogens to new
infection sites in the human body 8.
The present study was undertaken to detect the
prevalence of biofilm producer and non producer
Staphylococci isolated from blood specimen in
our laboratory by three different methods, viz.
tissue culture plate (TCP) method, tube method
(TM) and Congo red agar (CRA) method and to
compare the above mentioned three different
methods for biofilm detection and to study the
profile of antibiotic drug resistance.
After obtaining Institutional ethical clearance

and taking informed written consent, a total of
70 consecutive Staphylococcal isolates obtained
from blood cultures of patients with fever (>38
degree Centigrade) chills, tachycardia and
attending a tertiary care hospital of Uttarakhand,
over a period of twelve months was further
analysed. Bacteremia was defined as per
CDC/NHSN Surveillance Definitions for
Specific Types of Infections, except that even a
single blood culture growing CONS was not
considered as a contaminant 9. All clinically
significant blood cultures positive for CoNS
nosocomial bacteremia were isolated and
identified as Staphylococcal species by Gram
staining, Catalase and Coagulase tests. Patients
on antibiotics were excluded.
Reference strains of Staphylococcus epidermidis
ATCC 35984 (formerly RP62A) (biofilm
producer) and HAM 892 (non biofilm producer)
as positive and negative controls respectively

were included in this study.
Detection of biofilm production of 70
Staphylococci species was done by following
methods: Reference strains of Staphylococcus
epidermidis ATCC 35984 (formerly RP62A)
(biofilm producer) and HAM 892 (non biofilm
producer) as positive and negative controls were
included in this study.
1. Tissue culture plate method (TCP)
The TCP method described by Christensen et al

10
is most widely used and is considered as a
standard test for detection of biofilm formation.
Isolates were inoculated in Trypticase soya broth
(10 ml with 1% glucose) from overnight culture
on nutrient agar and incubated at 37 C for 24
hours. This was further diluted 1 in 100 with
fresh medium. 96 wells flat bottomed tissue
culture plates were filled with 0.2 ml of diluted
cultures and only sterile broth served as control
to check sterility. Similarly control organisms
were also diluted, incubated and put in tissue
culture plates. The culture plates were then
incubated at 37C for 24 hours. After incubation,
gentle tapping of the plates without inverting was
done. The wells were washed with 0.2ml of
phosphate buffer saline (pH 7.2) four times to
remove free floating bacteria. Then adherent
biofilm was fixed with 2% sodium acetate and
stained with 0.1% crystal violet. Optical densities
(OD) of stained adherent biofilm were obtained
with
a
micro
ELISA
auto
reader
(Mindraymorepan MR 96 A) at wavelength
570nm. An experiment was performed in
triplicate and it was repeated thrice.
Table 1: Classification of Biofilm formation of
Staphylococcal isolates based on OD values
obtained from TCP method (n=70)
OD Value of TCP
Adherence
0.24
0.12-0.24
0.12
Strong
Moderate
None
Biofilm Formation
High
Moderate
None
23
Garima etal.,
2.Congo Red Agar Method (CRA)

Freeman et al 11 described this alternative method
of biofilm screening. The medium composed of
brain heart infusion broth (37 gm/l), sucrose (5
gm/l), agar number 1 (10 gm/l) and Congo red
dye (0.8 gm/l). Congo red stain was prepared as a
concentrated aqueous solution and autoclaved at
121C for 15 minutes. Then it was added to
autoclaved brain heart infusion agar with sucrose
when the agar was cooled to 55C. Plates were
inoculated with test organism and incubated at
37C for 24 to 48 hours aerobically. Positive
(high) result was indicated by black colonies
with a dry crystalline consistency. A darkening
of the colonies with the absence of a dry
crystalline colonial morphology indicated a
moderate result and red/ pink colonies showed
non biofilm producing isolates
3. Tube Method 12
Trypticase soya broth (10 ml with 1% glucose)
was inoculated with test organism of overnight
culture from nutrient agar. The broths were
incubated at 37 C for 24 hours. The cultures
decanted and tubes were washed with phosphate
buffer saline (pH 7.3). The tubes were then dried
and stained with 0.1% crystal violet. Excess stain
was washed with deionized water. Tubes were
dried in inverted position. In positive biofilm
formation, a visible stained film was seen lining
the wall and bottom of the tube. An experiment
was done in triplicate for 3 times and read as
absent, moderate and strong1.
Statistical analysis: Data was analysed by using
statistical software (excel and epi-info). The
comparative statistical analysis for all methods
by using 2X2 table given by Greenhalgh. Data

obtained from standard TCP method was
considered as gold standard for this study and
was thus compared with other two methods.
Parameters like sensitivity, specificity, positive
predictive value, negative predictive value and
accuracy were evaluated. Antibiotic sensitivity
testing was conducted of all isolates by Kirby
Bauer disc diffusion method
RESULTS
A total of 70 clinically significant isolates of
staphylococci were obtained. Mean age of the
patients was 47.8 years. Maximum number of
patients were in the age group of 51-60 years (22.8%)
followed by 41-50 years (17.1%). Staphylococci were
almost equally isolated from both males and females
in a ratio of 1.1:1 and maximum number of
staphylococci were obtained from IPD patients
(95.7%). 55.7% of them were from Medicine and
allied ward, whereas 7 patients (10%) were from
Critical care units. 32.8% patients were suffering
from kidney disease followed by fever under
evaluation and respiratory diseases (15.8% each).
Table 2. shows the comparative detection rates by
different methods.
Considering TCP as gold standard, data from CRA
and TM were compared. True positives (i.e. biofilm
producers) were 59 out of 70 staphylococcal isolates,
which were positive by TCP. As per classification of
biofilm formation by OD values obtained by TCP
method, 21.4% staphylococci were high biofilm
producers, 62.8% staphylococci were moderate
biofilm producers and 15.4% were non-biofilm
producers. Similar pattern was seen in S. aureus and
CONS isolates.
Table 2: Comparison of Biofilm detection using Congo red Agar (CRA), Tissue Culture Plate (TCP) and
Tube method (TM)
S.aureus (n=52)
CONS (n=18)
TCP(Taken as gold standard for comparison)

Positive
44(84.6%)
15(83.3%)
Negative
8(15.4%)
3(16.7%)
CRA
Positive
42(80.7%)
8(44.5%)
Negative
10(19.2%)
10(55.5%)
TM
Positive
35(67.3%)
11(61.1%)
Negative
17(32.6%)
7(38.8%)
Sensitivity
Specificity
PPV
NPV
Accuracy
72.8%
36.3%
86%
20%
67.2%
72.8%
72.7%
93.5%
33.4%
72.9%
PPV-positive predictive value, NPV-Negative predictive value

24
Garima etal.,
Table 3: Comparative analysis of biofilm formation by TCP, CRA and TM in different regions of India
Current study
Mathur et al1
Bose et al 2
Khan et 13
Sensitivity
Specificity
PPV
NPV
CRA
72.8%
36.3%
86%
20%
TM
72.8%
72.7%
93.5%
33.4%
CRA
6.8%
90.2%
66.6%
25.3%
TM
73.6%
92.6%
93.4%
66.6%
CRA
8.25%
96.34%
72.72%
47.02%
TM
76.27%
97.56%
97.36%
77.66%
Table 4: Association of indwelling devices with Biofilm production

RISK FACTOR
Foleys %
Ryles %
CVC/ IV %
catheter
tube
cannula
CRA
89.13%
67.65%
91.73%
69.83%
Biofilm producers
27
45.8%
18
30.5%
59
100%
Other
indwelling
devices
06
(N=59)
Biofilm
nonproducers
(N=11)
04
36.7%
03
27.3%
08
72.7%
00
TOTAL
31
21
Out of total 59 biofilm producers, 20.3 % (12) were

methicillin resistant(MR) and all these were S.
aureusisolates. Out of total 11 biofilm non-producers
only 19% (1) were MR. Out of 13 MRSA 92% (12)
were Biofilm producers.
In biofilm producing strains of staphylococci all
patients had Central venous catheter (CVC)/IV
cannula, 45.8% patients had Foleys catheter, 30.5%
had Ryles tube and 10.2% had other indwelling
devices as shown in table 4. Fifty five patients stayed
<10 days and 85.5% of their blood culture isolates
showed biofilm production whereas only 3 patients
stayed for more than 30 days and all three blood
culture isolates showed biofilm production as shown
in table 5.All the data was retrieved from patient case
records.
Table 5: Association of Duration of hospital stay
with biofilm production
Duration
Number
Biofilm
Percentage
of hospital of
producers
stay (days) patients
55
47
< 10
85.5%
8
6
11-20
75%
4
3
21-30
75%
3
3
>30
100%
Total
70
59
Antibiotic susceptibility of biofilm producers and non
producers as per figure 1shows that Vancomycin and
67
TM
95.78%
99.40%
99.11%
95.29%
0%
10.2%
06
linezolid resistance was not detected in any of the

isolates. Maximum resistance was observed in
biofilm producers to cotrimoxazole (74.5%) and
erythromycin (62.7%). Due to few numbers it was not
possible to state whether this difference was
statistically significant as shown in fig 1.
Fig 1: Resistance pattern in Staphylococcal

isolates
Maximum number of patients i.e. 46 (65.7%)
recovered, whereas 13 (18.6%) expired. No
difference was noted in the outcome of patients
infected with or without biofilm producing
staphylococci.
DISCUSSION
Biofilm formation is an important characteristic of all
staphylococcal species, associated with the infection
25
Garima etal.,
of biomedical devices 13. National institute of Health

report that more than 60% of infections in health care
are caused by biofilms2. A total of 70 clinically
relevant staphylococcal isolates were obtained from
blood cultures during the study period. 52 (74%)
were S. aureus and 18 (26%) were CONS. Although
the formation of biofilm on indwelling medical
devices is generally associated with CONS, S.aureus
strains are also capable of production of biofilm2. In
our study maximum blood culture isolates were S.
aureus. Biofilm production is considered to be a
marker of clinically relevant infection caused by S.
aureus and isolation of S. aureus from blood culture
represents true infection and isolation of CONS as a
contaminant14,15, however recent studies recommend
that even single isolation of CONS from patients with
clinical signs of sepsis16. In the current study similar
isolation rates of biofilm production was seen in S.
aureus and CONS.
Although usefulness of species identification of
CONS in clinical laboratory has not met with
universal agreement, most microbiologists and
clinicians recommend the need to identify them. It is
generally recommended now to report isolates as
CONS if speciation is not being done 9, like in our
case.
Biofilm production by staphylococci have been
evaluated mainly by TCP, the gold standard method,
and CRA & TM, which are simple and inexpensive
tests, but results have been found to be variable in
different studies conducted so far as shown in Table
2.
In our study we had a higher biofilm detection rate by
modified TCP (84.2%) as compared to other workers
using traditional TCP method1,2,13. Modified TCP has
been taken as a gold standard as it has been
recommended as superior to TCP by several
researchers 2,13,17-19. Furthermore higher detection rate
of biofilm in our study can be attributed to the fact
that our study isolates were obtained from clinically
relevant cases of bacteremia9, a majority who had
pre-existing indwelling devices like CVC,
Intravenous cannula, Foleys catheter, Ryles tube
and Endotracheal tube which predispose to
developing bacteremia by biofilm producing strains
of S. aureus and CONS. Similarly high detection
rates of biofilm formation was reported by Khan F et
al 13 (64.89%) as compared to other workers like
Mathur et al 1 (53.8%)and Bose et al 2 (54.19%) who
had studied biofilm production in isolates obtained

from other clinical specimens too including blood.
We found better specificity, PPV, NPV with TM as
compared to CRA especially in the biofilm producing
strains, same has been observed in TCP and TM by
various researchers 1,2,13,20.
Staphylococcal infections with biofilm production are
extremely difficult to eradicate and antibiotic
treatment may not give desired clinical benefits .In
these cases invasive treatments like removal of
infected device and surgical removal of infected
tissue may be necessitated. Hence timely detection of
biofilm producing phenotype should be carried out
using TCP method in patients with hospital acquired
infections and also in Methicillin resistant
staphylococcal infections 21 .Various studies
recommend the use of a combination of detection
methods especially for blood culture isolates of
staphylococci. Grinholc and co-workers 22 showed
that among 48 icagenes positive S. aureusisolates
from bacteremia, 50% and 46% produced biofilm on
CRA and TCP, respectively. Lorio et al 19 found a
similar rate of positivity for both CRA (67.5%) and
TCP (62.5%) in 40 S. aureus isolates from blood
cultures that were positive for the ica gene and this
figure increased to 85% (P =0.022 in relation to TCP
and P =0.066 in relation to CRA) when the results of
both phenotypic methods were combined, making the
correlation with the presence of the ica gene closer.
Moreover, since negative isolates for the ica gene
were also negative for both phenotypic methods
analyzed, they suggest that a combination of methods
would more accurately predict the presence of this
gene in S. aureus isolates from blood cultures.
Among the studies that have employed the two
phenotypic methods one detected 100% positivity by
both methods in 44 ica genes positive S. epidermidis
isolates from blood23and Lorio et al 19found detection
rates of 66.7% for TCP and 41.7% for CRA
increasing to 75% when they used a combination of
both methods for ica gene positive S.epidermidis
isolates.
Our results were similar to those described by these
authors, out of 70 staphylococcal isolates 84.2% were
positive by TCP and 74.4% by CRA and 94.3%
(66/70) were positive by CRA and TCP thus showing
that these isolates were clinically relevant.
Bacterial colonization of CVCs occurs rapidly and
biofilm can be found on the CVCs of all patients
26
Garima etal.,
whose catheter had been in place for less than 3 days

and bacteria can adhere to medical devices as early as
within 24 hours. Catheters in place for 10 days tend
to have extensive biofilm formation on the external
surface of the catheters. For long-term catheters (up
to 30 days), biofilms are more extensive on the
internal lumen 24,25.
In our study the antibiotic resistance pattern of
biofilm producing staphylococci was higher than in
biofilm non producers and the same has been reported
by other workers too2,26,27. It was noted that MR
strains of staphylococci (92%) were more prone to
biofilm formation as compared to the methicillin
sensitive strains of staphylococci (82.5%). Similarly
biofilm producers were more MR (20.3%) when
compared to biofilm non producers (9%). Methicillin
susceptibility of S. aureus has been shown to
influence the biofilm formation [9].
It was seen that out of follow up available of 49
patients; 20.4% of patients infected with biofilm
producing staphylococcal strains had expired and
30% of patients infected with non-biofilm producing
strains had expired. No statistical difference could be
observed in these groups. Other coexisting morbid
conditions of the patients may have been responsible
for the patients outcome.
Limitation of study : We have only carried out
phenotypic tests for detecting biofilm production and
detection of ica gene was not done furthermore
speciation of CoNS would have provided a better
picture of clinical relevance and effectiveness of the
methods carried out for detection of biofilm
production.
CONCLUSION
Biofilm production was seen to in most of the
staphylococcal isolates obtained from patients with
signs and symptoms of septicaemia. S. aureus was
found to be the major pathogen. Biofilm production
was detected equally in both S. aureus and CONS.
Using TCP 84.2% of Staphyloccocci from blood
cultures were detected with biofilm production Since
these infections are extremely difficult to eradicate
timely detection of biofilm producing phenotype
should be carried out using a simple and reproducible
method like TCP .
It is recommended that more reliable methods for
detecting biofilm producers should be developed and
preventive strategies be worked out to prevent their
Garima etal.,
production since this will reduce infection rates and

their associated morbidity.
Acknowledgement: Will like to acknowledge our
technical staff for helping us in laboratory work.
Conflict of Interest: None
REFERENCES
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Fatma T, Rattan A. Detection of biofilm
formation among the clinical isolates of
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2. Bose S, Khodke M, Basak S, Mallick Sk.
Detection of biofilm producing Staphylococci:
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3. Del Rio A1, Cervera C, Moreno A, Moreillon
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5. Arber N, et al. Pacemaker endocarditis.
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6. Jones SM, Morgan M, Humphrey TJ,
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7. Lorio NPL, Lopes APCN, Schuenck RP,
Barcellos AG, Olendzki AN, Lopez GL, Santos
KRN. A combination of methods to evaluate
biofilm production may help to determine the
clinical relevance of Staphylococcus in blood
cultures. MicribiolImmunol. 2011; 55: 28- 33.
8. Michael Otto.Staphylococcal Biofilms.Curr Top
MicrobiolImmunol. 2008; 322: 207228.
9. Favre B, Hugonnet S, Correa L, Sax H, Rohner
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Barrett FF,
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Adherence of Coagulase-Negative Staphylococci
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Clinical
Microbiology. 1985; 22(6): 996-1006.
Freeman DJ, Falkiner FR, Keana CT. New
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Christensen GD, Simpson WA, Bisno AL,
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Khan F, Shukla I, Rizvi M, Mansoor T, Sharma
SC. Detection of Biofilm Formation in
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Karatan E, Watnick P. Signals, regulatory
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bacterial biofilms. MicrobiolMolBiol Rev. 2009;
73: 310-347.
Elder M J, Stapleton F, Evans E and Dart
JKG.Biofilm related infections in ophthalmology.
Eye. 1995; 9:102109.
Anaissie E, Samonis G, Kontoyiannis D,
Costerton J, Sabharwal U, Bodey G et al.Role of
catheter
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catheter-related
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1995; 14: 135137.
Ludwicka A, Switalski LM, Lundin A, Pulverer
G, Wadstrom T. Bioluminescent assays for
measurement of bacterial attachment to
polyethylene. J Microbiol Methods.1985; 4:169
77.
Kim L. Riddle of biofilm resistance.
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45(4): 999-1007.
Lorio NPL, Lopes APCN, Schuenck RP,
Barcellos AG, Olendzki AN, Lopez GL et al. A
combination of methods to evaluate biofilm
production may help to determine the clinical
relevance of Staphylococcus in blood cultures.
MicribiolImmunol. 2011; 55: 28- 33.
20. Knobloch JKM, Horstkotte MA, Rohde H, Mack

D. Evaluation of different detection methods of
biofilm formation in Staphylococcus aureus. Med
MicrobiolImmunol. 2002; 191: 101-106.
21. Rao PK, Rao S. Inducible clindamycin resistance
in Staphylococcus aureus Isolated from Clinical
Sample. Journal of Laboratory Physicians. 2011;
3:25-7.
22. Grinholc M, Wegrzyn G, Kurlenda J. Evaluation
of biofilm production and prevalence of the ica D
gene in methicillin-resistant and methicillinsusceptible Staphylococcus aureusstrains isolated
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carriers. FEMS Immunol Med Microbiol.2007;
50:3759.
23. Ziebuhr W, Heilmann C, Gotz F, Meyer P,
Wilms K, Straube E et al. Detection of the
intercellular adhesion gene cluster (ica) and
phase variation in Staphylococcus epidermidis
blood culture strains and mucosal isolates. Infect
Immun.1997; 65: 890896.
24. Donlan RM, Murga R, Bell M, Toscano CM,
Carr JH, Novicki TJ et al. Protocol for detection
of biofilms on needleless connectors attached to
central venous catheters. Journal of clinical
microbiology. 2001; 750753.
25. Raad II. Management of intravascular catheterrelated infections. J AntimicrobChemoth. 2000;
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26. DonlanRM, Costerton W. Biofilms: Survival
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27. Souli M, Giamarellou H. Effects of slime
produced by clinical isolates of coagulase
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Chemotherapy. 1998; 42(4): 939-941.
28
Garima etal.,
DOI: 10.5958/2319-5886.2015.00005.3

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
STUDY ON ASSOCIATION OF SERUM HOMOCYSTEINE WITH CORONARY HEART DISEASE IN

RURAL POPULATION
*Mohanraj P1, Poongodi A2, Anbazhagan G3, Kalaivalli S4
1
Assistant Professor, 3Professor, 4Professor Department of Medicine, Meenakshi Medical College Hospital and
Research Institute, Kanchipuram, Tamil Nadu
2
Assistant Professor, Department of Medicine, Chengalpattu Medical College, Chengalpattu
*Corresponding author email: mohandr76@yahoo.co.in
ABSTRACT
Background: CAD is the major cause of death. Many factors are responsible for causing CAD, but in 5 to 10
percent of CAD patients have none of the known risk factors. Risk factor modification is an integral part of the
management of patients who have or are at risk for cardiovascular disease. Clinicians who care for patients with
cardiovascular disease should be aware of new risk factors. Significant associations exist between established and
new risk factors, and better understanding of new risk factors may shed light on the pathogenetic mechanisms of
established risk factors. Objectives: To study the association of homocysteine in patients with coronary heart
disease. Methods: This study was conducted in 50 patients of CAD and 50 people as a control group. All patients
underwent a standard clinical examination and a blood draw for a lipid profile and total fasting serum
homocysteine assay. Pearson chi-square test was used to assess the statistical significance. P value of less than
0.01 indicates highly significant and value of less than 0.05 indicates significant. Results: The cutoff value of
homocysteine used in this study was 17micro mol/L. In case group 43 patients (86%) were showed raised
homocysteine, and in control group 12 patients (24%) were showed raised homocysteine. And here the p value is
<0.001 with the relative risk of 19.45. It shows raised homocysteine is statistically highly significant.
Conclusions: The association of hyperhomocysteinemia with CHD was significant. Homocysteine values were
higher in smokers and hypertensives.
Keywords: Coronary heart disease, Homocysteine,
INTRODUCTION
Coronary artery disease (CAD) is the major cause of
death in the world today.1 Many factors are
responsible for causing CAD, but some patients have
none of the known major risk factors. Some of the
risk factors for CAD such as age, sex and family
background cannot be altered, but others such as
arterial hypertension, diabetes, smoking and
hyperlipidemia could be controlled. It is notable that
5 to 10 percent of CAD patients have none of the
known risk factors. 2 Common symptoms of CAD are
angina, dyspneoa, palpitation and profuse sweating.

Regarding physical examination in CAD patients
with diabetes and/or peripheral arterial disease,
clinicians should search for evidence of
atherosclerotic disease at other sites, such as an
abdominal aortic aneurysm, carotid arterial bruits,
and diminished arterial pulses in the lower
extremities. Risk factor modification is an integral
part of the management of patients who have or are at
risk for cardiovascular disease. In addition to
29
Mohanraj et al.,
established cardiovascular risk factors, clinical

research has identified more than 100 other
conditions that may be associated with an increased
risk for cardiovascular disease. Clinicians who care
for patients with cardiovascular disease should be
aware of new risk factors. Almost 25% of patients
with premature cardiovascular disease do not have
any established risk factors. 3As a result of reductions
in morbidity and mortality attributable to
hypertension, smoking, and dyslipidemia4,5, the
relative contribution of new risk factors to the total
burden of cardiovascular disease is likely to increase.
Significant associations exist between established and
new risk factors, and better understanding of new risk
factors may shed light on the pathogenetic
mechanisms of established risk factors. On the basis
of a growing body of evidence, the 1996 Bethesda
Conference
acknowledged
left
ventricular
hypertrophy, hyperhomocysteinemia, lipoprotein (a)
excess, hypertriglyceridemia, hyperfibrinogenemia
(among other thrombogenic factors), and oxidative
stress as possible risk factors for CAD. The serum
concentration of the amino acid homocysteine is
positively associated with the risk of ischemic heart
disease, deep vein thrombosis and pulmonary
embolism, and stroke.6 There is uncertainty over
whether these associations are causal.7 Resolving the
question of causality is important because serum
homocysteine can be lowered by the B vitamin folic
acid,8 raising the prospect of a simple and safe means
of prevention. In order to consider homocysteine a
causative rather than coincidental factor, plausible
mechanisms for homocysteine action must be tested.
The most common and plausible mechanism are
oxidative damage and vascular smooth muscle cell
proliferation. Much of the endothelial dysfunction
attributed to homocysteine is thought to occur
primarily from oxidative stress.9 This is also one of
the proposed mechanisms for DNA damage and
carcinogenesis. In numerous in vitro studies,
homocysteine was able to trigger proliferation of
vascular smooth muscle cells10an effect which is
attenuated by folic acid. By increasing vascular
smooth muscle proliferation, the arterial lumen space
will be narrower, typically considered to be
deleterious for coronary artery disease. The normal
reference range for plasma total homocysteine is
usually defined as the 2.5th to 97.5th percentile
Mohanraj et al.,
interval for presumably healthy people. The lower

limit is typically 5 mol/L, but the upper limit varies
considerably
among
clinical
laboratories.
Furthermore, in different populations, the upper limit
may vary between 10 and 20 mol/L, depending on
age (levels increase with age), sex (levels are higher
in men than in women), ethnic group, and dietary
intake of folate. Rather than defining a level of
homocysteine as either normal or abnormal, it may be
more useful to consider homocysteine, like
cholesterol and C-reactive protein, as a graded risk
factor for cardiovascular disease.11
Aim of the study
1. To study the association of homocysteine in
patients with coronary heart disease.
2. To study the role of raised homocysteine levels as
risk factors when compared to other known risk
factors in coronary heart disease.
After getting Ethical committee clearance, this study
was conducted in 50 patients with coronary heart
disease above 16 years of age, of both sex and also
included 50 age and sex matched people as a control
group. Informed consent was obtained from all the
participants. This study was conducted in the
department of medicine, Meenakshi medical college
hospital and research institution, Kanchipuram during
July 2013 to January 2014.
Study design: Case control study.
Exclusion criteria : Patients with Renal impairment,
Pregnancy, Hypothyroidism, Nephrotic syndrome,
cancer and Patients on Drugs like Sodium Valproate,
Carbamazepine,
Cyclosporin,
Methotrexate,
Theophylline, Levodopa, Metformin, Estrogen
(OCP), INH, Fibrates and Niacin were excluded.
All patients (cases and controls) underwent a standard
clinical examination by nurses and physicians, which
included anthropometry (height, weight, waist-hip
ratio), blood pressure, and a blood drawn after six
weeks of acute coronary event, for Basic Biochemical
Analyses and Fasting total cholesterol, HDL-C, LDLC, and triglycerides and tHcy. Patients also received
dietary and smoking counselling when necessary.
Individuals also completed a questionnaire that
incorporated numerous risk related issues, including a
history of hypertension, family history, cholesterol
medication use, and diabetes (ever treated or
30
diagnosed by a physician), and, in women,

menopausal status and use of hormones. Patients
were classified as either never- or ever-smokers.
Hypertension was defined as a blood pressure above
140/90 mm Hg, a history of hypertension, or the use
of antihypertensive medications. Diabetes mellitus
was diagnosed if the patient was using insulin or an
oral hypoglycemic agent or reported a history of
diabetes mellitus.
tHcy Assay : Total fasting serum tHcy was measured
on samples drawn on follow up visit. Serum tHcy has
been shown to be '10% to 30% higher than plasma
tHcy. A tHcy cut off point of 17 micro mol/L was
used for all initial interaction analyses, which is the
90th percentile of tHcy values obtained in the lab.
The plasma homocysteine levels were calculated by
using the (Bio-Rad kit) homocysteine microplate
enzyme immunoassay.12 This is intended for the
quantitative determination of L-homocysteine in
human serum or plasma.
Protocol: Venous blood samples were obtained from
a study population by trained medical or senior
nursing staff from antecubital vein. Blood was
transferred into containers containing EDTA for
homocysteine and lipoprotein assay. Within 15 mins
of collection, platelet poor plasma was obtained by
centrifugation at room temperature for 15 mins at
3000 rpm and then transferred to a - 80C freezer.
Blind analysis of all samples was performed in
batches at completion of sample collection.
Statistical analysis: The comparison of risk factors
in case and control group was done by the t- test for
equality of means. All values were calculated as
mean standard deviation. Pearson chi-square test
was used to assess the statistical significance. P value
of less than 0.01 indicates highly significant and
value of less than 0.05 indicates significant. The odds
ratio is used to estimate the relative risk.
RESULTS
The case group comprised patients with age ranging
from 34 to 85, and a mean age of 55.96. In the control
group age ranged from 34 to 70, with a mean age of
51.50. A male preponderance of 70% was seen in
the case group, but was not of statistical significance.
The cutoff value of homocysteine used in this study
was 17micro mol/L. In case group 43 patients (86%)
were showed raised homocysteine, and in control
group 12 patients (24%) were showed raised

homocysteine. Pearson chi-square test was used to
assess the statistical significance. And here the p
value is <0.001 with the relative risk of 19.45. It
shows raised homocysteine is statistically highly
significant. LDL-C value of more than 130 mg/dl was
observed in 18 patients (36%) when compared to 1
(2%) in the control group. And value of 100 to 129
mg/dl was observed in 23(46%) when compared to
31(62%) in control group. Value of 90 to 99 mg/dl
was observed in 3(6%) when compared to 12(24%) in
control group. Value of less than 90 mg/dl was
observed in 6(12%) when compared to 6(12%) in
control group. Mean value of LDL-C is 122.64 in
case group and 106.48 in control group. T-test for
equality means shows p-value of <0.001 and is highly
significant. HDL-C value of less than 40 mg/dl was
observed in 28 patients (56%) in case group when
compared to 35 (70%) in the control group. And
value of more than 40 mg/dl was observed in
22(44%) when compared to 15(30%) in control
group. Mean value of HDL-C is 39.10 in case group
and 38.88 in control group. T-test for equality means
shows p-value of 0.842 and is not significant. The
mean value of total cholesterol in case group is
160.34 mg/dl and 171.98 in control group. And the
association in between these two is not statistically
significant. The mean value of triglyceride in case
group is 115.52 mg/dl and 106.50 in control group.
And the association in between these two is not
significant. Family history of premature CHD was
present in 16 patients in case group and 5 in control
group. Pearson chi-square test shows p-value of 0.007
and the association is statistically significant.
Sedentary lifestyle was present in 25 patients in case
group and 12 in control group. P-value is 0.007 and
the association is statistically significant. In case
group 19 patients (38%) were alcoholics when
compared to 12 (24%) in the control group. p-value is
0.130 and the association is not statistically
significant. Diabetes was present in 22 (44%) patient
in case group and 8(16%) in control group. p-value is
0.002 and the association is statistically significant. In
case group 22 patients (44%) were smokers when
compared to 13 (26%) in the control group. p-value is
0.059 and the association is not statistically
significant. Hypertension was present in 26 (52%)
patient in case group and 5(10%) in control group. p31
Mohanraj et al.,
value is < 0.001 and the association is highly

significant. In case group 52% of patients were
hypertensive and in that hypertension population 86%
have raised homocysteine and the association of
raised homocysteine and hypertension is statistically
significant with P-value was 0.023. In case group
44% of patients were smokers and in that smoker
population 86% have raised homocysteine. P-value
was 0.017 and the association of raised homocysteine
and smoking is statistically significant.
Age, lifestyle, Family history of premature CHD, and
parameters like BMI and waist to hip ratio were not
statistically associated with levels of homocysteine.
100%
95%
80%
80%
60%
40%
20%
63%
50%
50%
37%
62%
57%
43%
38%
Sensitivity = 43/50 = 0.86 = 86%, Specificity = 38/50 =

0.76 = 76%, Odds Ratio = (43x38)/(7x12) = 19.45
53%
Case
20%
0%
Control
Fig: 1 Comparison of LDL-C between Case and

Control Group
100%
76%
80%
60%
40%
43%
57%
24%
20%
Case
Control
0%
No
Yes
Fig: 2 Comparison of Family History of

premature CHD between Case and Control Group
73%
80%
60%
40%
60%
40%
27%
Case
Control
20%
0%
No
Table: 1Comparison of Homocysteine between

Case and Control Group
Group
Case Control Total
HCY Count
7
35
45
<17
% with In HCY
15.6
84.4
100
% with In GROU 14
76
45
HCY Count
43
12
55
>17
% with In HCY
78.2
21.8
100
% with In GROU 86
24
55
Total Count
50
50
100
% with In HCY
50
50
100
% with In GROU 100
100
100
P value
Value
df
Peasrson chi square
38.82 1
.000
N of valid cases
100
Yes
Table 2: Homocysteine in smokers and non-smokers
Smoking
Case Control Total
HCY Count
6
1
7
<17
% with In HCY
85.7
14.3
100
% with In GROU 21.4
4.5
14
HCY Count
22
21
43
>17
% with In HCY
51.2
48.8
100
% with In GROU 78.6
95.5
86.0
Total Count
28
22
50
% with In HCY
56.0
44
100
% with In GROU 100
100
100
P value
Value
df
Peasrson chi square
11.79 3
0.017
N of valid cases
50
Table 3: Homocysteine in hypertensive and nonhypertensives
Hypertension
Case Control Total
HCY Count
5
2
7
<17
% with In HCY
71.4
28.6
100
% with In GROU 20.8
7.7
14
HCY Count
19
24
43
>17
% with In HCY
44.2
55.8
100
% with In GROU 79.2
92.3
86
Total Count
24
26
50
% with In HCY
48
52
100
% with In GROU 100
100
100
P value
Value
df
Peasrson chi square
11.79 3
0.017
N of valid cases
50
Fig: 3 Comparison of presence of Diabetes

between Case and Control Group
32
Mohanraj et al.,
DISCUSSION
The major risk factors, along with elevated LDL
cholesterol, are power- fully associated with the
development of CHD. Although several of them are
directly atherogenic, their power to predict CHD is
still limited. Most of the excess risk for CHD can be
explained by the major risk factors; this is shown by
the very low risk in persons who have optimal levels
of all of these risk factors. Nonetheless, when major
risk factors are present, they account for only about
half of the variability in CHD risk; other factors, yet
to be identified, seemingly influence how much the
major risk factors affect absolute CHD risk. One of
that is hyperhomocysteinemia, which is studied here.
Consequently, there has been intensive research to
identify new risk factors that will enhance predictive
power in individuals. These newer factors can be
called emerging risk factors. One of that is
hyperhomocysteinemia, which is studied here.
Elevations of serum homocysteine are positively
correlated with risk for CHD.13-16 The mechanism of
the link between homocysteine and CHD is not well
understood, although persons with inherited forms of
severe homocysteinemia have premature vascular
injury and atherosclerosis. In any case, the strength of
association between homocysteine and CHD is not as
great as that for the major risk factors. Moreover, an
elevation of homocysteine is not as common as that
of the major risk factor. For these reasons, ATP III
does not list elevated homocysteine as a major risk
factor to modify Low Density Lipoprotein-cholesterol
goals.
Even though elevated homocyteine is not classified as
a major risk factor, some investigators hold that the
association with CHD is strong enough to make it a
direct target of therapy. The available intervention for
raised homocysteine was dietary folic acid, perhaps
combined with other B vitamins (B6and B12).
Several clinical trials are underway to test whether
homocysteine lowering will reduce CHD risk 17. ATP
III does not recommend routine measurement of
homocysteine as part of risk assessment to modify
LDL-cholesterol goals for primary prevention. This
lack of recommendation is based on uncertainty about
the strength of the relation between homocysteine and
CHD, a lack of clinical trials showing that
supplemental B vitamins will reduce risk for CHD.
Measurement of homocysteine nonetheless remains

an option in selected cases, e.g., with a strong family
history of premature CHD in an otherwise low-risk
patient. If elevated, the clinical approach favoured by
ATP III is to determine vitamin B12 level and, if this
is normal, to ensure adequate folate intake rather than
modifying the LDL cholesterol goal.
In in-vitro models, elevated homocysteine levels
induced a hyper-coagulable state by reducing
thrombomodulin level, protein C activity,18 and
heparin sulphate level,19 as well as inhibiting the
binding of tissue plasminogen activators to
endothelial cells. 20 In addition to that, they activated
factors V and XII, 21 increased tissue factor
expression on endothelial cells, 22 and induced platelet
adhesiveness and aggregation. In clinical studies,
hyper homocysteinemia was associated with
activation of coagulation systems in patients with
premature atherosclerotic arterial disease and with
thrombin generation in patients with acute coronary
syndrome.
Hyperhomocysteinemia was also found to be an
independent risk factor for venous thromboembolism.
Furthermore, homocysteine induces expression and
release of the inflammatory cytokines monocyte
chemotactic protein 1 in human monocytes and
monocyte chemotactic protein 1, vascular cell
adhesion molecule 1, and interleukin 8 in endothelial
cells, resulting in increased adhesion of T cells and
monocytes to homocysteine-exposed endothelial
cells.23,24
Both
the
prothrombotic
and
proinflammatory effects of elevated homocysteine
levels may account for the increased risk of recurrent
coronary events in patients with elevated levels of
homocysteine, irrespective of the extent of the
underlying coronary disease.
A number of retrospective (case-control and
observational) studies done over the past 15 years
indicate that homocysteine is a graded, independent
risk factor for myocardial infarction, stroke, and
venous
thromboembolism.25 In
this
study
homocysteine levels were elevated and statistically
highly significant.
Prospective studies, in contrast, were revealing both
positive and negative associations.26,27 The Tromso
study, one of the longitudinally followed cohorts,
revealed a 40% increase in the risk of myocardial
infarction associated with a 4 mmol/L increase in
33
Mohanraj et al.,
tHcy, although reanalysis of the Physicians Health

Study data and initial findings of the Atherosclerosis
Risk In Communities trial revealed no such
associations. In the current study, the association of
high tHcy with age were not established. These
results are concordant with the results from the study
by Nguyen et al.
A study on lipoprotein (a): better assessor of coronary
heart disease risk in south Indian population by D.
Rajasekhar et al shows Low levels of total-C and
High Density Lipoprotein-Cholesterol observed in
patients when compared to controls. Low levels of
HDL-C are reported to increase the risk of CHD even
when total cholesterol is not elevated. But in this
present study, HDL-C levels are not correlated with
CHD. Increased total-C and LDL-C levels are
reported in patients than in controls. In this study,
high levels of LDL-C was observed in patients
against controls.
A meta-analysis28 found that for every 2.5- mol/L
increase in plasma total homocysteine, the risk of
myocardial infarction increases by about 10% and the
risk of stroke increases by about 20%. The
relationship between homocysteine and risk appears
to hold for plasma concentrations of total plasma
concentrations of total homocysteine between 10 and
30 mol/L.
For almost two decades we have known that a high
plasma homocysteine level (hyperhomocysteinemia)
is associated with increased cardiovascular risk. But
whether elevated homocysteine causes cardiovascular
disease or is a consequence of it remains unknown.
Adding folic acid and other B vitamins to the diet is
effective in lowering levels, but whether it improves
the clinical outlook is also still uncertain and is the
focus of several ongoing clinical trials. On the other
hand, there is good reason to believe that
homocysteine is an independent cardiovascular risk
factor and that homocysteine lowering therapy
ultimately may prove to have a modest clinical
benefit. Treating with either folic acid 0.45.0
mg/day or vitamin B12 0.51.0 mg/day or both are
inexpensive and presumably safe, and is likely to be
cost effective for preventing cardiovascular events if
ongoing clinical trials confirm that homocysteine
lowering therapy is beneficial. Even without
definitive evidence of clinical benefit, a case can be
made
for
detecting
and
treating
hyper
homocysteinemia in selected patients (ie, those with a

history of premature cardiovascular disease, stroke, or
venous thromboembolism, or those thought to be at
high risk because other risk factors are present). In
such cases, treatment is unlikely to cause harm and
may produce an important benefit. In this study the
association of hyperhomocysteinemia with other
emerging risk factors, like lipoprotein A and hs-CRP
were not analyzed. This is the limitation of this study.
CONCLUSION
The association of hyperhomocysteinemia with CHD
was significant. Homocysteine values were higher in
smokers and hypertensives. Established risk factors
like hypertension, diabetes, LDL-C, family history of
CHD were higher in cases than controls. Smoking
and decreased HDL-C were not significantly
associated with CHD.
ACKNOWLEDGEMENT
The authors are grateful to the Dean, the Head Of the
Department, General Medicine and Biochemistry of
our institution Meenakshi medical college hospital
and research institution, Kanchipuram for providing
facilities for research.
Financial support: Nil.
Conflict of Interest: Nil.
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Eikelboom JW, Lonn E, Genest J, Hankey G,
Yusuf S. Homocyst(e)ine and cardiovascular
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Lowering blood homocysteine with folic acid
based supplements: meta- analysis of randomised
trials. BMJ 1998;316:894- 8.
Durand P, Prost M, Loreau N, Lussier-Cacan S,
Blache D. Impaired homocysteine metabolism
and atherothrombotic disease. Lab Invest. 2001;
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Taha S, Azzi A, Ozer NK. Homocysteine induces
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Graham IM, Daly LE, Refsum HM, et al. Plasma
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Refsum H, Ueland PM, Nygard O, Vollset SE.
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Boushey CJ, Beresford SAA, Omenn GS,
disease: probable benefits of increasing folic acid
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Malinow MR, Bostom AG, Krauss RM.
Homocyst(e)ine, diet, and CVD: a statement for
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Stehouwer CDA, Weijenberg MP, van den Berg
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DOI: 10.5958/2319-5886.2015.00006.5

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 31st Oct 2014
ALPHA 1 ANTITRYPSIN IN SMOKERS AND NON SMOKERS CHRONIC OBSTRUCTIVE

PULMONARY DISEASE
*Panchal Mittal A1, Shaikh Sahema M2, Sadariya Bhavesh R3, Bhoi Bharat K1, Sharma Hariom M4
1
Resident Doctor, 2 Tutor, 4 Professor and Head, Department of Biochemistry, Govt. Medical College, Bhavnagar,
Gujarat, India
3
Assistant Professor, Department of Biochemistry, Pacific Medical College, Bhiloka-bedla, Udaipur, Rajasthan,
India
*Corresponding author email: myth2911@ymail.com
ABSTRACT
Aim: The aim of the present study is to correlate and compare alpha-1 antitrypsin level in smoker and non smoker
chronic obstructive pulmonary disease patients. Material and Methods: A comparative study was carried out in
200 subjects, more than 40 years of age and having chronic obstructive pulmonary disease for more than 1 year
with a history of smoking at least 20 cigarettes per day (Group A) and without a history of smoking (Group B).
Pulmonary function tests were used to diagnose the disease as per the Global Initiative for Chronic Obstructive
Lung Disease (GOLD) classification. Alpha-1 antitrypsin level was done by turbidimetry method on fully auto
analyzer I-Lab 650 (Instrumentation Laboratory, USA) at Clinical Biochemistry Section, Laboratory Services Sir
Takhtsinhji Hospital, Bhavnagar. Statistical analysis was done by using unpaired t-test and Pearsons correlation
coefficient. Results: Results of present study shows that alpha-1 antitrypsin level was decreased in smoker
chronic obstructive pulmonary disease patients (150.8318.853) when compared to non smokers
(183.9729.383). There was statistically significant difference in alpha-1 antitrypsin level between the two
groups with p value of <0.0001. Pearsons correlation test show negative correlation between smoker and nonsmoker chronic obstructive pulmonary disease patients. Conclusion: The values of serum alpha-1 antitrypsin
levels were more significantly decreased in smokers indicating an important role of smoking in pathogenesis of
chronic obstructive pulmonary disease. Alpha-1 antitrypsin can act as a predictor for future development of
chronic obstructive pulmonary disease in smokers and in nonsmokers.
Keywords: Alpha-1 antitrypsin, Chronic Obstructive Pulmonary Disease (COPD), Forced Expiratory Volume
(FEV), Global Initiative for Chronic Obstructive Lung Disease (GOLD)
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is
defined as a disease state characterized by airflow
limitation that is not fully reversible and it includes
emphysema, an anatomically defined condition
characterized by destruction and enlargement of the
lung alveoli; chronic bronchitis, a clinically defined
condition with chronic cough and phlegm; and small
airways disease, a condition in which small
bronchioles are narrowed 1. The chronic airflow
limitation is caused by a mixture of small airway
Mittal et al.,
disease (obstructive bronchiolitis) and parenchymal

destruction (emphysema) 2. In developing countries,
cooking on open fire with subsequent exposure to
excessive smoke in close environments, and miningrelated pollution can cause the disease3. Chronic
obstructive pulmonary disease is a major cause of
health care burden worldwide and the only leading
cause of death that is increasing in prevalence. The
regional chronic obstructive pulmonary disease
working group for 12 Asia Pacific countries and
36
regions used a prevalence model for this disease and

estimated an overall prevalence rate of 6.3 % with a
range from 3.5 to 6.7 %4. Prevalence of COPD in
India with a median of studies (up to 1995) was 5.0%
and 2.7% in men and women, respectively and in
2006 was 5.0% and 3.2% in men and women
respectively5. Chronic obstructive pulmonary disease
(COPD) is rapidly becoming a global public health
crisis with smoking being recognized as its most
important causative factor. There is mounting
evidence that the rate of progression of chronic
obstructive pulmonary disease can be reduced when
patients at risk of developing the disease stop
smoking, while lifelong smokers have a 50%
probability of developing chronic obstructive
pulmonary disease during their lifetime6. Cigarette
smoke activates macrophages and epithelial cells to
release chemotactic factors that recruit neutrophils
and CD8 cells from the circulation. These cells
release factors that activate fibroblasts, resulting in
abnormal repair processes and bronchiolar fibrosis 7.
Alpha-1 antitrypsin deficiency is associated with a
substantially increased risk for the development of
chronic obstructive pulmonary disease, often by the
third or fourth decade, and is also associated with
risks for development of liver disease, cutaneous
panniculitis,
bronchiectasis,
vasculitis,
and
8
Wegeners
granulomatosis .
There
are
posttranslational modifications of alpha-1 antitrypsin
in patients with chronic obstructive pulmonary
disease, is that of oxidation, thought to be due to
exposure to cigarette smoking components. Reactive
oxygen and nitrogen species, which are increased in
smokers, may target and modify the alpha-1
antitrypsin 9. Alpha-1 antitrypsin deficiency is
inherited as an autosomal co dominant disorder,
characterized by serum (and hence, lung) level of
alpha-1 antitrypsin far below the laboratory reference
range of 90 200 mg/dl. Normal level neutralizes the
activity of neutrophil elastase, a protease that destroys
elastin and other connective tissue components in the
lung; however, a deficiency of alpha-1antitrypsin
represents an imbalance in favour of neutrophil
elastase and, therefore, increases the risk of
emphysematous lung destruction 10, 11.
The present study is designed to measure and
compare the changes in alpha-1 antitrypsin level in
patients with chronic obstructive pulmonary disease
with and without smoking.
Mittal et al.,

Study was conducted on the patients of COPD
attending the Pulmonary Medicine department at Sir
Takhtsinhji General Hospital, Bhavnagar during
period of November 2013 to March 2014. Study
included 100 patients of chronic obstructive
pulmonary disease (COPD) with smoking (Group A)
and 100 patients without smoking (Group B).
Inclusion criteria: Included patient age more than 40
years, both male and female with prior diagnosis of
chronic obstructive pulmonary disease (COPD) by
PFT (pulmonary function test). Ethical clearance was
obtained from the institutional review board of Govt.
Medical College, Bhavnagar. Informed consent was
taken from all the subjects.
Exclusion criteria: Patient has alternative cause for
their respiratory disorders e.g. asthma, lung cancer,
sarcoidosis, tuberculosis, lung fibrosis, cancer or had
cancer in the 5 years prior to study entry or had
undergone lung surgery, patient having diabetes
mellitus, renal failure, hypertension, cardiac
disorders, liver disorders, hepatocellular carcinoma
and bladder cancer, patient with habit of tobacco
chewing along with smoking were excluded.
Venous blood was collected in plain vacutte from all
the participants. Fresh serum was separated by
centrifugation. Assay was performed on ILAB-650
fully auto analyzer (Instrumentation Laboratory,
USA) at Biochemistry Laboratory accredited by
National Accredited Board for Testing and
Calibration Laboratory as per ISO 15189:2007
guideline. AAT was analyzed by serum anti-human
alpha-1 antitrypsin which reacts specifically with the
alpha1-antitrypsin of the sample to yield an insoluble
aggregate which is measured by turbidimetry
method12 with commercially available ready to use
reagent kits. The recorded parameters were compared
in both the groups.
Stastical analysis: All the values were presented as
Mean SEM. Data were checked for normal
distribution using GraphPad InStat (version 3.00,
GraphPad Software, California USA). In data
analysis, comparison of this parameter between
smokers and non-smoker COPD patients was carried
out by applying unpaired t-test and their correlation
was studied by applying Pearson Correlation test.
Pearsons correlation coefficient test was used for
correlation of serum AAT level and predicted FEV1
37
RESULTS
Table 1: Comparison of serum AAT level between
two groups
Serum AAT(mg/dl)$
Statistics
Group A
Group B
Mean SD
Minimum
(COPD
Smoker)
150.818.8
116
(COPD Non
Smoker)
183.929.3
Maximum
229
309
136
Significance
*** p < 0.0001
*** p < 0.0001: highly significant difference between
two groups by applying unpaired t-test with
confidence interval. $Reference Interval (90-200
In this study we measured Serum activity of AAT in

both groups. There is highly significant difference
observed in between group A and group B patients.
A positive correlation was observed between AAT
levels and FEV 1% in smoker and non smoker
COPD patients with a Pearson correlation coefficient
of 0.3370 and 0.5026 (p<0.0001) respectively. (Fig 1
and 2)
120
100
FEV 1%
% in smoker and non smoker COPD patients.

Interpretation was done according to p-value. P value
<0.05 was considered as statistically significant.
80
60
40
FEV 1 %
20
Linear (FEV 1 %)
r=0.5026
0
0
200
400
.
p<0.0001
AAT (mg/dl)
mg/dl)
Group A
(COPD
Smoker)
Group B
(COPD
Non-Smoker)
Fig 2: Correlation between serum AAT and FEV

1% in Non Smoker COPD Patients
On analysis by using unpaired t test the differences
in AAT levels between the two groups was
statistically highly significant with p value of
<0.0001.
Mean SD
48.8413.6
77.1714.7
DISCUSSION
Minimum
16
32
Maximum
88
96
Significance
*** p < 0.0001
Chronic Obstructive Pulmonary Disease (COPD) is a

major cause of chronic morbidity and mortality
throughout the world. The chronic airflow limitation
is caused by a mixture of small airway disease
(obstructive
bronchiolitis)
and
parenchymal
destruction (emphysema). Globally, COPD has been
expected to become the 3rd most leading cause of
death and the 5th leading cause of loss of Disability
Adjusted Life Years (DALYs) as per projection of
the Global Burden of Disease Study (GBDS) 2, 13 .
Tobacco use kills more than five million people a
year and accounts for 10% of adult deaths worldwide.
Smoking recognized as a most important causative
factor for COPD. Several meta-analyses have shown
that all pharmacotherapy for smoking cessation are
twice as likely more efficacious than placebo with an
abstinence rate in the 25-30% range at one year when
pharmacological treatment and behavioural support
are combined 6.
Alpha-1-antitrypsin has 394 amino acids and 3
glycosylated side chains coupled to asparagines. The
Table-2: Comparison of FEV 1 % between Group

A and Group B
FEV 1 % (Normal:80%)
Statistics
Unpaired t-test with confidence interval of 95%

100
FEV 1%
80
60
40
FEV 1%
20
Linear (FEV 1%)

r=0.3370
p<0.0001
100
200
300
AAT (mg/dl)
Fig 1: Correlation between serum AAT and FEV

1% in Smoker COPD Patients
Mittal et al.,
38
amino acid methionine is present at position 358 and

it is susceptible to convert in methionine sulfoxide by
oxidants from cigarette smoke, rendering it much less
potent inhibitor of neutrophil elastase 14.
AAT level was lower in COPD patients with smoking
as compared to COPD patients without smoking. The
present study shows the significant difference in
serum AAT level between the two groups
(p<0.0001). This study supports the data of previous
studies F. Ogushi et al. 1991 15, Oliver Senn, Erich W
Russi, Christian Schindler et al. 2008 16 and Deore
Deepmala et al. 2012 2.
There are, however, some limitations to the current
study most notably that, the cost of the parameter is
high and the sample size is small.
Findings of the present study suggest that serum AAT
levels were significantly reduced in smokers COPD
in comparison to non smoker COPD patients.
Therefore, AAT levels can be taken as a parameter to
determine the progress of COPD and it can be used as
an important tool in the management of COPD.
Moreover, serum AAT and FEV 1% can also be used
as a risk factor of chronic obstructive pulmonary
disease along with smoking as they have significant
correlation in chronic obstructive pulmonary disease.
CONCLUSION
In conclusion, serum AAT levels were significantly
lower in smoker COPD patients in comparison to
non-smoker COPD patients and there was a positive
correlation between alpha-1 antitrypsin and FEV 1%
in smoker and non-smoker COPD patients. Therefore,
smoking cessation and correction of alpha-1
antitrypsin levels may be beneficial in COPD patients
for better management of the disease.
ACKNOWLEDGEMENT
Authors gratefully acknowledge all participants of
pulmonary medicine OPD, Institution, Department
and clinical biochemistry laboratory for technical
help and cooperation.
Conflict of Interest : Nil
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Pulmonary Disease. 2008; 1635
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Urjita, Badaam Khaled. Correlation of Alpha-1
Antitrypsin and Smoking in Chronic Obstructive
Lung Disease: An Observational Study.
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4. Surinder K. Jindal. Emergence of chronic
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5. SK Jindal. COPD: The Unrecognized Epidemic
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6. Rafael Laniado-Laborn. Smoking and Chronic
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Journal of Environmental Research and Public
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7. William MacNee. ABC of chronic obstructive
pulmonary disease Pathology, pathogenesis, and
pathophysiology. BMJ. 2006; 332; 1202-04
8. Tomas P. Carroll, Catherine A. OConnor, Emer
P. Reeves and Noel G. McElvaney. Alpha-1
Antitrypsin Deficiency A Genetic Risk Factor
for COPD. 2012. www.intechopen.com.
9. Angelia D Lockett, Mary Van Demark, Yuan Gu,
Kelly S Schweitzer, Ninotchka Sigua, Krzysztof
Kamocki et al. Effect of Cigarette Smoke
Exposure and Structural Modifications on the -1
Antitrypsin Interaction with Caspases. Molecular
Medicine. 2012; 18:445-54
10. Pyng Lee, Thomas R. Gildea, James K. Stoller.
Emphysema in nonsmokers: Alpha 1-antitrypsin
deficiency and other causes. Cleveland clinic
journal of Medicine. 2002; 69, 12; 928-46
11. Dati F, Schumann G, Thomas L, et al. Consensus
of a Group of Professional Societies and
Diagnostic Companies on Guidelines for Interin
Reference Ranges for 14 Proteins in Serum based
on
the
Standardization
against
the
IFCC/BCR/CAP Reference Material (CRM 470).
Eur J Clin Chem Biochem. 1996; 34: 517-20
12. Jose. Vledma, Alberto de Ia Iglesia, Magdalena
Parera, and Maria Teresa Lopez. A New
Automated Turbidimetnc Immunoassay for
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Quantifying a1-Antitrypsin in Serum. Clinical

Chemistry1986, 32(6):1020-1022
13. SK Jindal. COPD: The Unrecognized Epidemic
in India. Supplement to Japi, 2012, 60: 14-16
14. Laura Fregonese and Jan Stolk. Hereditary alpha1-antitrypsin deficiency and its clinical
consequences. Orphanet Journal of Rare Diseases
2008, 3:16
15. F. Ogushi, R. C. Hubbard, C. Vogelmeier, G. A.
Fells, and R. G. Crystal. Risk Factors for
Emphysema Cigarette Smoking Is Associated
with a Reduction in the Association Rate
Constant of Lung al-Antitrypsin for Neutrophil
Elastase. The Journal of Clinical Investigation.
1991 87; 1060-65
16. Oliver Senn1, Erich W Russi, Christian
Schindler, Medea Imboden, Arnold von
Eckardstein, Otto Brndli. Circulating alpha1antitrypsin
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Mittal et al.,
40
DOI: 10.5958/2319-5886.2015.00007.7

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Received: 25 Aug2014
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 3rd Nov 2014
STUDY OF DEPRESSION AMONG ADOLESCENT STUDENTS OF RURAL MAHARASHTRA AND

ITS ASSOCIATION WITH SOCIO-DEMOGRAPHIC FACTORS: A CROSS-SECTIONAL STUDY
*Shelke Umesh S1, Kunkulol Rahul R2, Phalke Vaishali D3, Narwane Sandeep P4, Patel Prashant C5
1
Undergraduate Student, Rural Medical College (PIMS-DU), Loni, Maharashtra, India

Professor, 4Assistant professor, 5Postgraduate Student, Department of Pharmacology Rural Medical College
(PIMS-DU), Loni, Maharashtra, India
3
Professor, Department of Community Medicine, Rural Medical College (PIMS-DU), Loni, Maharashtra, India
2
*Corresponding author email: umeshshelke01@gmail.com

ABSTRACT
Introduction: Depression is the most common psychiatric disorder that appears in adolescents. It has an adverse
effect on physical as well as mental health. Many adolescents remain undiagnosed due to no accessibility to
clinics. Objectives: To study demographic factors and their association with depression among adolescents of
rural Maharashtra. Methods: A cross sectional study was conducted on 300 students (30 of either sex from 8th to
12th class). 6 item KADS (Kutcher Adolescent Depression Scale), BG Prasads modified socioeconomic scale and
demographic data were collected from volunteers. Results: 6.66% of students were screened positive for
depression by the scale. No statistical difference was found in number of students with depression with respect to
sex, class and socioeconomic status. However the residence and type of family showed significant difference in
number students of depression. Conclusion: the KADS is a good screening tool for depression and should be
implemented for adolescents studying in rural areas for prevention and early treatment of depression.
Keywords: Depression, Socioeconomic scale, Rural, Kutcher Adolescent Depression Scale, BG Prasads
modified socioeconomic scale.
INTRODUCTION
Depression is a state of low mood and aversion to
activity that can affect a person's thoughts, behaviour,
feelings and sense of well-being.1 Depressive
disorders tend to first appear in adolescence or early
adulthood.2,3 One in every five adolescents is likely to
experience a diagnosable depressive episode by the
age of 18.4,5
Depressed people feel sad, anxious, empty, hopeless,
worried, helpless, worthless, guilty, irritable, hurt or
restless. They may lose interest in activities that once
were pleasurable, have problems concentrating,
remembering details, or making decisions, and may
contemplate, attempt, or commit suicide. Depression
can also present as somatic disturbances like
Umesh et al.,
Insomnia, excessive sleeping, fatigue, loss of energy,

or aches, pains, or digestive problems that are
resistant to treatment may also be present.6,7
The socio-demographic factors of age, gender,
education and income have been identified as
important factors in explaining the variability in the
prevalence of depression. 7
About 11% of adolescent have a depressive disorder
by age 18 according to National Co-morbity SurveyAdolescent Supplement (NCS-A). Depression is more
in girls depression than boys. 8
Cash et al. found that up to 60% of adolescent suicide
victims suffered from depression at the time of
death9.
41
Low socioeconomic status is generally associated

with high Psychiatric morbidity, more disability and
poorer access to health care. Among Psychiatric
disorders, depression exhibits a more controversial
association with socioeconomic status. 10 A survey
was planned to study the socio-demographic factors
and their association with depression among
adolescents of rural Maharashtra.
A cross sectional study was conducted to evaluate
socio-demographic factors and their association with
depression among adolescents of rural Maharashtra.
The subjects of the study were students from School
and junior college from Pravaranagar, Ahmednagar.
IEC approval was taken before the commencement of
study. 300 students willing to participate were
enrolled into the study from 8th to 12th class (30 males
and 30 females from each class). Students of either
sex in the age group of 12-18 years and willing to
give written informed consent were taken in the
study. Data were collected at pre-tested structured pro
forma from each study subject. Questionnaire
included the 6- Item Kutcher Adolescent Depression
Scale (KADS) 11,12, age, gender, standard, religion,
hosteller or day scholar, type of family, education and
occupation of father and mother and socioeconomic
status (by BG Prasads modified socioeconomic
scale) of family. Informed and written consent were
taken from Principal as well as informed verbal
consent was taken from students before filling
questionnaire. Duration of the study was 2 months.
The KADS tool is a self-report scale and is meant to
be completed by the young person following
direction from the health provider, educator or other
responsible person.
The KADS is scored using a zero to three systems
with hardly ever scored as a zero and all of the
time scored as a three.
Total scores at or above 6 suggest possible
depression and a need for a more thorough
assessment. The total score below 6 -Indicate
probably not depressed Statistical Analysis: Data
collected were pooled, tabulated, and subjected to Chi
square test.
to 31th March 2014.

Out of 300 adolescents 20 (6.66%) were suggested
the possibility of depression. There is no statistical
difference in depression with respect to sex of the
students (Table 1). The number of students with
depression was not significantly different in the
classes of 10th and before (8th and 9th) as compared to
students of class 11th and 12th (Table 2). Table 3 and
Figure 1 show that there is significant number of
students of depression living in hostel as compared to
the day scholars. A statistical difference is also seen
in the students that belong to nuclear family with that
to joint family (Table 4). Table 5 shows association
between depression and Socioeconomic Status (B G
Prasads socioeconomic scale) of family. No
statistical significance was found among the students
belonging to different socioeconomic classes. Table 6
shows Frequencies of answers to individual KADS
items in percentages. The last item on the KADS is
very sensitive to suicide risk and was answered as
much of the time by 5% adolescents.
Table: 1Association between Depression (by KAD6 scale) and Gender
Gender Depressed Not Depressed Total
RESULTS
Boys
6(4%)
144(96%)
150(50%)
Girls
14(9.33%) 136(90.67%)
150(50%)
Total
20(6.66%) 280(93.43%)
300(100%)
2
=1.131, P=0.1052
Table:2 Association between Depression(by KAD6 scale) and class
Class
Depressed Not Depressed Total
8th to 10th 11
169
180
11th & 12th 9
111
120
Total
20
280
300
2=0.055, P=0.81
Table:3 Association between Depression(by KAD6 scale) and Residence
Depressed Not
Total
Depressed
Day
10(4.48%) 213(95.5%) 223(100%)
Scholar
Hostelite
10(13%)
67(87%)
77(25.66%)
P value = 0.0157 by Fisher's Exact Test
Table:4 Association between Depression(by KAD6 scale) and Type of Family
Type of Depressed Not
Total
Family
Depressed
Nuclear 10(3.33%) 104(34.66%) 114(37.99%)
In this study responses of survey questionnaire were

received from 300 adolescents from 1st February 2014
Joint
10(3.33%) 176(58.66%)
Total
20(6.66%) 280(93.34%)
2
=0.43, P=0.0389
Umesh et al.,
186(61.99%)
300(100%)
42
100%
Not Depressed
Depressed
80%
60%
40%
95.5
87
4.48
13
Day Scholar
Hostelite
20%
0%
Figure 1: Association between Depression (by

KAD-6 scale) and Day Schooler/Hostelites
Table:5 Association between Depression(by KAD6 scale) and Socioeconomic Status
Class
Depressed Not
Total
Depressed
Upper
8(2.66%) 166(55.33%) 174(58)
Class
Upper
5(1.66%) 64(21.33%)
69(23%)
Middle
Lower
4(1.33%) 20(6.66%)
24(8%)
Middle
Upper
3(1%)
27(9%)
30(10%)
Lower
Lower
0(0%)
3(1%)
3(1%)
Class
Total
20(6.66%) 280(93.34%) 300(100
%)
2=Chi-squared for trend = 0.2878 (1 degree of
freedom), P= 0.5916.
Table: 6 Frequencies of answers to individual
KADS items in Percentages (n=300)
Items
Hardly Much Most
All of
Ever
of the of the the
time
time
time
Sadness
85
28
5.6
0
Hopeless
48.3
15.3
3
3
ness
Tiredness 62.3
31.3
2.6
3.6
Difficultie 79.6
14
6.3
0
s in life
Worry
72.3
19.3
4.6
3.6
Suicidal
95
5
0
0
thoughts
Umesh et al.,
DISCUSSION
Depression is a mood disorder which is divided into
depressive disorders, bipolar disorder and depression
associated with medical illness or substance abuse.
Diagnosis of depression is based on criteria which
consist of symptoms and their duration. The treatment
of depression is psychotherapy, drug treatment or
both. Psychotherapy involves cognitive and
behavioral therapy. Tricyclic antidepressants,
selective serotonin reuptake inhibitors, serotonin and
noradrenaline reuptake inhibitors and newer atypical
antidepressant form the drug treatment of
depression.11
There are three different KADS scales: the 6-item,
the 11-item and the 16 item. The 16 item is designed
for clinical research purposes while the 11-item
KADS is designed for use in clinical settings in
which health providers treat young people who have
depression.
The 6-item KADS is designed for use in institutional
settings (such as schools or primary care settings)
where it can be used as a screening tool to identify
young people at risk for depression or by trained
health care providers (such as public health nurses,
primary care physicians) or educators (such as
guidance counselors) to help evaluate young people
who are in distress or who have been identified as
possibly having a mental health problem.12,13
It has sensitivity for depression of over 90 percent
and specificity for depression of over 70 percent
putting it into the top rank of self-report depression
assessment tools currently available. A score of six or
greater is consistent with a diagnosis of Major
Depressive Disorder and should trigger a more
comprehensive mental health assessment of the
young person.
The last item on the KADS is very sensitive to
suicide risk. Any young person scoring one or higher
on the last item should have a more thorough suicide
risk assessment.,12,13 Depression can be prevented in
high risk adolescents by problem solving for life
intervention and Penn-Resiliency Program conducted
in school, family and adolescents psycho education,
cognitive and behavioral therapy.14
Studies done by Black G et al15AND Mojs E et
al16using KADS, reported depression in 18% AND
6% of students respectively. In our study depression
was observed in 6.66% of students which is similar to
43
study conducted by Mojs E et al16 while three times

less as compared to study conducted by Black G et
al15.
In a study conducted by Chen et al17, using Beck
Depression Inventory in Chinese university students,
it was found that there was no statistical differences
in the incidence of depression in males and females17.
Study by Chen et al15and Sarkar J et al18reported
more number of students depressed belonging to
higher family income while study done by Mojs E et
al16 reported more number of students depressed who
belong to lower income group. In our study, no
statistical difference was found in students belonging
to different socioeconomic strata.
Sarkar J et al18 and Mojs E et al16 found a significant
difference in depression in students residing in
hostels that those residing at homes. Our study
supports the findings of these studies.
A study done by Chen et al (15) showed a difference in
depression in students belonging to different classes.
In our study, no such difference was found when the
classes below tenth and that above tenth were
compared.
Nuclear family system is a strong independent
predictor of depression.19 In present study it is found
that in depression is more common in nuclear than in
Joint family. The finding of our study supports this
study.
Thoughts, plans or actions about suicide or self-harm,
this item on the KADS is very sensitive to suicide
risk. 5% adolescents were sensitive to suicide risk in
the rural area of Maharashtra. In a study conducted by
Mojs E et al16, 1.1% were sensitive to suicide risk.
The difference found in our study as compared to
other studies could be due to a small sample size
being a student project of short duration, which was a
limitation of the present study. Yet the findings of the
study suggest that depression is common among
students.
CONCLUSION
Depression is common in the adolescent population.
Because the adolescents are deprived of regular
clinical assessment due to scarcity of facilities, the
KADS questionnaire is a good screening tool. It is
also necessary to assess the students by such
questionnaires and if required, by psychiatrists for
any subclinical depression that could be prevented
Umesh et al.,
earlier. This would help to prevent and manage

depression among adolescents of rural Maharashtra.
ACKNOWLEDGEMENT
Principals and students from School and Junior
college from Pravaranagar, Ahmednagar, Mr. Hemant
Pawar (Statistician), Department of Pharmacology
&Research cell, Rural Medical College (PIMS- DU),
Loni.
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45
DOI: 10.5958/2319-5886.2015.00008.9

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Coden: IJMRHS
th
Received: 5 June 2014
Revised: 28th July 2014
Research article
Copyright @2014
ISSN: 2319-5886
Accepted: 2nd Sep 2014
MAST CELLS AND ANGIOGENESIS IN ORAL EPITHELIAL DYSPLASTIC LESIONS AND ORAL
SQUAMOUS CELL CARCINOMA
*Hegde Veda1, Marla Vinay2
1
Associate Professor, Department of Oral Pathology, SDM College of Dental Sciences and Hospital, Sattur,
Dharwad, Karnataka, India.
2
Post Graduate Student, SDM College of Dental Sciences and Hospital, Sattur, Dharwad, Karnataka, India
*Corresponding author email: hegdeveda6@rediffmail.com

ABSTRACT
Background: The progression of oral epithelial dysplastic lesions into oral squamous cell carcinoma is
characterized by an angiogenic switch which is characterized by an increase in neo-vascularization in the subepithelial lamina propria which can be considered an indicator of malignant transformation. Mast cells are a rich
source of various angiogenic factors. Moreover mast cells secrete various proteolytic enzymes which degrade the
extracellular matrix and create space for the developing blood vessels. Aims: This study was undertaken to
determine the relationship between mast cell density and microvessel density in normal oral mucosa, oral
epithelial dysplasia and oral squamous cell carcinoma and to find out whether any correlation exists between
these two parameters. Material and Methods: This retrospective study was performed using formalin fixed,
paraffin embedded tissues of previously diagnosed cases of oral epithelial dysplasia and oral squamous cell
carcinoma. Mast cells were stained using toluidine blue, whereas in the capillaries, immunohistochemical staining
technique was performed using mouse monoclonal antibody against CD34. Results: Mast cell density and
microvessel density were higher in oral epithelial dysplasia and in oral squamous cell carcinoma compared to the
normal mucosa. However, statistically significant positive correlation was noted only in oral epithelial dysplasia
Conclusion: The above results probably indicate a role of mast cells in angiogenic switch. These angiogenic
factors secreted by mast cells promote angiogenesis either directly by stimulating the migration and/or
proliferation of mast cells or indirectly through degradation of extracellular matrix. Targeting the mast cells may
contribute in preventing the progression of the lesion.
Key words: Angiogenesis, CD34, Epithelial dysplasia, Mast cells, Microvessel density and Oral squamous cell
carcinoma
INTRODUCTION
Oral squamous cell carcinoma is the sixth most
common cancer in the world and is the leading cause
of death in India accounting to more than 90% of all
oral cancers 1. Oral squamous cell carcinoma arises
de novo or from pre-existing lesions. The progression
of oral epithelial dysplastic lesions to squamous cell
carcinoma is characterized by an increase in neo-
vascularization in the sub-epithelial lamina propria

and can be considered as an indicator of malignant
transformation.2It is also well known that tumour
growth is limited to 1-2mm in the absence of
adequate perfusion and require adequate vascularity
to grow.3 Angiogenesis, the growth of new vessels
from existing ones is a complex phenomenon,
46
Hegde Veda et al.,
Int J Med Res Health Sci. 2015;4(1): 46-52
required for the absolute growth and survival of

neoplasm Pain is the characteristic feature which
may be aggravated on eating or swallowing. This
angiogenesis are triggered by hypoxia resulting from
an increasing distance of the growing tumour to the
capillaries. Tumour angiogenesis is a complex event,
mediated by angiogenic factors released by cancer
cells and or by host immune cells.1 Among the host
immune cells, mast cells have been implicated in
tumour progression via promoting angiogenesis.1
Mast cells are recruited early in tumour development
and play a key role in both angiogenesis and tissue
remodeling. Mast cells are a source of several
proangiogenic and angiogenic factors such as
histamine, heparin, chymase, basic fibroblastic
growth factor, vascular endothelial growth factor,
transforming growth factor.4
Microvessel density has been used as a method for
assessment of angiogenesis. The technique involves
the immunohistochemical staining of endothelial cells
of the capillaries by using monoclonal antibodies
against CD34. CD34 is a transmembrane
glycoprotein expressed by the endothelial cells.
Although expression of CD34 is evident in other
cells, these do not have any effect on the assessment
of microvessel density, unlike CD31 which in
addition to being expressed by endothelial cells is
also localized in macrophages 5. The accumulation of
mast cells is usually estimated by counting the mast
cell density, which is the number of mast cells per
optical field in tissue sections. Mast cells are easily
recognized in light microscopy by toluidine blue
staining because of the metachromatic granules that
fill the cytoplasm.6
The objectives of the present investigations were to
compare the mast cell density and microvessel
density in normal oral mucosa, oral epithelial
dysplasia and oral squamous cell carcinoma and
correlate the microvessel and mast cell density in
each of the above groups in order to know the
function of mast cells in tumour invasion, in
promoting angiogenesis or its role in anti-tumour
activity.
This After obtaining the ethical clearance, this
retrospective study involved the use of buffered
formalin fixed, paraffin embedded tissues of
previously diagnosed cases of oral epithelial
dysplasia and oral squamous cell carcinoma, retrieved
from the archives of Department of Oral &
Hegde Veda et al.,
Maxillofacial Pathology in SDM College of Dental

College and Hospital, Dharwad, India from 20102013. A total of 50 cases, 10 cases of normal oral
mucosa, 20 cases each of oral epithelial dysplasia and
oral squamous cell carcinoma were selected. Ten
cases of clinically normal oral mucosa obtained from
non-inflamed third molar extraction sites were used
as control samples Haematoxylin & Eosin (H&E)
stained sections were evaluated for the presence of
the lesion and also for the adequacy of the connective
tissue depth. Only OSCC biopsy specimens which
contained sufficient stroma for evaluation were
selected. The exclusion criterion constituted recurrent
cases with or without radiotherapy.
Examination of slides:
Staining of endothelial cells:
I. Interpretation of staining: The antibody used was
antihuman CD34 [Biogenex Life Science limited
(CA, USA)]. The presence of brown coloured blood
vessel with lumen or cluster of endothelial cells
without evidence of lumen formation was considered
as a single microvessel unit.
II. Selection of field for counting cells: The stained
sections were scanned under low power
magnification to determine the epithelial connective
tissue junctions in case of epithelial dysplasia and
presence of tumour islands in case of oral squamous
cell carcinoma. Such representative fields were
selected carefully in each slide by scanning the slides
form left to right of every slide to avoid recounting of
the same areas.
III. Counting of cells: The microvessel density
counting was performed with a binocular light
microscope under high power magnification (400x)
Counting in cases of oral epithelial dysplasia was
done in the connective tissue adjacent to the epithelial
basement membrane in 10 successive fields (400x).
The total count was divided by the 10 (number of
fields studied) to get the average microvessel density
in each field. In each slide, cells were counted in
consecutive fields to avoid recounting the same areas.
Staining of mast cells: The most striking
morphological feature of mast cells is the large
number of strongly stained metachromatic granules
present in the cytoplasm. Similar method as used for
counting microvessel density was used for counting
mast cell density.
Statistical analysis: Statistical analysis was
performed using Kruskal- Wallis, Mann-Whitney U
test and Pearsons correlation test. The software used
47
for statistical analysis was SPSS version 10. A

significance level of p <0.05 was used for all tests
and comparison.
RESULTS
as an ulcer between 2-4 cms in dimension. There was

no clinical evidence of nodal involvement. The
presence of distant metastasis could not be assessed
in any of the above cases.
In normal oral mucosa mast cells were localized near
the basement membrane, near the capillaries and in
the sub mucosa. Endothelial cell lined capillaries
were observed in the lamina propria which were
evenly distributed.
In oral epithelial dysplastic lesions, numerous mast
cells were localized close to the basement membrane
and around the capillaries (Fig 1). Degranulated mast
cells were also observed Metachromatic granules
clustered outside the mast cell were considered as
single mast cells for counting. Numerous endothelial
cell lined capillaries were evident in the stroma of
oral epithelial dysplastic lesions. The capillaries were
lined by flattened to plump endothelial cells (Fig 2).
In oral squamous cell carcinoma, numerous
granulated and degranulated mast cells were observed
close to the epithelium, around the capillaries, around
the tumour islands (Fig 3) and in the intra-tumoural
region. Numerous plump to flattened endothelial
lined capillaries and clusters of endothelial cells were
observed around the tumour islands (Fig.4).
Inter-observer bias: Counting the parameters was
done by observers (observer one and two) to reduce
the observer bias. Mann-Whitney U test was done to
test the consistency in the values obtained between
the two observers. As no statistically significant
difference in the mast cell density and microvessel
density were observed between the two observers, it
was decided to use the values of the first observer for
further analysis.
On analysis, there was a statistically significant
increase in above values from normal oral mucosa to
oral epithelial dysplasia and to oral squamous cell
carcinoma (p=0.00). However, when the mast cell
density and microvessel density were correlated in
each of the study samples, group I and III showed a
positive correlation which was not statistically
significant. While in group II, a statistically
significant correlation was noted between mast cell
density and microvessel density (p=0.002).
The age of presentation of the study group ranged

between 25-72 years of age. Nineteen [95%] were
males and one was female [5%] with oral epithelial
dysplasia. A history of either smoking smoking is
associated with combustion of tobacco which releases
various types of carcinogenic elements or eating
tobacco was noted in all males. Buccal mucosa was
the most predominant site of involvement [84.19%].
Lesions presented most commonly as speckled
leukoplakia [68.42] with most lesions more than 2
cms in dimension with no clinical evidence of nodal
involvement. In the single female, the lesion
presented as an ulcer of less than 2cms without habits
and no clinical evidence of lymph node involvement.
There was no information regarding the location of
the lesion.
Eighteen were males [90%] and two were females
[10%] with oral squamous cell carcinoma. In contrast
to oral epithelial dysplasia, lesions of oral squamous
cell carcinoma in males were located predominantly
in the lateral border of the tongue [38.88%] with
buccal mucosa being the next most common site
[27.77%]. History of tobacco habit was noted in most
of them [83.33%]. There was no information
regarding the habit history in one patient. Tobacco
consumption in smoke or smokeless form, alcohol
consumption, source of chronic irritation, viruses and
other lesser known risk factors are associated with
squamous cell carcinoma. If a known factor is
elucidated, it has to be eliminated to reduce the risk.
Most lesions presented as ulcers [66.66%] with only
5.5% cases exhibiting the appearance of speckled
leukoplakia. Lesions were between 2-4 cms [77.77%]
with no information in three patients. Clinical
evidence of lymph node involvement was noted in
more than half the number of patience [61.11%]. In
females, the lesions were located in the buccal
mucosa and gingiva. There was no history of tobacco
use in any form. In both the cases the lesion presented
Table: 1. Comparison of the three study groups with mast cell density values by Kruskal-Wallis test.
Groups
Sample size Mean Std. Dev. Mean rank p-value
Normal oral mucosa
10
2.9701.679
5.550
0.000
Oral epithelial dysplasia
20
11.2352.866
23.98
Oral squamous cell carcinoma 20
16.1653.838
37.03
48
Hegde Veda et al.,
Table:2.Comparison of the three study groups with microvessel density values by Kruskal-Wallis test:
Groups
Sample size Mean Std. Dev. Mean rank p-value
Normal oral mucosa
10
7.4601.223
6.00
0.00
20
12.2152.013
23.98
17.2754.520
36.78
Table: 3. Pearsons correlation test for determining the relationship between microvessel density and mast
cell density in normal oral mucosa, oral epithelial dysplasia & oral squamous cell carcinoma
Groups
Sample size r-value p-value
Normal oral mucosa
10
0.264
0.460
20
0.651
0.002
0.341
0.142
Fig 1: Oral epithelial dysplasia shows mast cells in the

lamina propria adjacent to the capillaries. (Toluidine
blue stain, original magnification, 400x).
Fig 4: Oral squamous cell carcinoma shows endothelial

lined
capillaries
in
the
lamina
propria.
(Immunostaining, DAB chromogen- CD34 monoclonal
antibodies, original magnification, 400x)
DISCUSSION
Fig 2: Endothelial lined capillaries in the lamina

propria of oral epithelial dysplasia. (Immunostainiing,
DAB chromogen- CD34 monoclonal antibodies, original
magnification, 400x)
Fig 3: Oral squamous cell carcinoma shows mast cells

around tumour epithelial islands. (Toluidine blue stain,
original magnification, 400x)
The oral mucosa undergoes various reversible and

irreversible changes to carcinogens. These changes
have been observed in the epithelial cells as well as in
the connective tissue.7 The changes in the connective
tissue have been evident by the occurrence of an
inflammatory component as well as an increase in
vascularity.2 Mast cells are one of the inflammatory
components involved in the process of angiogenesis.
Although several methods, including tryptase exist in
accurately detecting mast cells, we used toluidine
blue as this method is very simple, less time
consuming, and inexpensive. Moreover, mast cells
are easily recognized in light microscopy by toluidine
blue staining because of the metachromatic granules
that fill the cytoplasm.6
In normal oral tissues, mast cells have been found to
be present in the connective tissue of gingiva, tongue
and lining mucosa. Mast cells have also been reported
in normal periodontal ligament and pulp although in
very low densities.9
49
Hegde Veda et al.,
Bivji showed an increase in the number of mast

cells/unit microscopic field in oral leukoplakia (which
represents an increase in the thickness of the
epithelium and its keratinization without dysplasia in
this study) compared to normal mucosa. The authors
concluded that pharmacologically active agents in the
mast cells might contribute to inflammatory reaction
seen in leukoplakia.10 Mast cells may release
interleukin -1 which causes increased epithelial
proliferation that is seen in leukoplakia. Histamine
may also cause increased mucosal permeability,
which could facilitate increased access for the antigen
to the connective tissue.10 Mohtasham et al., Pazouki
et al observed an increase in vascularization during
transformation from normal oral mucosa, through
dysplasia, to in-situ and infiltrating carcinoma
supporting the pivtal role of angiogenesis in
malignancy progression.11,12 Flynn E et al,
demonstrated a direct co-relation between sequential
mast cell infiltration, activation and distinct stages of
hyperkeratosis, dysplasia, carcinoma in-situ in the
oral cavity and implicated the role of mast cells in
configuring
the
angiogenic
phenotype
in
premalignant lesions.13 Similarly Iamaroon et al also
observed a linear increase from normal oral mucosa,
hyperkeratosis, premalignant dysplasia to squamous
cell carcinoma suggesting the role of mast cells in upregulation of angiogenic process.14 Michailidou et.al.
observed that the mast cell density & microvessel
density did increase significantly between normal oral
mucosa and oral leukoplakia without dysplasia and
oral leukoplakia with mild, moderate or severe
dysplasia. 4 They concluded that an angiogenic switch
seemed to be turned on in the later stages of dysplasia
indicating a transformation into malignancy. Also a
possible role of mast cells during the progression
from normal oral tissue to oral epithelial dysplasia &
subsequently to oral squamous cell carcinoma was
elucidated. 4
In contrast to the above studies, Oliverira- Neto et al.
observed a decrease in mast cell numbers in
premalignant and malignant oral lesions which was
attributed to the failure of mast cell migration.15
Our study showed an increase in mast cell density
(mast cells are activated in allergic, inflammatory,
autoimmune conditions, in response to factors
released by the tumour cells, and in response to
infections) & microvessel density from normal oral
mucosa to oral epithelial dysplasia to oral squamous

cell carcinoma (Table 1and 2). A hypothesis can be
suggested that hypoxia might induce tumour cells to
release angiogenic factors which in turn could chemo
attract mast cells to migrate into the hypoxic areas of
the tumour. After migration into the hypoxic areas,
mast cells might produce stimulating factors that help
in further angiogenesis. Mast cells are also an
important source of several pro-angiogenic and
angiogenic factors, such as histamine, heparin,
chymase, basic broblast growth factor (bFGF),
vascular endothelial growth factor (VEGF), and
transforming growth factor- (TGF-) etc.1 These
angiogenic factors secreted by mast cells either
directly promote angiogenesis by stimulating the
migration and/or proliferation of endothelial cells or
indirectly through degradation of extracellular
matrix.4 Tryptase is a serine endopeptidase that is
released in abundant quantities from mast cells in a
bound form with heparin. Both heparin and tryptase
are potent angiogenic factors. Tryptase also activates
latent metalloproteinases and plasminogen activator,
which degrades the extracellular matrix, is important
in the initial stages of angiogenesis. 8
The mast cell density and microvessel density in our
study showed a positive correlation in normal oral
mucosa, oral epithelial dysplasia and oral squamous
cell carcinoma. However, a statistically significant
correlation between them with an increase in the mast
cell density and microvessel density was observed
only in oral epithelial dysplasia. All the cases of oral
squamous cell carcinoma used in our study were well
differentiated squamous cell carcinoma. From the
above, we can probably conclude that tumours that
are rapidly growing may have a high nutritive
demand that is provided by the vasculature. When the
epithelium is altered as in oral epithelial dysplasia,
recruitment of inflammatory cells is noted. The
inflammatory and mast cells that migrate to areas of
altered epithelium may stimulate angiogenesis by
secreting proangiogenic and angiogenic components
either directly or indirectly prior to the invasion.
However, once invasion is established as in oral
squamous cell carcinoma, the role of mast cells is
probably shifted from angiogenesis to further
promoting invasion as seen in our case. Another
hypothesis why such a finding was observed in oral
squamous cell carcinoma is probably that mast cells
50
Hegde Veda et al.,
are involved in cytotoxic function corresponding to

the invasion of dysplastic tumour epithelial cells
rather than supporting angiogenesis which would take
place once invasion is established. Cell-mediated
cytotoxic effects of mast cells have also been
reported, with mast cell: tumour ratio greater than
20:1.16 Conversely, cytotoxic effects of mast cells
were nullied and tumour progression was found to
be enhanced when the mast cell-tumour ratios were
increased from 20:1 to 1:100.16 Hence, the effect of
mast cells against cancer cells might depend on the
concentration of mast cell products in the
microenvironment. Tomita M et. al. hypothesized that
reversing this process, i.e., enhancing the cytotoxic
functions of mast cells and suppressing their
angiogenic functions, could lead to a new anti-cancer
treatment strategy.16
Kalra et al observed an increase in angiogenesis in
different histological grades of oral squamous cell
carcinoma.1 Poorly differentiated and moderately
differentiated oral squamous cell carcinoma attained a
highly angiogenic phenotype as compared to well
differentiated.1 Similarly Sharma et al observed that
mast cell density and microvessel density to be higher
in moderately differentiated compared to well
differentiated squamous cell carcinoma supporting
our hypothesis. 17 Thus when different grades of oral
squamous cell carcinoma are compared, poorly
differentiated
carcinoma
and
moderately
differentiated carcinomas are known to be more
proliferative and invasive thus in such cases mast
cells may have a dual role of promoting angiogenesis
and invasion and the cytotoxic function of mast cells
may be too ineffective in such situations. The
treatment of oral squamous cell carcinoma is surgical,
radiotherapy or chemotherapy or a combination
depending whether it is a primary or a recurrent
tumour. However, research is being done to promote
targeted therapy against angiogenesis, mast cells or
other factors that promote tumour growth
CONCLUSION
To conclude, there was a statistically significant
increase in mast cells and microvessel density from
normal mucosa to oral epithelial dysplasia and
squamous cell carcinoma consistent with the
pathogenesis. However, a statistical significance in
the ratio of the mast cells to microvessel density was
noted only in oral epithelial dysplasia. Thus mast

cells either promote or inhibit tumour growth either
alone or in association with other cells in the
microenvironment and exert an effect on the altered
tissue. Thus the present study has been valuable in
defining the role of mast cells in dysplastic
epithelium, while highlighting the role of mast cells
in modifying the stroma for invasion in oral
squamous
cell
carcinoma.
Thus
thorough
understanding the role of mast cells in premalignant
lesions and oral squamous cell carcinoma would help
in the development of anticancer therapies utilizing
angiogenesis as a target for the drugs.
REFERENCES
1. Karla M, Rao N, Nanda K, Rehman F, Girish KL,
Tippu S et al. The role of mast cells on
angiogenesis in oral squamous cell carcinoma.
Med Oral Patol Oral Cir Bucal. 2012; 17(2): 1906.
2. Raica M, Cimpean AM, Ribatti D. Angiogenesis
in premalignant conditions. Eur J Cancer. 2009;
45: 1924-34
3. Weidner N, Semole JP, Welch WR, Folkman J.
Tumour angiogenesis and metastasis- a
correlation in invasive breast cancer. N Engl J
Med. 1991; 324(1): 1-8.
4. Michailidou E Z, Markopoulos A K, Antoniades
D Z. Mast cells and angiogenesis in oral
malignant and premalignant lesions. The Open
Dent J. 2008; 2: 126-32.
5. Hung P H, Chou K C, Hsieh S H, Shieh Y S.
Tumour angiogenesis in oral squamous cell
carcinomas: the significance of endothelial
markers and hotspot selection. J Med Sci. 2009;
29(2):67-74.
6. Elpek G O, Gelen T, Aksoy N H, Erdogan A,
Dertsiz L, Demircan A, et al. The prognostic
relevance of angiogenesis and mast cells in
squamous cell carcinoma of the oesophagus. J
Clin Pathol. 2001; 54:94044
7. Trapero J C, Sanchez J C, Sanchez B P, Gutierrez
J S, Gonzalez M A, Martinez A Update on
molecular pathology in oral cancer and precancer.
Anticancer Res. 2008; 28 :1197-06.
51
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8. Leon C, Kempen L V, Rhee J S, Dehne K

Epithelial carcinogenesis: Dynamic interplay
between
neoplastic
cells
and
their
microenvironment. Differentiation. 2002; 70:
610-23.
9. Madhuri A R, Alka K D, Ramakant N. Mast cells
are increased in leukoplakia, oral submucous
fibrosis, oral lichen planus and oral squamous
cell carcinoma. J Oral Maxillofac Pathol. 2007;
11(1): 18-22.
10. Bivji AT. Mast cells in normal and leukoplakic
buccal mucosa J Ind Dent Assoc. 1973; 45: 18991.
11. Mohtasham N, Babakoohi S, Salehinejad J,
Montaser- Kouhsari L, Shakeri MT, Shojaee S et
al. Mast cells density and angiogenesis in oral
dysplastic epithelium and low and high grade oral
squamous cell carcinoma. Acta Odontol Scand.
2010; 68(5): 300-04.
12. Pazouki S, Chisholm DM, Adi MM, Carmichael
G, Farquharson M, Ogden GR et al. The
association between tumour progression and
vascularity in the oral mucosa. J Pathol. 1997;
183:39-43.
13. Flynn E, Schwartz j, Shklar G. Sequential mast
cell infilteration and degranulation during
experimental carcinogenesis. J Cancer Res Clin
Oncol. 1991; 117:115- 22.
14. Iamaroon A, Pongsiriwet S, Jittidecharaks S,
Pattanaporn K, Prapayasatok S, Wanachatararak
S. Increase of mast cells and tumour angiogenesis
in oral squamous cell carcinoma. J Oral Pathol
Med. 2003; 32: 195-99.
15. Oliveira Neto HH, Leite AF, Costa NL, Alencar
RC, Lara VS, Silva TS et al. Decrease in mast
cells in oral squamous cell carcinoma: possible
failure in the migration of these cells. Oral
Oncol.2007; 43 4:84-90.
16. Tomita M, Matsuzaki Y, Onitsuka T. Effect of
mast cells on tumor angiogenesis in lung cancer.
Ann Thorac Surg. 2000; 69(6): 1686-90.
17. Sharma B, Sriram G, Saraswathi TR,
Sivapathasundaram B Immunohistochemical
evaluation of mast cells and angiogenesis in oral
squamous cell carcinoma Indian Dent Res. 2010;
21(2): 260-64.
52
Hegde Veda et al.,
DOI: 10.5958/2319-5886.2015.00009.0

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Received: 14 Sep 2014
Research article
Coden: IJMRHS
Revised: 25th Oct 2014
Copyright @2014
ISSN: 2319-5886
Accepted: 2nd Dec 2014
IMPACT OF AGGRESSIVE SURGICAL INTERVENTION IN FOURNIERS GANGRENE AND ITS

CORRELATION TO THE OUTCOME IN PATIENTS AT A RURAL HOSPITAL
*Shaikh M.H.1, Singh Puneet2, Kamal Tausif Syed2, Shaikh Simran3
1
Professor, 2Resident, 3Medical Student, Department of Surgery, Pravara Institute of Medical Sciences (DU),
Loni, Maharashtra
*Corresponding author email: drmeena15@yahoo.com.

ABSTRACT
Background: Fourniers gangrene is rare and rapidly spreading aggressive and progressive infection of the
perineum in which fascial necrosis is more extensive than the visible gangrene. Early surgical debridement
prompt antibiotic administration, are essential for a better prognosis. Delay in diagnosis or treatment increase
the mortality rate. This could be because of the multi factorial and poly microbial association of the disease.
Aim: We attempt to describe the importance of early radical debridement and its effect on the outcome of the
disease. Methodology: We conducted an analytical study on 26 patients of Fournier gangrene admitted in the
rural hospital from July 2011 to July 2014. On admission, their Fournier gangrene severity index was calculated.
The broad spectrum antibiotics were started and radical debridement was done in all patients on the same day
within 6 hours of admission. Daily dressing was done till the wound showed healthy granulation tissue. The
scrotal skin was mobilized and suturing was done. Result: In our studies there was no mortality. This indicates
that early aggressive resuscitation to correct the dehydration and early radical debridement improves the
outcome in this rare and fatal disease.
Keywords: Fournier gangrene severity index, Radical debridement, Mortality.
INTRODUCTION
Fourniers gangrene involves the deep and superficial
fascia of the perineum1. Fascial necrosis is more
extensive than the visible gangrene. Early radical
debridement, prompt antibiotic administration with
nutritional support is essential for better prognosis2.
A French venerologist Jean Alfred Fournier in 1883
first described Fourniers gangrene3. He used the term
Fulminant gangrene4. The infection starts in the
anorectal, genitourinary, cutaneous areas suddenly
without any cause. Diabetes, suppressed immunity
are predisposing factors. Yanar et al showed that
mortality rates are relatively higher in patients with
diabetes mellitus, delayed admission to hospital and
in patients with sepsis at first admision5. The study

was conducted on 26 patients of Fourniers gangrene
admitted in our hospital. Delay in diagnosis or
treatment increase the mortality rate. Most studies
emphasized on the general management of the
disease. This could be because of the multi factorial
and poly microbial association of the disease. In most
of studies the mortality rate was high. There was no
protocol for management for this fatal rare disease.
Our study tries to emphasize on the specific protocol.
Time of surgical intervention is important in the
management. In our study of 26 patients the surgical
intervention was done within 6 hours of admission.
This reduced mortality in our patients.
53
Shaikh et al.,
Aim: We attempt to describe the importance of early

radical debridement and its effect on the outcome of
the disease.
Table 1: Symptoms of the patients (total =26)

History and symptoms
N
History of trauma
5
Sudden onset without any cause
21
History of pain
26
Swelling at the perianal region and
10
genitals
Swelling at the genitals, perineal and
16
perineum region extending to the
anterior abdominal wall
History of temperature
15
History of diabetes
5
All routine Pathological and Biochemical tests were
done at the time of admission and repeated alternate
day to know the progress. Based on the investigations
and signs, the Fourniers gangrene severity index was
calculated on the day of admission and alternate day
with the help of Fourniers Gangrene Severity Index
Parameters (Table 2).
The study was conducted after the institutional ethical

committee approval in the surgical department of the
PIMS Loni from July 2011 to July 2014.
Inclusion criteria: The patients presented in the
surgical O.P.D. with the severe inflammation of the
perianal region, genitals, perineal regions extending
to the anterior abdominal wall were diagnosed
clinically by us as Fourniers gangrene was included
in our study. The written consent of all the patients
were taken. All the patients were male from age
group 30 years to 80 years. All the patients were
admitted in the ICU. Table 1 shows the symptoms of
the patients. Exclusion criteria: Malignancy of penis
and perineal region with infection was excluded from
the study.
Table 2: Fourniers Gangrene Severity Index Parameters 6
High Abnormal Values
Normal
Low Abnormal Values
Physiological Variables
+4
+3
+2
+1
0
+1
+2
+3
+4
38.5343230Temperature (oc)
>41 39-40.9
36-38.4
<29.9
39
35.9
33.9
31.9
110Heart Rate ( beats/minute)
>180 140-179
70-109
55-69 40-54
<39
139
Respiratory Rate (/min)
>50
35-49
25-34
12-24
10-11
6-9
<5
266350120111Serum Sodium (mmol/L)
>180 160-179
130-149
<110
159
354
129
119
Serum Potassium (mmol/L)
>7
6-6.9
5.5-5.9 3.5-5.4 3-3.4 2.5-2.9
<3.5
Serum Creatinine
(mg/100/ml*2 for acute renal >3.5
2-3.4 1.5-1.9
0.6-1.4
<0.6
failure)
504620Hematocrit
>60
30-45.9
<20
59.9
49.9
29.9
2015WBC (Total/mm*1000)
>40
3-14.9
1-2.9
<1
39.9
19.9
Serum Bicarbonate
321815>52 41-51.9
22-31.9
<15
(Venous, mmol/L)
40.9
21.9
17.9
showed a 75% probability of mortality. The score of
Fourniers gangrene severity index helps to predict
9 or less showed a 78 % probability of survival6.
the prognosis in the patients of Fourniers gangrene.
Aggressive resuscitation was done in all the patients.
As shown in the table 2 Fourniers gangrene severity
The Ringer lactate was started as the intravenous
index has 9 parameters, the degree of deviation from
fluid and further fluids were given as per the blood
normal is graded from 0 to 4. The individual values
report, central venous pressure recording and urine
are summed to obtain the Fourniers gangrene
output. Injection Agumentin 1.2 gm intravenously
severity index of the patient. The score greater than 9
54
Shaikh et al.,
was started and repeated 12 hourly. Injection

Metronidazole 500 mg was started and repeated 8
hourly. The physicians anticipation was taken for the
treatment of diabetes. All the patients kept nil by
mouth. The urinary catheter was inserted for
estimation of urine output. All the patients were
posted for emergency operation. 21 patients were
taken within 2 hours of the admission and 5 were
taken within 6 hours of admission. 20 patients
received spinal anesthesia, 4 received general
anesthesia and 2 received local anesthesia. Radical
debridement was done in all patients. All dead tissue
was removed along with some part of healthy tissue
and the skin (Fig: 2). The removed tissues were sent
for histopathology.
The daily dressing was done from the 2nd
postoperative day. The wound was washed with
hydrogen peroxide and saline. The Chloromycetin
powder was applied to the wound and covered with
sterile dressing. The dead tissue was removed daily
during dressing. These patients were shifted to the
wards. The 5 patients those were diabetic needed 7
days to settle clinically. They were shifted to the
wards after 7 days. The metronidazole 500mg. was
given intravenously 8 hourly for 7 days. The
injectable Amoxiclav was given for 5 days then
shifted to the oral antibiotics depending on culture
sensitivity report. The above treatment continued till
the wound had shown the healthy granulation tissue
without infection. All the patients were subjected to
the elective operation. The skin surrounding the
wound was mobilized and suturing was done with
non-absorbable suture material (Fig: 3). Sutures were
removed on 13th postoperative day. The 5 diabetic
patients had shown wound infection after suturing. In
these patients after treating wound infection the
resuturing was done, sutures were removed on the 7th
postoperative day and patients were discharged. All
the patients received high protein diet, Vitamin C and
hematinics. All these measures helped the patient to
improve his metabolic variation and gave the good
outcome. All the patients were called for review after
7 days. Out of 26 patients, 15 patients came for
regular check up. They are free from the disease.
RESULTS
During the study period from July 2011 to July 2014
all the patients were male from 30 years to 80 years.
21 patients were non diabetic and 5 were diabetic. 5

diabetic patients had minor trauma leading to
Fourniers gangrene.
In 21 patients, no cause was detected. In the present
study 13 patients showed the Fourniers gangrene
severity index 16 on the day of admission that came
to 10 on the 2nd postoperative day and came to the
normal between 7 to 12 postoperative days. In 9
patients it was 10 and in 4 it was 9. In all patients the
score started declining after surgical intervention. In
21 patients within one hour of the admission radical
debridement was done. In 5 patients due to
uncontrolled diabetes, surgery was done after 4 hours.
All patients received injectable Amoxiclav on
admission and shifted to the other antibiotic
depending on pus culture report. (Table 3)
Table 3: Pus culture sensitivity
Organisms
Sensitivity
No of
patients
Amoxiclav,
Staphylococcus
13
Chloramphenicol
aureus
Gentamycin,
E.coli
10
Chloramphenicol
Klebsiella
Diphtheroids
Gentamycin.
2
Gentamycin,
1
Amikacin.
Local use of Chloramphenicol powder helped the
wound to heal early. From the 2nd postoperative day,
21 patients showed improvement clinically. Their
blood reports came to normal.
Fig 1: Signs and symptoms of Fourniers gangrene

The minimum time taken for Fourniers gangrene
severity index to come to normal was 15 days and
maximum was 2 months after operation.
The histopathological reports of all patients have
shown the fascial necrosis, inflammatory cells and the
normal tissue indicating the adequacy of the excision.
The most prominent associated disease was diabetes.
55
Shaikh et al.,
The interval from the onset of clinical symptoms to

the initial surgical intervention seems to be the most
important prognostic factor with a significant impact
on outcome.
All were survived without any
complications.
Fig 2: Emergency radical debridement
fact in mind in our all patients, we excised the dead

tissue along with some part of normal tissue so we
called it as aggressive radical debridement to remove
facial necrosis. The Fourniers gangrene was
originally thought to be an idiopathic gangrene of the
genitalia; however, a specific etiology is found in
approximately 95% of cases9. Anorectal abscess,
genitourinary infection, and traumatic injury are the
most common causes10. Localized tenderness, softtissue crepitus, or occult wounds in the genitalia,
perineum, and anorectal area should alert the
examiner to the possibility of Fourniers gangrene.
High mortality rate was noted in literature11. In our
study, we excised extensive tissues to remove the
infection completely. (Fig: 2). Emergency operation
was done in all the patients within 6 hours. Early
aggressive radical debridement with nutritional
support improves the outcome in this fatal rare
disease as shown in our patients.
CONCLUSION
Fig 3: Mobilization of local skin of scrotum and

suturing
DISCUSSION
In our study all the patients were from low socioeconomical group and their hygiene was poor. This
had given the infection of the genitals and perianal
region. Due to the lack of cleanliness and poor
resistance the infection spread rapidly. The time
interval from the onset of the pain and swelling to the
presentation to the hospital was from 5 days to 10
days. The early radical debridement and use of broad
spectrum antibiotics changed the course of this fatal
disease. All the 26 patients in our study were showing
the aggressive spreading necrotizing fasciitis, of the
deep and superficial fascia of the perineum
resembling Fourniers gangrene7. Fascial necrosis
was more than the visible gangrene8. Keeping this
In the present study all the 26 patients had severe pain

and tenderness in the genitalia. Pain and tenderness
are hallmarks of this infection. Even though the
patients were presented to the hospital late, early
radical debridement with nutritional support gave the
good outcome. We removed the infection by early
radical debridement and supported by the broad
spectrum antibiotic to prevent the spread of the
infection and nutritional support to improve the
immunity. The above management is good as all the
patients survived and are free of disease. The early
aggressive surgical intervention in Fourniers
gangrene has a definite impact on the outcome. We
recommend this method in which early radical
surgery is the important predictor for the outcome in
patients.
ACKNOWLEDGEMENT
We authors are grateful to the Management of
Pravara Institute of Medical Sciences for support.
We are thankful to our all colleagues for their
support. We are grateful to all the patients who
participated in the project.
56
Shaikh et al.,
REFERENCES
1. Yaghan RJ, Al-Jaberi TM, Bani-Hani I.
Fourniers gangrene: changing face of the
disease. Dis Colon Rectum. 2000; 43(9):1300-08.
2. Harden SP, Creasy TS. Case of the month. All
that glistens isnt gold (so do be sure the
surgeons Told!). Br J 2003; 76(911):841-42.
3. Paty R, Smith Ad. Gangrene And Fourniers
Gangrene. Urol Clin North Am. 1992; 19
(1):149-162.
4. Corma JM,Moody JA,Aranson WL:Fourniers
gangrene in a modern surgical setting:
improved survival with aggressive manage
ment. Br. J. Urol int 1999,84: 85-88.
5. Yanar H, Taviloglu K, Ertokin C,Guloglu
R,Zorba U,Cabioglu N.etall : Fournier gangrene
:Risk factors and strategies for management.
World J.Surg 2006,30:1750-54.
6. Rohan khandelwal, Chintamani, megha
Tondon, Arjun Saradna, Deepansh Gupta,
Bhavya Bahl,department of surgery Vardhaman
Medical College Safdarjang Hospital, Delhi,
India.: FournierGangrene Severity Index as a
Predictor of outcome in patients with Fourniers
Gangrene:A Prospective Study Clinical Study at
a Tertiary care center.Journal of Young Medical
Reserchers: Published on line on 7Oct.2013.
7. Morua AG,Lopez JA,Garcia JD,Montelongo
RM,Guerra L.S.: Fourniers gangrene:our
experience in 5 years, bibilographic review and
assessment of the Fourniers gangrene severity
index. Arch ESP Urol 2009, 62: 532-40.
8. Yaghan RJ, Al-Jaberi TM, Bani-Hani I.
Fourniers gangrene: changing face of the
disease. Dis Colon Rectum. 2000; 43(9):130008.
9. Harden SP, Creasy TS. Case of the month. All
that glisten isnt gold (so do be sure the
surgeons told!). Br J Radiol. 2003;
76(911):841-42.
10. Clayton MD, Fowler JE Jr, Sharif R, Pearl RK.
Causes, presentation and survival of fifty-seven
patients with necrotizing fasciitis of the male
genitalia.
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11. Eke N: Fourniers gangrene: a review of 1726
cases. Br.J Surg 2000; 87:718-28
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Shaikh et al.,
DOI: 10.5958/2319-5886.2015.00010.7

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 7 Nov 2014
Accepted: 11th Dec 2014
ASSESSMENT OF THE FACTORS INFLUENCING AND COMPARING THE INTRAOCULAR

PRESSURE WITH THE HELP OF SCHIOTZ INDENTATION TONOMETER AND GOLDMANNS
APPLANATION TONOMETER: A CLINICAL STUDY
*Mridula V Amarnath1, Christina Samuel1, Sundararajan D2
1
Postgraduate, 2Professor & Head, Department of Ophthalmology, Meenakshi Medical College, Kanchipuram,
Tamil Nadu, India
*Corresponding author email: mridulavenugopal.88@gmail.com
ABSTRACT
Background: Intraocular pressure (IOP) is the fluid pressure inside the eye and is maintained by the equilibrium
between the forces determining the formation of aqueous humour and the alteration in the resistance to its
outflow. IOP is important to evaluate patients who are at an increased risk of glaucoma. Clinically measurement
of IOP is based on principles of indentation and applanation and such a method is called Tonometry. The
tonometers used today are the Schiotz Indentataion Tonometer (ST) and the Goldmanns Applanation Tonometer
(GAT). However the latter is accepted as the standard one. Aim: 1) To estimate the normal mean IOP for the
population under study.2) To study the various factors- age, sex, refractive errors that influence the IOP.3) Merits
and demerits of the individual tonometers. Method: A sample size of 100 cases of 200 sets of eyes was taken and
divided into 2 groups, Group A with emmetropia, myopia, hypermetropia of both sexes and Group B with frank
glaucomatous changes of both sexes. 3 consecutive measurements with GAT were recorded in each eye followed
by ST with 5.5gm weight first followed by ST with 7.5gm weight. The whole database was recorded and
statistically analysed. Results: Out of the total 200 eyes studied, Group A consisted of 168 apparently normal
eyes which included emmetropes, myopes and hypermetropes and Group B comprised of 32 eyes which were
frank glaucomatous cases with glaucomatous field defects. On estimating the mean IOP with the help of GAT and
ST between the 2 eyes there was not a significant difference. On comparing the refractive status, myopes showed
a higher IOP than hypermetropes and emmetropes. With both GAT and ST females had higher IOP than males.
The mean IOP increased as age progressed. Group B studies which had frank glaucoma cases showed that the IOP
measured with GAT was higher and more accurate to the actual IOP value whereas the readings with Schiotz
were variable and unreliable. Conclusion: IOP is one of the key metrics which is used to monitor the health of
ones eye especially an eye with glaucoma. The IOP measured with GAT was more accurate towards the true
intraocular pressure and hence Applanation Tonometer is considered gold standard in measuring IOP.
Keywords: Intraocular pressure, Goldmanns applanation tonometer, Schiotz indentation tonometer
INTRODUCTION
The intraocular pressure of the eye is determined by
the balance between the amount of the aqueous
humor that is manufactured by the eye and the ease
with which it leaves the eye. Early in the 17th century,
Mridula et al.,
an English physician Richard Bannsiter noticed that

in spite of performing cataract surgeries there was no
improvement in the vision1. Later in the 19th century,
William Bowman developed a method to estimate the
Int J Med Res Heatlh Sci. 2015;4(1):58-64
58
tension of the eye by palpating the closed eyelid with

his fingers. Eventually they came to a conclusion the
higher the IOP, the greater is the chance that the eye
would become blind. Later instruments were being
developed for more objective measurement of IOP
and it was believed that IOP above 21 mmHg is
abnormal and the goal of glaucoma treatment was to
lower the IOP below 21 mm Hg.2
There are various factors that can influence the IOP.
Some of the short term factors are-ocular pulse,
straining, breath holding, posture, accommodation,
eye rubbing, contact lens removal. While the medium
term factors include diurnal variation, eating and
drinking, smoking, systemic medication, exercise,
Optometric techniques and the long term factors
include age, general health of the individual, gender,
season and ocular factors.
The main symptom of increase in intraocular pressure
is the gradual loss of vision. Hence it is very
important to have a regular eye check up for
glaucoma later in life as in some cases the
progression is gradual and the patient may not even
realise it. Sudden onset of throbbing pain and redness
in the eye, headache, blurring of vision, halos around
light, dilated pupil, nausea and vomiting are some of
the common and critical symptoms of raised intra
ocular pressure. In cases of young children watering
from the eyes, sensitivity to light and eye lid spasm is
common.
According to the current census ophthalmologists
define the normal intraocular pressure as that
pressure, which is within 10 to 20 mm Hg3 with the
average value being 15.5 mm Hg with fluctuations of
2.75 mm Hg.4 Ocular hypertension is defined when
the intra ocular pressure is higher than normal, in the
absence of optic nerve damage or visual field loss.
Hypotony can be defined as IOP less than or equal to
5 mm Hg. This could probably be due to fluid
leakage and deflation of the eye ball.5
Glaucoma is group of ocular disorders that results in
optic nerve damage or a loss to the field of vision
which is caused by an increase in the intraocular
pressure. 6 It can be classified into open or closed
angle glaucoma wherein the angle refers to the space
between the iris and the cornea through which the
aqueous fluid escapes via the trabecular mesh-work.
Glaucoma tends to be inherited and may not show up
until later in life7 and usually gets worse with time. If
the damage to the optic nerve due to the increased
Mridula et al.,
intraocular pressure continues, then it can lead to a

tunnel vision and finally a permanent loss of vision.
Tonometry is a non invasive technique of
measurement of IOP. It measures the pressure
without cannulating the eye. However manometry in
reference to the eye is undoubtedly the only accurate
technique, but it is not applicable clinically. Hence a
more indirect approach was taken up using a
tonometry wherein the tension of the outer coats of
the eye is assessed by measuring its impressibility or
applanability8
METHODS AND MATERIALS
Patients were selected from the OPD of Dept of
Ophthalmology, Meenakshi Medical College,
Kanchipuram. Written consent was taken from the
subjects and was explained to them in their own
language. Prior to the study the ethical clearance was
obtained from the Institutional Ethics Committee.
Sample size: The study material consisted of 100
cases of 200 sets of eyes.
Inclusion criteria: Normal anterior segment, patient
with glaucoma having an increase in IOP,
glaucomatous field defects and optic disc changes.
Exclusion criteria: anterior segment disorders viz
infections like conjunctivitis, viral keratitis, corneal
ulcers, corneal opacifications, corneal oedema and
uveitis.
Type of study: A cross sectional descriptive study for
a period of 12 months.
Procedure: The subjects were divided into two
groups. Group A had 168 eyes with emmetropia,
myopia and hypermetropia of both sexes. Group B
had 32 eyes with frank glaucomatous changes which
included Angle closure glaucoma, Lens induced
glaucoma, Closure suspect glaucoma in both sexes.
In both the group of patient, 4 % lignocaine was
instilled in the eye. Tonometric examination was
performed in a uniform sequence in all eyes using a
Goldmann application tonometer (GAT) first
followed by Schiotz tonometer (ST) with 5.5 gm and
ST 7.5 gm weight3
For evaluation of the IOP using GAT a fluorescent
dye was instilled so that the measurement mires are
visible. The tonometer which is mounted on the
microscope is illuminated with a beam which is
placed at an angle of 45 degrees. The cobalt blue
filter is moved into place. The patient is then advised
to look straight ahead at the target point and the
59
tonometer tip is guided to touch the corneal apex. The

position of the mires is observed and made sure they
are centred in the field of equal size, with the inner
surface touching each other. And thereby the pressure
from the scale on the knob attached to the side of the
tonometer is read.
In case with a Schiotz tonometer, after instillation of
the anaesthetic drop, the patient is made to lie down
with the nose facing upwards. The base of the
tonometer gently rests on the cornea and the
movement of the scale is noticed and is compared
with the chart. A high scale reading indicates a low
IOP and vice versa.
Three consecutive measurements were recorded on
each eye and their average was taken. All tonometer
were calibrated according to the manufactures
instruction each day before use. The whole database
was statistically analysed with reference to the
following:
Mean IOP using both the instruments, IOP in
different age groups, IOP in both sexes, -IOP in
subjects with different refractive status
Statistical analysis was done using Statistical Package
for Social Sciences (SPSS version 12.0). Chi square
test and t- student test was used to compare the
variables.
Significance was considered if P<0.05
Figure 1 shows the mean IOP among group A which

was 15.30mmHg in GAT, 15.06 mmHg with ST 5.5
and 14.84 mmHg with ST 7.5. Among group B the
mean IOP recorded with GAT in males was 38.18
mmHg and 48.43 mmHg in females. With ST 7.5
mean IOP in males showed 36.19 mmHg and 46.28
mm Hg. With regards to the mean IOP between both
the eyes, Figure 2 showed that the mean IOP in right
eye with GAT was 15.39mmHg, 15.06 mm Hg with
ST 5.5. &14.81 mm Hg with ST 7.5. Figure 3 showed
that the mean IOP in the left eye with GAT was 15.37
mm Hg, 15.01 mm Hg with ST 5.5 and 14.87 mm Hg
with ST 7.5.The IOP difference with GAT was 0.02
higher in the right eye whereas ST 5.5 showed no
difference and ST 7.5 showed 0.06 mm Hg higher in
left eye.
REFRACTIVE STATUS OF EYES AMONG GROUP A
GAT
ST 5.5
33%
ST 7.5
34%
33%
RESULTS
In our study 200 eyes were taken into consideration
and divided into two groups of which, Group A
consisted of 168 apparently normal eyes, which
included emmetropes, myopes and hypermetropes
and Group B comprised of 32 eyes which were frank
glaucomatous cases with glaucomatous field defects.
15.6
IOP among Group A
15.4
15.2
15
14.8
14.6
14.4
mmHG
GAT
Mean IOP
ST 5.5
St 7.5
Rt eye IOP
Lt eye IOP
Fig 1: IOP among Group A with different

instruments
Mridula et al.,
Fig 2: shows the refractive status of the eyes

among group A
Figure 2 shows the refractive status of the eye among
group A of which 57% were emmetropes, 26% were
myopic and 17% were hypermetropics. In Figure 5 it
showed that in emmetropes, GAT in right eye
revealed 15.10 mm Hg and 15.14 mmHg in left eye.
With ST 5.5 it showed 14.88 mm Hg in right eye and
15.01 mm Hg in left eye. With ST 7.5 mean IOP in
right eye showed 14.61 mmHg and 14.73 mm Hg in
left eye. Figure 4 shows the IOP recorded in 44
myopes with GAT in right eye showed 16.40 mm
Hg and 16.40 mm Hg in left eye. With ST 5.5 right
eye recorded 15.7 mm Hg and 15.86 in left eye. With
ST 7.5, right eye showed 15.4 mm Hg and 15.8 mm
Hg in left eye. In Figure 5, among the 28
hypermetropes, GAT in right eye recorded 14.78 mm
Hg and 14.42 mm Hg in left eye. With ST 5.5 right
eye showed 14.62 mm Hg and left eye showed
60
13.97mm Hg. With ST 7.5 right eye recorded 14.41

mm Hg and left eye showed 13.85 mmHg Figure 6
shows the sex percentile in study group A with 55
percentile being males and 45percentile being
females.
IOP IN mm Hg
IOP IN EMMETROPES
recorded 15.17 mm Hg in males, 15.55 mm Hg in

females. With ST 5.5 males showed 14.9 mm Hg and
females showed 15.19 mm Hg. With ST 7.5, males
showed 14.56 mm Hg and females recorded 15.06
mm Hg. Thus while comparing it revealed that
females have higher mean IOP than males with both
GAT and ST
SEX PERCENTILE IN STUDY GROUP A
15.5
MALES
15
FEMALES
14.5
14
GAT
ST 5.5
ST 7.5
INSTRUMENTS
RIGHT EYE
45%
LEFT EYE
55%
Fig 3: The IOP in Emmetropes

IOP IN MYOPES WITH DIFFERENT INSTRUMENTS
SEX WISE DISTRIBUTION IN GROUP A
GAT
ST 5.5
ST 7.5
INSTRUMENTS
RIGHT EYE
IOP IN mm Hg
IOP IN mm Hg
Fig 6: Sex percentile in group A

16.5
16
15.5
15
14.5
16
15.5
15
14.5
14
GAT
LEFT EYE
ST 5.5
ST 7.5
INSTRUMENTS
Fig 4: The IOP in myopes

MALES
IOP IN mm Hg
IOP IN MYOPES WITH DIFFERENT INSTRUMENTS
FEMALES
Fig 7: The mean IOP among both the sexes.
16.5
16
15.5
15
14.5
AGE DISTRIBUTION AMONG STUDY GROUP A
4% 1%
GAT
ST 5.5
20%
ST 7.5
31%
INSTRUMENTS
RIGHT EYE
44%
LEFT EYE
Fig 5: Shows the IOP in hypermetropes

In Figure 7 the mean IOP in both the sexes were
estimated. Of the 76 males and 92 females, GAT
Mridula et al.,
31-40
41-50
51-60
61-70
>70
Fig 8: Age distribution among study group A

61
Figure 8 shows the number of subjects in the different

age categories. In the age group 31-40 yrs 34 eyes
were evaluated, with 74 eyes in the age group 41-50
years, 52 eyes in the age group 51-60 years, 6 eyes
between
61-70 years and above 70 years 2 eyes
were evaluated for.
Figure 9hows the age wise difference in mean IOP
with both GAT and ST. In 31-40 yrs age group, it
showed 14.88 mm Hg, 14.63 mm Hg and 14.52
mmHg with GAT, ST5.5 and ST 7.5 respectively. In
41 to 50 age group it was 14.9 mm Hg, 14.56 mm Hg
14.25 mm Hg with GAT, ST 5.5 and ST 7.5
respectively.In 51 to 60 yrs age group, it was 16.43
mm Hg, 15.73 mm Hg and 15.55 mm Hg with GAT,
ST 5.5 and ST 7.5 respectively. In 61 to 70 yrs it was
17.4 mm Hg, 16.80 mm Hg, 15.93 mm Hg with GT,
ST 5.5 and ST 7.7 respectively. And above 70 yrs it
showed 21 mm Hg, 20,6 mm Hg, 21.9 mm Hg with
GAT, ST 5.5 and ST7.5 respectively.
IOP IN mm Hg
AGE WISE DISTRIBUTION OF IOP

25
20
15
10
5
0
31-40
41-50
51-60
61-70
>70
AGE INTERVAL IN YEARS

GAT
ST 5.5
ST 7.5
Fig 9: The Mean IOP in different age groups with

GAT AND ST
IOP IN MM Hg
IOP AMONG MALES ANF FEMALES IN GROUP B
60
50
40
30
20
10
0
MALES
FEMALES
INSTRUMENT USED
GAT
ST 7.5
Fig 10: Mean IOP among males and females in

group B
Mridula et al.,
Figure 10 shows the mean IOP among males and

females in group B using both ST and GAT
DISCUSSION
Glaucoma initially was defined as an increase in IOP
resulting in damage to the visual system and thus
causing irreversible blindness. Various instruments
used for measuring IOP vary in terms of the design,
mechanism and accuracy. However the GAT
tonometer is considered as a gold standard in
measuring IOP
However, there is a controversial study about the
relationship between blood pressure and the
intraocular pressure. Some studies have shown that
low blood pressure predisposes to low ocular
perfusion pressure (OPP), which can increase the
chance of hypoxic or ischemic stress. This correlates
with the nocturnal IOP elevations and blood pressure
dips. Although the role of low blood pressure in
glaucoma is clearly detrimental, the effect of high
blood pressure is still more complex. In the short term
however, the high blood pressure can improve the
OPP and provide some protection against the IOP
induced ischemia
Recent studies have shown that on lowering the
ocular perfusion pressure, the chances of visual field
loss can be reduced. The OPP is largely determined
by cardiovascular fitness.
While checking the calibration error one must be
attentive. It is noted that the calibration check bar
should be positioned with the long arm towards the
examiner while changing the settings, since the GAT
is based on a balancing principle. The intra observer
and the inter observer agreement in the measurement
of calibration error of GAT is rarely reported in
literature.
A number of western studies were done like the
Armaly 9 which recorded a mean IOP of 16.22mmhg,
Goldmann and Schmidt recorded a mean IOP of
15.45mmhg. In our study a mean IOP among group A
with GAT revealed 15.30 mm Hg, with ST 5.5 as
15.06 mm Hg and with ST 7.5 as 14.84 mm Hg.
Comparing the readings of GAT and ST in population
a study was conducted and according to Bayard there
was a close relation between GAT and ST. Bawton
Smith et al10 showed GAT recorded a higher value
than ST in 84% of the eyes and the difference
between the two tensions was less than 1 mm Hg.
Mansoor F and Armaly MD11,12,13(1966) compared
62
GAT and ST and concluded that the difference was

due to co efficient of ocular rigidity and position of
the patient. In this study GAT revealed a higher value
in apparently normal eyes and the average difference
between GAT and ST being 0.24 mm Hg.
Comparing mean IOP between right and left eye,
Davanger14 showed that the difference in mean IOP of
the two eyes of the same individual had no difference
in nearly 46% of the population and a difference of
less than 3 mm Hg in the remainder. In our study, the
mean IOP of the 2 eyes, GAT revealed a higher value
of 0.02 in right eye; ST5.5 revealed no difference and
ST 7.5 showed 0.07 higher values in the right eye.
Comparing IOP in subjects with different refractive
status. Badlani and Telang, 15,16 showed a mean IOP
higher in myopes which was between 13-19 mm Hg.
This study showed that myopes had a higher IOP
with GAT recording a value of 16.4 mm Hg, ST 5.5
as 15.8 mm Hg and ST 7.5 as 15.4 mm Hg.
Comparing IOP in reference to the sexes Bankes17
recorded a mean IOP in males and females, and
females had a higher value between the age group 4049 and equal value in the age group of 50-59. Our
study showed that females had a higher value
compared to mean values in males, the value
differing less than 1 mm Hg with both GAT and ST.
Comparing IOP in different age groups, Bengtsson B
18
compared GAT and ST, revealed that both gave
similar values till the age of 50 years and with
advancing age GAT revealed higher values than ST.
Our study showed an increase in IOP with increasing
age, GAT revealing higher values, and with more
difference in mean IOP with ST as age progresses.
Some of the advantages of GAT are that it is
repeatable, less dependent on sclera rigidity and
hence it is more accurate than Schiotz, most
commonly used tonometer in the world, and allows
comparability of readings, usable readings obtained
in nystagmus. Disadvantages include difficulty in
sterilising the tip, condoms and disposable tips reduce
the accuracy, must be a slit lamp mounted with the
patient in an upright position and expensive
Limitations of the study: In all mechanical
tonometers certain amount of instrumental error are
bound to occur due to friction and mechanical faults.
Some amount of extra ocular muscle contraction
occurs when the tonometer is placed on the eye and
this can cause an increase in the IOP. However
accommodation has a reverse effect since the
Mridula et al.,
contraction of the ciliary muscles will cause an

increase in the outflow of the aqueous and reduce the
IOP.
Certain amount of resistance is offered by the eyeball
to a change in the intra ocular volume, which
manifests as a change in the IOP. The distensibilty of
the eyeball is small, thus when the volume increases
by 0.1% the IOP rises between 20-30mmhg, however
such measurements can be recorded accurately only
by a manometer.
CONCLUSION
In the study that was conducted it was observed that
the IOP measured with GAT was more accurate and
higher value than ST. The values also correlated with
the true intra ocular pressure. With respect to the
difference in the IOP between the two eyes, the mean
IOP did not show any significant difference with both
GAT and ST. Regarding the refractive status, myopes
showed a higher mean IOP than emmetropes and
hypermetropes. Considering the sex difference, with
both GAT and ST females had a higher reading. With
respect to age, the mean IOP increased with age.
Group B studies which had frank glaucoma cases
showed that the IOP measured with GAT was higher
and more accurate to the actual IOP value whereas
the readings with Schiotz were variable and
unreliable.
ACKNOWLEDGEMENT
It is with the sense of accomplishment and deep
gratitude that I dedicate the work to all those who
have been instrumental in its completion. I am greatly
thankful to the Department of Ophthalmology,
Meenakshi Medical College, Hospital and Research
Institute, Kanchipuram. I sincerely acknowledge the
invaluable help rendered by R. Balasubramanian
MSc, MPhil. Statistician cum lecturer.
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Ophthalmol
2000;44(13):367-408
2. Goldmann H, Schimdt T Uber. Apllanation
tonometrie. Ophthalmological. 1957;134(53):2142
3. Brooks AM, Robertson IF. Ocular Rigidity and
IOP. Aust J Ophthalmol.1988;12(9):31-42
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4. Bohm A, Kohlhaas M. Effect of changed

biomechanics. Ophthalmologe.1997;94(34):771-4
5. Cohen E J, Ozhek Z. Dynamic contour-a new
way to assess the IOP. Cornea.2006;25(76):890-9
6. Abhrahamson. Basics in Intraocular Pressure.
American
Journal
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Ophthalmology.
2003;89(48):12-17
7. Albert, Jakobiee. Applanation tonometer. British
journal of ophthalmology. 2000;143(32):78-90
8. Arun Kumar Jain. Measurement of IOP. All India
Ophthalmology Society.1997.195(45):36-43
9. Armaly.
Article
title.
Archive
Ophthalmology.1963; 23(70):12-15
10. Bowton Smith. Principles in Ophthalmology.
Archives Ophthalmology.1967; 67 (77):34-41
11. Mansour F Armaly. Goldmann Applanation
Tonometer. Archives of
Ophthalmology
.1997;113 (64):39-48
12. Mansour F Armaly. Introduction To Glaucoma.
Archives of Ophthalmology.1993; 67( 73):11-18
13. Mansour F Armaly M. Factors affecting IOP.
Archives of Ophthalmology. 1998;120 (78):825829
14. Davenger. Comparing the Intraocular Pressure.
Acta Ophthalmogica. 1992;89 (43):299-300
15. Badlani, Telang .Refractive status and IOP .All
India Ophthalmology Society.1990;156 (14):13
16. Badlani and Telang . Variations in IOP. All India
Ophthalmology Society. 1987;87 (21):34
17. Bankes. Assessment of the IOP. British Medical
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64
DOI: 10.5958/2319-5886.2015.00011.9

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Coden: IJMRHS
rd
Research article
Copyright @2014
ISSN: 2319-5886
Accepted: 23rd Dec 2014
PRO AND ANTI-INFLAMMATORY EFFECTS OF GRADED PHYSICAL EXERCISE

*Ambarish Vijayaraghava1, Radhika K2
1
Associate Professor, Department of Physiology, 2Lecturer Cum Statistician, Department of Preventive and Social
Medicine, M. S. Ramaiah Medical College, Matinee, MSRIT Post, Bangalore, India
*Corresponding author email: ambarishv@rediffmail.com

ABSTRACT
Background: It is generally believed that exercise is good for health. Exercise can be harmful to immune system
depending on type and duration. So it was decided to study the plasma levels of cytokines with increasing severity
of exercise. We observed plasma levels of cytokines on performing graded exercise. Cytokines are protein
molecules modulating the Immune system. Interferon Gamma and Tumour Necrosis Factor alpha are proinflammatory and anti-inflammatory cytokines respectively. Methods: Study design: Effect of single bout each
of moderate exercise and strenuous exercise and one month of regular moderate exercise on plasma TNF- and
IFN- was assessed. Blood samples were drawn from each subject soon after one bout of moderate exercise.
Another blood sample was drawn from each of the subjects after one bout of strenuous exercise which was
performed on next day. The third blood sample was drawn on last day of one month of regular moderate exercise
after performing the exercise. Subjects consisted of 18 healthy volunteers (10 males and 8 females) with mean
age, 20.94 years, range, 18-25 years. The sample size was calculated statistically based on a previous study. TNF and IFN- were estimated by Sandwich ELISA technique. Friedman test was used for analyzing TNF- and
IFN- values. Results: Mean and SD values of IFN- and TNF- (in pictograms per ml) for baseline (no exercise)
was: 54.56 28.54 and 26.17 17.62 respectively, for acute moderate exercise: 28.72 27.57 and 53.83 27.25
respectively, for acute strenuous exercise: 20.36 16.96 and 93.50 5.39 respectively and after one month of
regular moderate exercise: 106.33 21.51 and 15.61 8.89 respectively. TNF- and IFN-showed overall
significance between different grades of exercise (p < 0.05). Conclusions: Plasma TNF- increases with one bout
of acute moderate exercise and increases further with one bout of acute strenuous exercise and decreases to below
baseline values at the end of one month of regular moderate exercise. IFN-levels exhibit opposite behaviour.
This shows that regular moderate exercise has beneficial effects on health by way of increasing plasma IFN-
level and decreasing TNF- level.
Keywords: Interferon gamma, Tumour Necrosis Factor alpha, Exercise, Inflammation.
INTRODUCTION
Tumour Necrosis Factor alpha (TNF-) is a proinflammatory cytokine and Interferon-Gamma (IFN) is an anti-inflammatory cytokine 1, 2. Higher levels
of inflammatory cytokines like TNF- and IL-6 is
associated with the genesis and complications of
several lifestyle disorders3, 4. Unaccustomed physical
activity can have harmful effects on health5. It

increases serum IL-6 levels and the hsCRP (highly
sensitive C reactive protein) to correlate with
increased incidence of cardiovascular diseases6.
Persisting physical stress increases secretion of IL-6
which in turn leads to premature onset of lifestyle
65
Ambarish et al.,
disorders 7. Moderate exercise performed regularly

decreases severity of inflammation in rheumatoid
arthritis 8,9. The performance of immune system
improves with daily practice of moderate exercise 10.
Regular moderate exercise improves overall health in
all age groups 11, 12.
Several studies have been undertaken to observe the
plasma cytokine changes with different modes of
exercises like marathon, military training, downhill
running on a treadmill, cycling, etc., on different
groups of individuals in different parts of the world.
Strenuous exercise as in military training and
unaccustomed marathon running led to decrease in
mucosal immunity. Performance of regular exercise
of moderate nature improved the performance of
immune system even in the elderly. Moderate
exercise performed on a regular basis decreased the
levels of IL-6 in patients of Systemic Lupus
Erythematosus (SLE) 13, 14, 15, 16. We undertook this
study in order to understand the impact of moderate
and strenuous exercise on the plasma levels of IFN-
and TNF- in unaccustomed individuals and the
benefit of exercise on accustumisation by the same
individuals.
This is a longitudinal study. 18 healthy volunteers, 10
males and 8 females in the age group of 18 to 25
years, with mean BMI of 21.641.83 (kg/m2) not
performing any kind of regular exercise were
included in this study, after obtaining prior consent.
Sample size was calculated for TNF- and IFN-
separately, based on a previous study 17. For IFN-,
with an effect size of 0.66, power of 80% and
significance of 5%, the minimum sample size was
estimated to be 15. For TNF- , with an effect size of
2 and power of 90%, sample size worked out to be 4.
However, in view of less sample size obtained on
calculation, it was increased to 16. Clearance was
obtained from the institutional ethics committee for
the study. The approved number of subjects was 20.
Two subjects dropped out during the study period and
hence only 18 subjects could be included in the study.
Exclusion Criteria: Individuals below and above,
the age range of 18 to 25 years, those suffering from
any kind of illnesses including chronic disorders and
on long term medication and people who smoke,
consume alcohol and/or take illicit drugs in any form.
The subjects were made to perform one bout of

moderate exercise of 7 minutes (acute moderate
exercise), one bout of strenuous exercise of 15
minutes (acute strenuous exercise) and one month of
scheduled moderate exercise on a daily basis. That is,
each day the subjects would perform one bout of
moderate exercise of seven minutes for one month 18.
The sequence of exercise was as follows: The
subjects were made to perform acute moderate
exercise on the first day. The subjects were made to
perform one bout of acute strenuous exercise on the
second day. The subjects were made to perform
scheduled regular moderate exercise from the third
day onwards, for 30 days. The third blood sample
was collected soon after performing the bout of
moderate exercise on the last day of the one month
period. The exercise was performed under
supervision. During one month of scheduled
moderate exercise, the subjects were made to perform
a single bout of moderate exercise daily for 30 days.
The exercise was graded as moderate or strenuous
based on the rise in heart rate. It was labelled as
moderate when the heart rate increased by 50% from
resting level and was labelled as strenuous when heart
rate increased by 100%19.
Shuttle Walk Test Protocol: The exercise regime
chosen was the standardized 10m Shuttle Walking
test regime, described by Glenfield Hospital,
Leicester, United Kingdom in collaboration with the
department of Physical Education and Sports Science,
Loughborough University of Technology, United
Kingdom 20, 21, 22, 23. In this exercise protocol, the
subjects walk on a 10 meter plain path at the two ends
of which are placed marker cones. The subjects walk
between the cones corresponding to the beeps given
out by a record player. Subjects have to increase their
speed of walking gradually in tandem with the
shortening of intervals between the consecutive beeps
as time progresses. The level of the shuttle walk
regime at which the heart rate increased by 50% of
the baseline was chosen as moderate exercise. The
level at which the heart rate increased by 100%, i.e.
doubled was considered as strenuous exercise. The
pulse was counted before and after each bout of
exercise to make sure the heart rate had increased by
50% for moderate exercise and 100% for strenuous
exercise.
5 ml of the venous blood sample from cubital vein
(using vacutainers) just before acute moderate
66
Ambarish et al.,
exercise (baseline) was collected. Another sample

was collected immediately after acute moderate
exercise on the same day. After performance of acute
strenuous exercise on the next day, third sample was
obtained. A sample was obtained after one month of
scheduled regular moderate exercise on the last day
after exercise. Baseline sample just before acute
strenuous exercise and just before a performance of
exercise on the last day of one month regular
moderate exercise was not obtained. The samples
were collected between 7 and 8 AM. The blood
samples were collected using all aseptic precautions.
If the blood could not be obtained at the first prick of
the needle, the subject was requested to come on the
next day. This is to exclude the possibility of a double
prick leading to local inflammation, which in turn
leads to a local increase in pro-inflammatory
cytokines like TNF-. The plasma was separated and
plasma samples from each individual were aliquoted
and stored at - 400C till analysis.
Plasma sample was used to estimate the levels of
cytokine IFN- and TNF-, by using ELISA (Enzyme
linked ImmunoSorbent Assay) method. ELISA was
performed using DuoSet ELISA development system
as per the manufacturer's instructions (R&D systems,
USA).
Estimation of IFN-:
Briefly, polystyrene microtiter plates (NUNC, U16
Maxisorp type, Denmark) were coated with
monoclonal capture antibody (antihuman IFN-)
obtained from mouse (R&D systems, USA) and
incubated at 4C overnight. The following day, the
plates were blocked and then incubated for 2 hours
with plasma. This was followed by addition of
corresponding biotinylated detection antibody
obtained from goat (R&D systems, USA) and
incubated for 2 hours. Strepatavidin, horseradish
peroxidise conjugate and then, 3,3, 5,5tetramethylbenzidine substrate (Bangalore Genie,
India) followed this incubation. The reaction was
stopped using 2 N sulphuric acid and optical density
(O.D) reading was taken at 450nm (Organon Teknika
Microwell system, Reader 230s, Germany). All the
experiments were conducted in duplicates. A standard
curve was obtained based on the standards provided
by the manufacturer. The results were expressed as
concentration of cytokines (in pg/ml) read from the
standard curve (concentration in range: minimum of 5
pg/ml, to maximum of 150 pg/ml).
Estimation of TNF-:
Polystyrene microtiter plates (NUNC, U16 Maxisorp
type, Denmark) were coated with monoclonal capture
antibody (antihuman TNF- ) obtained from mouse
(R&D systems, USA) and incubated at 4C
overnight. The following day, the plates were blocked
and then incubated for 2 hours with plasma. This was
followed by addition of corresponding biotinylated
detection antibody obtained from goat (R&D
systems, USA) and incubated for 2 hours.
Strepatavidin, horseradish peroxidise conjugate and
then, 3,3, 5,5- tetramethylbenzidine substrate
(Bangalore Genie, India) followed this incubation.
The reaction was stopped using 2 N sulphuric acid
and optical density (O.D) reading was taken at 450nm
(Organon Teknika Microwell system, Reader 230s,
Germany). All the experiments were conducted in
duplicates. A standard curve was obtained based on
the standards provided by the manufacturer. The
results were expressed as concentration of cytokines
(in pg/ml) read from the standard curve
(concentration in range: minimum of 5 pg/ml, to
maximum of 100 pg/ml) 24.
Statistical Analysis: The statistical analysis was

carried out using SPSS software version 18.0
(SPSS Inc. Chicago, USA). The variables in the
data was summarized as Mean SD. Friedman
test has been used for analyzing the differences
in TNF- and IFN- values in-between the
different grades of exercise in the group.
Pearsons correlation coefficient was used to find
the correlation between TNF values and BMI.
Spearmans correlation was used to find the
correlation between IFN- values and TNF-
value after different grades of exercise.
RESULTS
18 healthy volunteers in the age group 18 to 25
(mean: 20.94) were taken for the study. TNF- and
IFN- levels were studied with different grades of
exercises.
Changes in IFN-: There was a significant fall in the
levels of this cytokine with both acute moderate
exercise (p=0. 004) and acute strenuous exercise
(p=0. 001) compared to baseline values. There was a
significant drop in its levels after acute strenuous
exercise when compared to moderate exercise
67
Ambarish et al.,
Fig 1: Changes in the in IFN- and TNF- level

(pg/ml) with different grades of exercise.
Mean plasma cytokine(pg/ml)
120
100
80
60
40
20
0
At
During During 1 month
Baseline moderate strenous of regular
exercise exercise exercise
Types of exercise
IFN gamma
TNF alpha
Fig 2: Changes in the in IFN- and TNF- level

(pg/ml) with different grades of exercise.
40
35
30
25
20
15
10
5
0
IFN gamma(pg/ml) - one month

regular moderate exercise
(p=0.033). The rise of IFN- after one month of

regular moderate exercise was also significant
compared to baseline value (p=0.001). That is, the
IFN- level shot up after the bout of moderate
exercise on the last day of one month of regular
moderate exercise regime (Figures: 1 & 2).
Changes in TNF-: There was a significant increase
in the levels of this cytokine with both acute
moderate exercise (p=0.003) and acute strenuous
exercise (p=0.005) compared to baseline value. There
was a significant rise in its levels after acute
strenuous exercise when compared to moderate
exercise (p=0.043). The fall of TNF- after one
month of regular moderate exercise was also
significant compared to baseline value (p=0.001).
That is, the TNF- level decreased to below baseline
level after the bout of moderate exercise on the last
day of one month of regular moderate exercise
regime (Figures: 1 & 2).
It was found that a significant positive correlation
existed between TNF- at baseline, TNF- after one
bout of moderate exercise, TNF- after one bout of
strenuous exercise and BMI (r = 0.62,0.76,0.50)
(p<0.05) . Whereas there was a negative correlation
between TNF- level at end of one month of
moderate exercise and BMI (r = -0.34). However this
was not statistically significant (p=0.149).
We found that there was a significant negative
correlation between the IFN- values and TNF-
values during the one month of regular moderate
exercise(r= -0.530)(p=0.024) (Figure 3).
50
100
150
TNF alpha(pg/ml)-one month regular moderate exercise
Fig 3: Correlation between IFN- and TNF-

levels (pg/ml) after one month or regular
moderate exercise.
DISCUSSION
Sudden bout of physical activity is hazardous to
health 25. The immune system, in many ways, reacts
similarly to the sudden bouts of physical activity and
physical trauma 26. Pro-inflammatory cytokines like
TNF- and interleukin-6 are released is response to
acute and strenuous exercise27,28. Prolonged strenuous
exercise decreases the percentage of T cells in
circulation29. Regular practice of moderate exercise
inversely correlates with levels of pro-inflammatory
cytokines in coronary heart disease patients retarding
the process of atherosclerosis 30. Therefore, increased
levels of pro-inflammatory cytokines like interleukin6 and tumour necrosis factor alpha are deleterious to
health 31.
TNF- has pro-inflammatory properties and IFN-
has anti-inflammatory properties. In this study that
IFN- levels decreased significantly after a bout of
moderate exercise and there was a further significant
68
Ambarish et al.,
decrease following a bout of strenuous exercise. It

increased significantly compared to baseline levels
after one month of scheduled regular moderate
exercise done on a daily basis; that is, IFN- levels
shot up after the single bout of moderate exercise on
the last day of one month of scheduled moderate
exercise when compared to a single bout of moderate
exercise without accustumisation to regular moderate
exercise, in the same individuals. The TNF- levels
increased after a bout of moderate exercise and there
was a further significant increase following a bout of
strenuous exercise and decreased significantly
compared to baseline levels when compared with one
month of scheduled regular moderate exercise done
on a daily basis; that is, TNF- levels decreased to
below baseline level after the single bout of moderate
exercise on the last day of one month of scheduled
moderate exercise when compared to single bout of
moderate exercise without accustumisation to regular
moderate exercise, in the same individuals.
Therefore, in the individuals who adhere to regular
moderate exercise, the sudden fall in the antiinflammatory cytokine and rise in pro-inflammatory
cytokine may not occur if such individuals were to
get involved in bouts of unaccustomed physical
activity. It may induce a 'buffering capacity' or an
'adaptive cytokine response'. This may be beneficial
during sudden bouts of physical activity in normal
course of life to tolerate those physical stresses better.
Regular moderate exercise is beneficial for
maintaining good health and improving the immune
status 6, 7, 8, 10, 11. Since this study shows a rise in IFN-
and a fall in TNF- level with regular moderate
exercise, a rise in the plasma levels of IFN- and a
fall in TNF- level should also be beneficial for
maintaining health and immunity. IFN- is an anti
inflammatory cytokine and TNF- is proinflammatory cytokine, so their altered production
leads to unnecessary inflammation and tissue damage
32
. Thus regular moderate exercise seems to modulate
their release and alters their levels to the optimum
levels necessary for human body to maintain good
health.
Mental stress is also known to decrease plasma levels
of IFN- and increase the level TNF- 33. The
adaptive cytokine response may also help individuals
adhering to regular moderate exercise to cope with
bouts of psychological stresses encountered in daily
life 34.In these individuals, the levels of IFN- may
Ambarish et al.,
not fall as much as it would decrease in those not

performing regular exercise, facing the same level of
mental stress, likewise the levels of TNF- may not
rise drastically either 35. The mechanism behind this is
not clearly known till now
Several studies have shown that patients of various
diseases and disorders like atherosclerosis, coronary
artery disease and diabetes mellitus have elevated
levels of TNF- interleukin-6 (IL-6) and lower levels
of IFN-35. Stress by way of bursts of physical
activity in day-to-day life, in such patients increases
their levels much further and leads to exacerbation of
the disease. It can be postulated that the drastic rise in
TNF- and IL-6 and fall in IFN- with bursts of
physical activity or with 'acute on chronic infections'
tends to flatten if such patients follow a regular
moderate exercise regimen.
Certain autoimmune disorders like systemic lupus
erythematosus and rheumatoid arthritis are associated
with increased plasma levels of pro inflammatory
cytokines like TNF- and IL-6, which increased
inflammation. Mast cells release mediators to
stimulate T-cells to produce pro-inflammatory
cytokines to increase inflammation 36. The antiinflammatory properties of IFN- have been
demonstrated both in vitro and in vivo. IFN- inhibits
integrin mediated adhesion and migration of T-cells
in vitro. Flashion et al have demonstrated that when
IFN- was administered to nave T-cells and injected
to mice, such T-cells did not home in onto the lymph
nodes compared to the T-cells not treated with IFN1. IFN- decreases eosinophil infiltration in a dose
dependent manner 37. Increased levels of TNF- leads
to cachexia, increased levels of C-reactive protein and
other acute phase proteins, activates macrophages,
increases tumour cytotoxicity, activates neutrophils
and increases phagocytosis and induces secretion of
other pro-inflammatory cytokines like IL-6 38. This
study also demonstrates a positive correlation
between the pro-inflammatory cytokine TNF- and
BMI at baseline (no exercise), after one bout of
moderate exercise and after one bout of strenuous
exercise. This may indicate that obesity predisposes
to increased levels of pro-inflammatory cytokines.
Interestingly, found a negative correlation, though not
significant between TNF- level and BMI at end of
one month of regular moderate exercise. This may be
because the increase in BMI at end of one month of
69
exercise may be due to increase in the healthy lean

body mass and decrease in adiposity 39. Our study
also shows a negative correlation between TNF- and
IFN- in all the grades of exercise, but it is
statistically significant at the end of one month of
regular moderate exercise. This again proves the
beneficial effect of regular moderate exercise. Till
date very few studies have been undertaken in the
same group of human subjects to study the effects of
physical stress/exercise on levels of TNF- and IFN. Regular moderate exercise may benefit patients
suffering from inflammatory diseases and autoimmune disorders by bringing down the levels of proinflammatory cytokines like TNF- and increasing
the levels of IFN-. Since different grades of physical
exercise
have
pro-inflammatory
and
antiinflammatory effect, we propose that this study has
potential for clinical application.
Limitations of the study: Though the sample size for
the present study has been calculated statistically,
based on the sample size of a previous study, further
research with greater number of samples is needed to
throw more light on the pro and anti inflammatory
effects of different grades of exercise.
CONCLUSION
Plasma TNF- increase with one bout of acute
moderate exercise and increases further with one bout
of acute strenuous exercise and decreases to below
baseline values at the end of one month of regular
moderate exercise. IFN- levels exhibit opposite
behaviour. This shows that regular moderate exercise
has beneficial effects on health by way of increasing
the plasma level of the anti-inflammatory cytokine,
IFN- and decreasing plasma level of proinflammatory cytokine, TNF-.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
ACKNOWLEDGEMENT
We would like to acknowledge the support and
valuable inputs of Dr. Chandrashekara. S, Director,
Chanre Rheumatology and Immunology center for
Research, Bangalore and Dr. Rajeev Sharma, former
head, Department of Physiology, M. S. Ramaiah
Medical College.
13.
14.

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DOI: 10.5958/2319-5886.2015.00012.0

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 28 Nov 2014
PRESCRIBING PRACTICES OF NON TEACHING GENERAL PRACTITIONERS OF PRIVATE

CLINICS AND PHYSICIANS OF A TERTIARY CARE TEACHING HOSPITAL: A COMPARATIVE
CROSS SECTIONAL STUDY
*Sudar Codi R1, Samiya Khan2, Manimekalai K1
1
Department of Pharmacology, 2Undergraduate student, Mahatma Gandhi Medical College & Research Institute,
Pondicherry, India
*Corresponding author email: sudarcodi@gmail.com
ABSTRACT
Background: Doctors prescription provides vivid information and instruction to the patient. In spite of the WHO
programs, irrational prescribing is still a common practice. Aim: To evaluate and compare the prescribing pattern
of private practitioners and physicians of a tertiary care teaching hospital in a semi urban area and detect their
rationality. Materials & methods: 150 prescriptions, each prescribed by private practitioners and physicians of a
tertiary care hospital were collected over a period of two months and evaluated. Information regarding the drugs
used, drugs from the essential drug list, the use of injections, fixed dose combinations, drug prescribed by generic
names were observed. Results: The average number of drugs per prescription prescribed by the private
practitioners was 2.47 compared to 1.58 by the physicians of a tertiary care hospital. 82% of prescriptions of
private practitioners had one injection prescribed in the prescription compared to 12% by physicians of a tertiary
care hospital. 30 unnecessary drugs, 46 unnecessary injections and 8 irrational fixed dose combinations were
prescribed by the private practitioners, whereas only 6 unnecessary drugs and 2 unnecessary injections were
prescribed by the physicians of a tertiary care hospital respectively. There was no irrational fixed dose
combination prescribed by them. The private practitioners prescribed 12 (3.2%) drugs by generic names, whereas
the physicians of a tertiary care hospital prescribed 72 (30.3%) drugs by generic names. (P<0.000). 36 (9.7%)
drugs prescribed by the private practitioners were not included in the essential drug list and only 2 (0.8%) drugs
prescribed by the physicians of a tertiary care hospital were not included in the essential drug list. Conclusion:
Private practitioners prescribe more irrational prescriptions on comparison with the physicians of a tertiary care
teaching hospital. This may be due to the promotional pharmaceutical incentives, lack of professional updates and
lack of standard treatment guidelines to the private practitioners motivating them towards irrational drug therapy
to survive the competition. Competitions can be conducted for the budding medical undergraduates to inculcate
the importance of rational drug therapy at early ages.
Keywords: Prescription audit, Irrational prescriptions, Rational prescribing
INTRODUCTION
Prescription writing is an art to be learnt by every
practitioner to provide clear, adequate information
and instruction to the patient1. The WHO program on
rational use of drugs aims to promote rational
prescribing through various strategies that include
prescribing by generic names, adoption of essential

drug list, instituting standard treatment guidelines and
creating awareness about the consequences of
irrational drug prescriptions2.
72
Sudar et al.,
In spite of these measures, irrational prescribing is

still a common practice among the practitioners
leading to ineffective treatment, increased adverse
effects and financial burden on the patient3.
Prescription monitoring can be used as a tool to
define the prescribing pattern among the practitioners
and provide information regarding the prevailing
trend of rational and irrational use of medications in a
particular region4. Moreover, it will provide feedback
to the practitioners for rational prescribing in the
future.
Although many studies have been undertaken to
study prescribing pattern among physicians, there are
scarce data on comparison between various sectors of
practitioners, which will bring to lime light the group
to be targeted more towards rational prescribing.
Hence the study was planned to compare the
prescribing patterns of private practitioners and
physicians of a tertiary care hospital in a semi-urban
area, to assess the quality of prescribing according to
WHO prescribing indicators and assess the rationality
of prescriptions.
MATERIALS & METHODS:
After getting approval from the Institutional Ethical
Committee, a prospective, comparative, cross
sectional study was conducted by reviewing the
prescriptions prescribed by physicians of a tertiary
care hospital in a semi urban area of Puducherry and
compared with the private practitioners practicing in
that area over a period of 2 months.
Patients of both sexes, visiting the outpatient clinics
of private practitioners and those attending the
outpatient department of medicine and patients
willing to participate and give informed written
consent were included in the study. Incomplete
prescriptions, prescriptions without diagnosis,
prescriptions with illegible handwriting were
excluded from the study.
10 randomly selected private practitioners out of total
48 identified practitioners (20%) in Kirumampakkam
commune of Puducherry were selected for the study
purpose. Each day 5 prescriptions from patients
visiting a private practitioner were collected for
consecutive 3 days, thus 15 patient prescriptions from
each practitioner to a total of 150 prescriptions from
10 private practitioners were considered for study
purpose.
Data was collected by xerox copying or photocopying

of the prescriptions from the nearby pharmacies of
private general practitioners clinics. Identity of the
prescriber and patient were kept confidential and
patient data was entered in the case record form.
Similarly each day approximately 10 prescriptions
from patients attending outpatient department (OPD)
of department of Medicine in tertiary care hospital
were collected for consecutive 15 days and
considered for comparison. Thus 150 prescriptions,
each prescribed by private practitioners and
physicians of tertiary care hospital were evaluated
and compared.
WHO rationality indicators:
The prescribing indicators5 that were measured
included:
1. The average number of drugs prescribed per
prescription was calculated to measure the degree
of polypharmacy. It was calculated by dividing
the total number of different drugs prescribed by
the number of prescriptions.
2. Percentage of drugs prescribed by generic name.
It was calculated by dividing the number of drugs
prescribed by generic name by total number of
drugs prescribed, multiplied by 100.
3. Percentage of prescriptions with an injection
prescribed. It was calculated by dividing the
number of patient prescriptions in which an
injection was prescribed by the total number of
prescriptions, multiplied by 100.
4. Percentage of drugs prescribed from an essential
drug list (EDL). Percentage is calculated by
dividing number of drugs prescribed and present
in the essential drug list by the total number of
drugs prescribed, multiplied by 100.
Collected data was entered and analyzed using
Microsoft office Excel 2010 computer software. Data
was presented as numbers, percentages and
proportions. To assess significance of study findings,
statistical tests (according to nature and distribution
of data e.g- Chi square test) was applied and p<0.05
was considered as statistically significant.
RESULTS
Demographic details: There was no statistical
significant difference in the demographic details
between the groups as depicted in Figure 1.
73
Sudar et al.,
100
90
80
70
60
50
40
30
20
10
0
SEX
61-75
46-60
31-45
16-30
0-15
Male
Female
No. of Prescription
Private
Tertitary Care
AGE
Number of drugs prescribed: Our study revealed

that 88 prescriptions prescribed by the physicians of
tertiary care hospital had one drug in it. Two drugs
were prescribed in 37 prescriptions and three drugs in
25 prescriptions. No single prescription had four or
five drugs per prescription.
Alternatively, most
of the private practitioners prescribed two drugs per
prescription (63 prescriptions), 48 prescriptions had
three drugs in it. One drug per prescription was seen
in 21 prescriptions. Four drugs were prescribed in 10
prescriptions and five drugs per prescription in 8
prescriptions respectively and was statistically
significant.
Fig 1: Sex and Age distribution between the

groups
Table 1: Number of drugs prescribed per prescription between the groups.
Number of drugs Number of prescriptions Number of prescriptions t test comparing general
prescribed per
prescribed by private
prescribed by physicians practitioners and physicians
prescription
practitioners
of a tertiary care hospital
of tertiary care hospital
1
21
88
7.8230
2
63
37
3.2173
3
48
25
2.8090
4
10
0
3.2838
5
8
0
2.9268
Mean + SD of drugs prescribed totally by both groups
2.47 1.01
1.58 0.76
8.5955
Table 2: Number of irrational drugs prescribed between the groups.
Parameter
Drugs prescribed by Drugs prescribed by physicians Chi
square
private practitioners
of tertiary care hospital
value
Number of unnecessary 30
6
17.5423
drugs prescribed
Number of unnecessary 46
2
45.3162
injections given
Number of irrational 8
0
8.2072
drug
combinations
prescribed
Table 3: Number of drugs prescribed by generic names between the groups
Parameter
Private practitioners Physicians of tertiary Chi
square
(%)
care hospital (%)
value
Number of drugs prescribed by 12 (3.2%)
72(30.3%)
51.5197
generic names
Number of drugs prescribed but 36(9.7%)
2(0.8%)
33.3994
not from the essential drug list
Injections prescribed: 82% of prescriptions of
private practitioners had one injection prescribed in
the prescription compared to 12% by physicians of a
tertiary care hospital.
The results of our study revealed that 30
unnecessary drugs, 46 unnecessary injections and 8
irrational fixed dose combinations were prescribed
by the private practitioners, whereas only 6
P value
<0.001
0.0013
0.0050
0.0010
0.0034
<0.001
P value
<0.001
<0.001
0.0042
P value
<0.000
<0.002
unnecessary drugs and 2 unnecessary injections

were prescribed by the physicians of a tertiary care
hospital. The injections, which did not comply with
the diagnosis were considered unnecessary injection.
There was no irrational fixed dose combination
prescribed by them. The result was found to be
statistically significant, revealing higher irrational
74
Sudar et al.,
use of drugs by private practitioners and is depicted

by the table 2 below.
Prescribing by generic names: The private
practitioners prescribed 12 drugs by generic names,
whereas the physicians of a tertiary care hospital
prescribed 72 drugs by generic names and this was
found to be highly statistically significant (P<0.000).
Drugs prescribed from the essential drug list: Our
study showed 36 drugs prescribed by the private
practitioners were not included in the essential drug
list. Only 2 drugs prescribed by the physicians of a
tertiary care hospital were not included in the
essential drug list
Most common drugs prescribed: The most
common drugs prescribed by the private
practitioners were paracetamol, aceclofenac and
vitamins. The physicians of a tertiary care hospital
prescribed ranitidine, certizine and amoxicillin more
commonly on comparison with the other group and
depicted in the following table..
Table 4: Most common drugs prescribed
between the groups
Drug prescribed
% of prescriptions
with the drug
prescribed by
private
practitioners
Paracetamol
Aceclofenac
Vitamins
Ranitidine
Pantoprazole
Cetrizine
Amoxicillin
Cephalosporins
23.3%
28.6%
31.3%
3.3%
17.3%
5.3%
4%
26.6%
% of prescriptions
with the drug
prescribed by
physicians of
tertiary teaching
care hospital
10%
6.6%
7.3%
14%
6.6%
6.6%
12%
4.6%
DISCUSSION
Number of drugs per prescription: The average
number of drugs per prescription per prescription
prescribed by the private practitioner was 1.58
0.76 and 2.47 1.01 by the physicians of a tertiary
care hospital. Similar studies by Ansari et al6 report
that
40%
of
the
prescriptions
showed
overprescribing. Polypharmacy defined as the
concurrent use of five or more medications per
single patient. The tendency of poly pharmacy was
more in private sector (5.05 medications per
prescription) than service sector (3.52). Over
prescribing leads to increased side effects, increased
cost7 and increased drug interactions.
Unnecessary drugs and injections: Our study

revealed that 82% of prescriptions had one injection
prescribed in private practitioner group whereas only
12% of prescriptions of teriary care hospital group
had one injection prescribed. Similar studies reveal
most of the prescriptions8-10 have one injection
prescribed and also have irrational fixed dose
combinations11.
Similar study by Anjali pillay et al12 revealed that
only 13.20% FDCs were in accordance with WHO
Model List of Essential Drugs. FDCs from antiinflammatory and ant rheumatic products, vitamins,
minerals, antianaemic preparations, drugs for acid
related disorders, antibacterial for systemic use and
cough and cold preparations were used more by
private non teaching hospitals as compared to
SKNMC & GH teaching hospital. This may be
attributed to the patient demand for symptomatic
relief and social beliefs of the patient that injections
are more efficacious.
Prescribing by generic names: The private
practitioners prescribed 12 drugs by generic names,
whereas the physicians of a tertiary care hospital
prescribed 72 drugs by generic names in our study.
Similar study was conducted by Patel et al13 and
analyzed 990 prescriptions. He observed that over
90% of the prescriptions contained branded
medicines only and reported that private
practitioners prescribed significantly greater number
of medicines and were more likely to prescribe
vitamins, tonics and branded medicines. Prescribing
by the brand names of the private practitioners is due
to the enormous discounts given by the
pharmaceutical companies to catch up the market,
which adds to the drug cost for the patient.
Prescribing from the essential drug list: Our study
showed 36 drugs prescribed by the private
practitioners were not included in the essential drug
list. Only 2 drugs prescribed by the physicians of a
tertiary care hospital were not included in the
essential drug list. Most of the drugs prescribed14 but
not included in the essential drug list were
Aeclofenac, Cetrizine and varied combinations of
Vitamins with Iron, Antioxidants. Similar studies
reveal antibiotics irrationally prescribed15.
Similar studies reveal that private practitioners
prescribe drugs more irrationally16,17,18. The
limitations of our study include the small sample
size and the limited duration of the study, which
75
Sudar et al.,
hinders the generalisability of the results. We did not

include the inpatient category.
CONCLUSION
It is quite obvious from the results of our study that
the private practitioners prescribe more drugs per
prescription, more unnecessary drugs and injection
and their prescriptions were found more irrational on
comparison with the physicians of a tertiary care
teaching hospital. This difference may be attributed
to the promotional incentives given by the
pharmaceutical companies to which they fall prey.
Secondly, it may be due to the hospital drug policy
to which the individual practitioner has to abide to.
Thirdly, it may be due to the lack of professional
updates by the private practitioners which on long
term leads to irrational prescribing. Fourth, being the
lack of standard treatment guidelines to the private
practitioners which motivates the doctors towards
irrational drug therapy in order to survive the
competition.
Therefore, it becomes highly essential that frequent
workshops on rational drug therapy should be
conducted and competitions can be conducted for
the budding medical undergraduates to inculcate the
importance of rational drug therapy at early ages.
ACKNOWLEDGEMENTS:
We whole heartedly thank the Indian Council of
Medical Research for funding our research project.
Conflict of interest: Nil
REFERENCES
1. Benet LZ. Principles of prescription order
writing and patients compliance instructions. In:
Goodman AG, Rall TW, Nies AS, Taylor P,
(eds).
Goodman
and
Gilmans
The
pharmacological basis of therapeutics. 8th ed.
New York: Pergamon Press Inc. 1991:1640.
2. How to investigate drug use in health facilities:
selected drug use indicators. Geneva, World
Health Organization, 1993 (EDM Research
Series No. 007).
3. Walker J, Mathers N. The impact of a general
practice group intervention on prescribing costs
and patterns. Br J Gen Pract. 2002; 52(476):
18186
4. Indira B, Arun B. Auditing of prescribing

pattern of doctors in tertiary care centre in
Bangalore. Pharmacologyonline 2011; 1:405-08
5. Desalegn AA. Assessment of drug use pattern
using WHO prescribing indicators at Hawassa
University teaching and referral hospital, south
Ethiopia: a cross-sectional study. BMC Health
Serv Res. 2013; 13: 170.
6. Ansari KU, Singh S, Pandey RC. Evaluation of
doctors for rational drug therapy. Indian J
Pharmacol 1998; 30:43-6
7. Taylor RJ. Prescribing costs and patterns of
prescribing in general practice.J R Coll Gen
Pract. 1978; 28(194): 53135
8. Moghdamnia AA, Mirbolooki MR, Aghili MB.
General practitioners prescribing patterns in
babol city, Islamic republic of Iran. Eastern
Mediterranean Health Journal 2002;8:551-55
9. Kshirsagar MJ, Langade D, Patil S, Patki PS.
Prescribing patterns among medical practitioners
in Pune, India. Bull World Health Organ 1998;
76:271-5
10. Sagar R, Pravin D, Nitin P, Reena V, Rajendra
KG. Current pattern use of irrational fixed dose
combinations: a prescription audit study.
RJPBCS 2012; 3:617-22
11. Somesh PR, Sujatha SD, Ganesh ND, Rohan
CH, Prashanth SD, Nilesh NG. Irrational fixed
dose combination in the Indian market:an
evaluation of prescription pattern using WHO
guidelines. Int J Basic ClinPharmacol
2013;2:452-7
12. Pillay A, Keche Y, Yegnarayanan R, Patil V,
Dangare R. Int J Basic Clin Pharmacol 2013;
2(1):61-8.
13. Patel V, Vaidya R, Naik D, Borker P. Irrational
drug use in India: Prescription survey from Goa.
J Postgrad Med. 2005;51:9-11.
14. Shewade DG, Pradhan SC. Auditing of
prescriptions in a government teaching hospital
and four retail medical stores in Pondicherry.
Indian J Pharmacol 1998; 30:408-10.
15. Hanmant A, Priyadarshini KOP. Prescription
analysis to evaluate rational use of
antimicrobials. Int J Pharm Bio Sci 2011; 2:314319.
16. Sneha Patel, Bharathgajjar. Evaluation and
comparison of prescribing pattern of general
practitioners from public and private
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sectors.Natl J Physiol Pharm Pharmacol 2012;

2:33-38.
17. Gajjar BM. Evaluation and comparison of
prescribing pattern of physicians from the
institute and private sector for rational drug
therapy [dissertation ], VallabhVidhyanagar,
S.P. Univ, 1999.
18. Avijit H, Santanu KT, Mirza SA. Prescribing
and dispensing activities at the health facilities
of a non governmental organization. Natnl Med
J India 2000; 13:177-82.
19. Bapna JS, Shewade DG, Pradhan SC. Training
medical professionals on the concepts of
essential drugs and rationale drug use.Br J
clinPharmac 1994;37.
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Sudar et al.,
DOI: 10.5958/2319-5886.2015.00013.2

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Coden: IJMRHS
th
Revised: 21st Nov 2014
Research article
Copyright @2014
ISSN: 2319-5886
EARLY DETECTION OF CRITICAL CONGENITAL HEART DISEASE IN NEWBORNS USING

PULSE OXIMETRY SCREENING
ShahForum1,Chatterjee Rajib2, *PatelPrashant C3, Kunkulol Rahul R4
1
MBBS Student, Rural Medical College, Pravara Institute of Medical Sciences (DU), Loni, Maharashtra
Professor, Department of Paediatrics, Rural Medical College,PIMS (DU), Loni, Maharashtra
3
PG Student,4Professor, Department of Pharmacology, Rural Medical College, PIMS (DU), Loni, Maharashtra
2
*Corresponding author email: prashant515@yahoo.com

ABSTRACT
Background: Congenital heart diseases which are dependent on the ductusarteriosus to maintain adequate
oxygenation or systemic blood flow are termed as a critical congenital heart disease (CCHD). Delay in the
diagnosis of CCHD is the major cause leading to morbidity and mortality in newborn infants. Clinical evaluation
is likely to miss the diagnosis in first few hours of hospital stay after birth due to absence of signs and symptoms
of CCHD.In the absence of clinical findings during early neonatal period, the best parameter that can be assessed
is the detection of hypoxemia by pulse oximetry screening. Objectives: To record the value of Pulse Oximetry
within 24 hours of birth and evaluate Pulse Oximetry as screening tool for early diagnosis of CCHD. Methods:
Longitudinal descriptive study was conducted on total 700 intramural neonates, satisfying the inclusion and
exclusion criteria, who were evaluated within 24 hours of birth with currently available pulse oximeter, after the
Institutional Ethical Committee approval. The study was conducted over a period of 4 months. Part-A: Neonatal
Case Record, Part-B: Pulse Oximetry Screening Record, Part-C: Clinical Examination Record, Part-D:
Echocardiography Record. Results and Conclusion: Total 700 neonates were screened by pulse oximeter with
consecutive sampling method. 4 (0.57%) subjects were detected to have positive screen and the diagnosis was
confirmed by echocardiography. Study revealed that Pulse Oximetry Screening can be an important primary
screening tool in routine neonatal care for early detection of Critical Congenital Heart Diseases particularly in
rural setup.
Keywords: Pulse Oximetry Screening, Neonates, Critical Congenital Heart Disease, Neonatal Heart Disease
INTRODUCTION
Congenital heart diseases (CHD) are a group of
morphologically heterogeneous disorders occurring in
6 to 8 per 1000 live births. Downs syndrome,
Turners syndrome, Noonan syndrome, maternal
diabetes, alcohol intake during pregnancy, rubella
infection and phenylketonuria are the known
etiological factors whereas up to 90% of CHDs occur
in pregnancies without any predisposing cause. One
fourth of the pregnancies with CHD after full term
delivery will have infants presenting with critical

congenital heart disease (CCHD).1
The fetal patent ductus is a major anatomic
component of an intrauterine great artery consisting
of pulmonary trunk or ductus or aortic continuity that
delivers 85% of right ventricular output into the
descending aorta.2 Many forms of CHD that depend
on the ductusarteriosus to maintain adequate
oxygenation or systemic blood flow are termed as
78
Shah et al.,
CCHD. Neonates with such unrecognized CCHD can

manifest with profound metabolic acidosis,
intracranial
hemorrhage,
hypoxic-ischemic
encephalopathy, necrotizing enterocolitis, cardiac
arrest or death if the ductus constricts or closes.
Effective strategies are available for stabilizing
neonates with known CCHD until intervention can be
performed, most notably continuous infusion of
prostaglandin E1 to maintain patency of the ductus.
These strategies cannot be used effectively unless
CCHD is diagnosed or at least suspected.3
Early surgical or catheter interventional therapy is
mandatory to achieve survival in case of CCHD.4
With advances in both palliative and corrective
surgery, the number of children with congenital heart
disease surviving to adulthood has increased
dramatically.5 Despite increased use of prenatal
diagnostic modalities for detection of CCHD is
increased over the last few decades, a significant
proportion of affected new-borns are still not
diagnosed before discharge after birth.6CCHD
remains the leading cause of death in children with
congenital malformations despite these advances.
Conventionally, in the first few hours after birth,
diagnosis of CCHDs is dependent on physical
examination findings such as heart murmurs,
tachypnea or overt cyanosis. These findings are not
always evident during first few hours of hospital
stay.6 Heart murmurs are one of the hallmarks of noncritical heart disease typically diagnosed later in life.
Many times these may be absent or misleading
because of the underlying anatomy, prolonged
decline of pulmonary vascular resistance or reduced
ventricular function.4 Recent trends of earlier
discharge within 24-48 hours and other changes in
postnatal care may aggravate this problem.
Majority of CCHD lesions in the newborns present
with some degree of hypoxemia resulting from the
mixing of systemic and venous circulations or
parallel circulations which may cause obvious
cyanosis. Importantly, newborn shaving mild
hypoxemia, with arterial oxygen saturation of 80% to
95%, will not have visible cyanosis. Early detection
of such cases may be enhanced by pulse oximetry, if
performed on asymptomatic new-borns within 24
hours of life.6
Early diagnosis in the first few days of life is
difficult. Prenatal diagnosis of CHD routinely is
carried out by ultrasonography in antenatal period,
Shah et al.,
but it picks up only less than half of all cases.

Limitations of prenatal fetal echocardiography are
related to: Availability of expertise and experience
(paediatric
cardiologist).
Availability
of
echocardiography machine, Image quality, Subtle
lesions, such as small ventricular septal defects,
Developing or progressive lesions, Lesions which are
undetectable before birth7
Delayed diagnosis of CCHD can lead to cardiac
failure, cardiovascular collapse and even death.
Clinical evaluation though mandatory can miss out
the diagnosis as the findings may not be obvious or
may be too subtle in the initial 24 hours of life. So
detection of CCHD without unnecessary delay should
be the task for providers of primaryneonatal care. In
the absence of clinical findings, the best parameter
that can be assessed is the detection of hypoxemia by
pulse oximetry screening.
Aim& Objectives:
1. To study the value of pulse oximetry within 24
hours after birth for predicting CCHD in newborns.
2. To study the clinical profile of new-borns
detected with abnormal pulse oximetry screening.
3. To confirm the diagnosis by echocardiography in
positively screened new-borns.
METHODOLOGY
This descriptive longitudinal (prospective) study was
conducted at the Neonatology Unit of Pravara Rural
Hospital, Pravara Institute of Medical Sciences, Loni.
Intramural neonates who were evaluated within 24
hoursage with currently available pulse oximeter
(EMCO 4040 NP NIBP Oximeter, India) were
enrolled in study.8
Inclusion criteria: Singleton, Inborn neonates
(intramural), Including neonates with extreme low
birth weights as well i.e. weight<1000gms
Exclusion criteria: Multiple gestations, Out born
neonates, Neonates with a life threatening congenital
anomalies, Neonates with lethal malformations,
Neonates requiring any surgical intervention
Sample Size & Study Period: The study was
conducted on approximately 700 neonates according
to inclusion and exclusion criteria, during 4 months
period starting from 8th February 2013 to 9th June
2013 after informed written consent and approval
from the Institutional Ethical Committee, Pravara
Institute of Medical Sciences, Loni.
79
hemoglobin level.9 Proper care was taken to rule out

any interference with pulse oximetry like agitation of
the infant, proper placement of the probe, human
error or equipment malfunction. Probe was placed at
on right hand and right foot.
Screening was considered positive if :
(1)Any oxygen saturation measure was <90% (in the
initial screen or in repeat screens)
(2) Oxygen saturation was <95% in the right hand
and foot on three measures, each separated by one
hour.
(3) A >3% absolute difference existed in oxygen
saturation between the right hand and foot on three
measures, each separated by one hour. Any screening
that was 95% in the right hand or foot with a 3%
absolute difference in oxygen saturation between the
right hand or foot is considered a negative screen and
screening was ended. Statistical Analysis: The
analysis was carried out with OpenEpiopen source
software version2. Sensitivity, specificity, positive
predictive value and negative predictive values for
pulse oximetry screening were calculated.
RESULTS
Table 1: On first Screening
Screen
Fig 1: Screening protocol for pulse oximetry

Study conduct: The study was conducted in 4 parts
as follows:
Part A: Neonatal Case Record
Part B: Pulse Oximetry screening Record
Part C: Clinical Examination Record
Part D: ECHO Record
Pulse Oximetry Screening was done using the
protocol displayed in Fig. 1. Oxygen saturation is a
relative measure of the amount of oxygen that is
dissolved or carried in blood. It is an indicator of the
percentage ofhemoglobin saturated with oxygen at
the time of themeasurement.Normal oxygen
saturation values are 97% to 99% in the healthy
individual. An oxygen saturation value of 95% is
clinically accepted in a patient with a normal
No. of
neonates
(n)
SpO2
Right
Right
Hand
Foot
>95%
>95%
<90%
<90%
Negative
688
Direct Hypoxemic
3
(SpO2<90%)
Indirect Hypoxemic
9
90-95% 90-95%
(SpO2 90-95%)
TOTAL
700
Table 2: Screening of neonates in Indirect
Hypoxemic Cases after Providing Oxygen
SpO2
No of
Screen
neonates Right
Right
(n)
Hand
Foot
Negative
688
>95%
>95%
Non-Hypoxemic
8
>95%
>95%
Persistent Indirect
1
90-95% 90-95%
Hypoxemic
Direct Hypoxemic
3
<90%
<90%
TOTAL
700
-
80
Shah et al.,
Table 3: Pulse Oximetry and Echocardiographic findings of Positive Cases

SpO2
Echocardiographic Findings
Right Right
Hand Foot
52
55
Single valve present at atrio-ventricular junction, enlarged heart
chambers
75
77
Transposition of great arteries, Small PFO, small PDA, Severe
Pulmonary hypertension
82
89
TAPVC-Supracardiac type, ostiumsecundum patent 7mm,
persistent left SVC draining into coronary sinus, All 4 pulmonary
veins drain anomalously in vertical vein through innominate vein
94
91
Coarctation of aorta, preductal type, bicuspid aortic valve
DISCUSSION
Critical congenital heart diseases are fatal if prompt
medical or surgical intervention is not provided.
Prenatal diagnosis with the help of an ultrasound is
not easily available in India particularly in rural areas.
Early detection of CCHD enables us for prompt
intervention which may save patients life as many of
the CHDs are duct dependent and closure of
ductusarteriosus at around 72 hours may lead to
sudden deterioration or death. Moreover, recent trend
of early discharge from the hospital also adds to the
problem.
Present study was carried out with screening time
within 24 hours of birth, on a total 700 neonates at
Neonatology Unit of Pravara Rural Hospital, Loni.
Most of the patients being from rural areas insist for
early discharge, within 24 hours after birth.
Moreover, literature suggests that many studies have
been carried out for screening after 24 hours of birth.
So it was thought prudent to evaluate the pulseoximetry findings within 24 hours of birth in an
attempt to provide a non-invasive screening tool
which can be easily performed and helpful in the
early diagnosis in rural setup.
95% SpO2 level was used as a cutoff value, at which
pulse oximetry screening has the best overall
performance. 1,10,11,12 On first screening, 12 neonates
were found to have abnormal SpO2levels. (Table 1)
Out of these, 3 neonates had SpO2 values <90% and
followed directly by clinical examination and
echocardiography and 9 having SpO2 levels 90-95%,
were provided oxygen and rescreened according to
the protocol. SpO2 level of only 1 neonate remained
<95% and was subjected to clinical examination and
echocardiography. (Table 2) Rest all were considered
Final Diagnosis
Complete atrio-ventricular
septal defect
Transposition of Great Arteries
Total Anomalous Pulmonary
Venous Connection
Coarctation of Aorta
negative in screening and no further actions were

taken.
POS in order to detect CCHD showed a very good
sensitivity, specificity and negative predictive value
(NPV), but positive predictive value(PPV) was less
than optimal. Results of present study were
comparable to the study done by Arlettazet al but
there were some differences in terms of sensitivity
and NPV with recent study done by Granelliet al.1,10
This variation in the PPV might be due to difference
in prevalence of the disease amongst the population
under study or use of movement-artifact resistant
pulse oximetry e.g. Masimo Technology.
Table 4: Comparison with other studies
Parameters
Arlettaz Granelli Present
et al1
et al10
Study
Sensitivity
100%
62.07%
100%
Specificity
99.7%
99.82% 98.85%
NPV(Negative
100%
20.69%
100%
Predictive Value)
PPV (Positive
63%
99.97% 33.33%
Predictive Value)
In present study, pulse oximetry had detection rate of
0.57% (4 out of 700) which was followed by clinical
examination and echocardiography.(Table 3) The
positive cases were diagnosed as: 1. Complete atrioventricular septal defect 2. Transposition of great
arteries 3. Total anomalous pulmonary venous
connection4. Coarctation of aorta
It has been well documented that POS sometimes
does not detect left heart obstructive lesions. In some
cases, there is right to left shunting via a patent
ductusarteriosus which may not get detected by
POS.13
81
Shah et al.,
POS is a complementary tool and should not be used

as an alternative to thorough physical examination.
Complex cyanotic lesions can also be missed by POS
alone, especially in the context of high pulmonary
blood flow. However, concomitant clinical
examination may detect tachypnea and prompt further
evaluation.4
The rate of false-positive results in our study was
1.14%. Riedeet al reported 0.10% false-positive
rate.4Higher false positive rate in present study might
be due to pulmonary hypertension, sepsis and other
conditions like human error or equipment
malfunction.
POS has been mentioned as a cost-effective tool in
the detection of CCHDs.14 With results of present
study and its comparison to already published
literature, it can be very well stated that the currently
available pulse oximeters as an adjunct to clinical
examination can substantially improve detection rate
of CCHDs and enables us to prevent burden of death
and sequelae of neurologic impairment or disability,
which may result from late diagnosis of CCHD.
CONCLUSION
The problem of late diagnosis of Critical Congenital
Heart Diseases and its potential sequelae has major
health impact. Pulse Oximetry Screening can be an
important primary screening tool in routine neonatal
care for early detection and effective management of
Critical Congenital Heart Diseases particularly in
rural setup.
Limitations of the study: The sample size is small
and makes the calculation of the effectiveness of POS
difficult. Extensive research for authentication and
standardization is still required.
2.
3.
4.
5.
6.
7.
8.
9.
10.
ACKNOWLEDGEMENTS
This study was selected as STS project and approved
by the Indian Council of Medical Research (ICMR).
We acknowledge the support and help of paediatric
cardiologists for carrying out echocardiography of the
study subjects.
11.
REFERENCES
1. Arlettaz R, Bauschatz AS, Mnkhoff M, Essers
B, Bauersfeld U; The contribution of pulse
oximetry to the early detection of congenital heart
12.
disease in newborns. Eur J Pediatr, 2006, 165:94

98
Joseph K. Perloff; Patent DuctusArteriosus;
Clinical Recognition of Congenital Heart
Disease, 5th edition, 2003, p403
Amy H. Schultz, A. Russell Localio, Bernard J.
Clark, ChitraRavishankar, Nancy Videon and
Stephen E. Kimmel; Epidemiologic Features of
the Presentation of Critical Congenital Heart
Disease: Implications for Screening; Pediatrics,
2008;121;751
Frank Thomas Riede, Cornelia Wrner, Ingo
Dhnert, Andreas Mckel, Martin Kostelka, Peter
Schneider; Effectiveness of neonatal pulse
oximetry screening for detection of critical
congenital heart disease in daily clinical
routineresults from a prospective multicenter
study; Eur J Pediatr, 2010, 169:975981
Daniel Bernstein; The Cardiovascular System;
Nelson Textbook of Pediatrics; 19th edition, 2011
NRC Roberton, Janet M Rennie. Intensive Care
Monitoring. Text book of Neonatology: Janet M
Rennie, NRC Roberton 3rd edition, 1999, p362
Lindsey Allan. Antenatal diagnosis of heart
disease. Heart 2000 83: 367
4040 NPO NIBP Oximeter [internet] available
from:
http://www.emcomeditek.com/4040_npo_content
.htm
Schutz SL. Oxygen Saturation Monitoring by
Pulse Oximetry. In: Lynn-McHale DJ, Carlson
KK, editors. AACN Procedure manual for
Critical Care. 4th edition, WB Saunders; 2001,
p77
Anne de-Wahl Granelli, MargaretaWennergren,
Kenneth Sandberg, Mats Mellander, Carina
Bejlum, Leif Inganas, Monica Eriksson et al.
Impact of pulse oximetry screening on the
detection of duct dependent congenital heart
disease: a Swedish prospective screening study in
39 821 newborns. BMJ 2009;338:a3037
Koppel RI, Druschel CM, Carter T, Goldberg BE,
Mehta PN, Talwar R, Bierman FZ. Effectiveness
of pulse oximetry screening for congenital heart
disease in asymptomatic newborns. Pediatrics,
2003; 111:451455
Meberg A, Brgmann-Pieper S, Due R Jr,
Eskedal L, Fagerli I, Farstad T etal., First day of
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life pulse oximetry screening to detect congenital

heart defects. J Pediatr, 2008; 152:761765
13. Valmari P. Should pulse oximetry be used to
screen for congenital heart disease? Arch Dis
Child Fetal Neonatal, 2007; Ed 92: F219F224
14. Griebsch I, Knowles RL, Brown J, Bull C, Wren
C, Dezateux C. Comparing the clinical and
economic effects of clinical examination, pulse
oximetry, and echocardiography in newborn
screening for congenital heart defects:a
probabilistic cost-effectiveness model and value
of information analysis. Int J Technol Assess
Health Care 2007;23:192-204
83
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DOI: 10.5958/2319-5886.2015.00014.4

&
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Volume 4 Issue 1
Coden: IJMRHS
th
Research article
Copyright @2014
ISSN: 2319-5886
BIOCHEMISTRY TEACHING: ITS TIME TO PREPARE FOR MULTIDISCIPLINARY INTEGRATION
*Vittal. B G1, Jaweed S A2

1
Associate Professor, 2Professor and Head, Department of Biochemistry, Bidar Institute of Medical Sciences,
Bidar, Karnataka.
*Corresponding author email: vittal.bg@gmail.com
ABSTRACT
Background: Biochemistry is taught for 1st MBBS students without much emphasis on its relevance to medicine.
This makes the subject less interesting for students. Medical Council of India (MCI) in its revised regulations on
graduate medical education has started the process of integration of medical teaching. Objectives: Study intends
to identify the areas of biochemistry subject for multidisciplinary, integrated teaching that will help in framing an
effective educational programme. Methodology: MBBS curriculum based on the Medical Council of India
regulations on graduate medical education 1997 was obtained. Course content of each subject was discussed with
two subject experts of concerned speciality. Subject content that overlaps with biochemistry or topics that need
preliminary knowledge of biochemistry for better understanding of concerned subject were noted, as they form
potential areas for integrated teaching. Information gained from all ten major subjects was compiled to arrive at
results. Results: Nearly 75% of topics (90 classes) could be taught by integrated teaching. Topics like Chemistry
of biomolecules, Bioenergetics, Quality control and few metabolic pathways (30%) were not amenable for
integrated teaching. Conclusion: Biochemistry can be made more relevant to learner by use of integrated
teaching. MCI has recommended multidisciplinary integration of subjects and our study is a humble beginning in
this direction.
Key words: Biochemistry, Integrated teaching.
INTRODUCTION
Biochemistry is a subject taught to MBBS students
during their first year of medical education. It is
taught to the students without much emphasis on its
relevance to life in health and disease. It makes the
subject less interesting and less relevant. Use of
clinical correlations try to bridge the gap, however,
students more often fail to understand them due to
lack of clinical exposure. Similarly during III-MBBS,
students find it difficult to comprehend the molecular
basis of disease which is an essential component for
understanding pathophysiology and natural course of
the disease. Integrated teaching paves the way for
better understanding of the concept by learners in

these scenarios. Integrated teaching offers many
advantages and can be an essential factor in delivery
of an effective educational programme.1
The necessity for greater integration of subjects in
medical curriculum has been stressed in
recommendations and reports of General Professional
Education of the Physicians (GPEP) of United States
of America2and General Medical Council of united
Kingdom.3In its Graduate medical education
Regulations 1997,4 Medical Council of India (MCI)
has stated the need for integrated teaching of subjects.
Further, in its Graduate medical education
84
Vittal et al.,
Regulations 2012,5MCI has initiated the process of

multidisciplinary integration of subjects both
horizontally and vertically. However MCI has not
defined the subject wise areas for integration.
Identifying the areas of biochemistry subject for its
multidisciplinary integration forms a first step in this
direction and hence the study was conducted.
Objective: Study intends to identify the areas of
biochemistry subject for multidisciplinary, integrated
teaching that will help in framing an effective
educational programme.
The study was conducted at Bidar Institute of
Medical Sciences, Bidar, Karnataka, involving inputs
from subject experts of different subject specialities.
Some subject experts from other colleges were also
consulted. This survey was a prospective
observational study that spanned over a period of 3
months from June 2014 to August 2014. Ethical
clearance was obtained from the Institutional Ethics
Committee, Bidar Institute of Medical Sciences,
Bidar. Subject experts with MBBS teaching
experience of not less than 5 years were only

considered for study as subject experts.
Curriculum of MBBS based on regulations of
Graduate Medical Education 1997 of MCI was
obtained. Course contents of all subjects (Anatomy,
Physiology, Biochemistry, Pharmacology, Pathology,
Microbiology, Forensic Medicine, Community
medicine, General medicine, Surgery and Obstetrics
and gynaecology) were segregated.
The course content of each subject was discussed
with two subject experts from the concerned
speciality who have teaching experience of not less
than five years in an MCI recognized medical college
after post-graduation.
Subject contents that overlap with Biochemistry or
topics of other specialities that need preliminary
knowledge of Biochemistry for better understanding
of concerned topic or subject area were noted, as
these are potential areas for integrated teaching.
Information obtained from all ten major subjects was
compiled to segregate subject wise areas for
integrated teaching and also to mark the areas of
biochemistry that are not amenable for
multidisciplinary integration.
RESULTS
Topics and subject areas that need integration with Biochemistry for better understanding of subjects are shown
below. (Table-1 to 10)
Table: 1.Topics that can be integrated with Anatomy
Hormones of
Neurotransmitters
Gametogenesis, Uterine cycle,
Enzymes of digestive system.
Placenta
Proteins of connective tissues
Genetics (except cytogenetics)
Actin, myosin, Collagen, Chondroitin, Bone tissue
Principles
of
Endocrinology,
Immunology
Table: 2.Topics that can be integrated with Physiology
Cell membranes
Renal Physiology
Lipids, Proteins, Transport.
Acid, base, Water and electrolyte balance, Renal
Metabolism
function tests, Renal stone analysis.
Carbohydrates, Lipids, Proteins,
Renin-Angiotensin system and Nitric oxide
Endocrinology
Haemoglobin
and
Haemoglobinopathies, Jaundice
Reproduction
Nerve muscle physiology
Changes in pregnancy, Prenatal diagnosis,
Neurotransmitters,
Muscle
Preterm/neonatal screening
proteins, Creatine, ATP, Myelin,
Cardiovascular system
Cholinesterase
Diagnosis of myocardial infarction, Mechanism
Gastro intestinal system
of hypertension
Gastrointestinal hormones and
Atherosclerosis
Enzymes of gastrointestinal tract,
Central Nervous system
Digestion
and
absorption,
Mediators of sleep-wake;
Bilirubin, gall stones
Cerebrospinal fluid analysis
85
Vittal et al.,
Respiratory system
Gas transport, acid base
balance and regulation,
Arterial
blood
gas
analysis,
Chemical
regulation of respiration
Synapse,
Mechanism
Parkinsons disease
Special sense mediators
of
Alzheimers,
Table: 3.Topics that can be integrated with Pharmacology

Biotransformation
Gout
Phase-1 and 2 reactions
Uric acid metabolism
Drugs of Blood
Mechanism of action of drugs
Iron, Folic acid, Vit-B12
Isomerism
Vit-K, Lipoproteins
Hypolipidemic drugs
Heparin, anticoagulants
Receptors
Autocoids
Insulin, Histamine, Muscarinic, cholinergic
Arachidonicacid, Prostaglandins,
5-HT
Thromoboxanes
Mechanism of action of Non-steroidal anti Endocrine system
inflammatory drugs
Mechanism of action
Therapeutic Drug Monitoring
Calcium, Vitamin D
Table: 4.Topics that can be integrated with Pathology
Cell injury
Neoplasia
Accumulation;
fat,
protein,
Cell cycle
glycogen, pigments
Oncogene, tumour markers
Amyloidosis
Nutrition
Inflammation
Protein energy malnutrition, Vitamin deficiency
Mediators of inflammation
Mineral metabolism
Immunoglobulins; antigenecity
Genetics
Circulation
Basics,
Water electrolyte balance
Molecular diagnostics
Edema, albumin,
Haematology
Haemoglobinopathies, electrophoresis
Lipid
profile,
Coagulation profile
Hypertension
Hepatobiliary system
Cardiac enzymes
Liver function tests, gall stone analysis
Endocrine
Jaundice, Bilirubin
Hormone analysis
Table: 5.Topics that can be integrated with Microbiology
Cell and Bacterial cell
Protein and DNA electrophoresis
Bacterial metabolism
Laboratory management and safety
Bacterial genetics
Sample collection, storage and transport
Interferon and cytokines
Disinfection
Prion and slow virus diseases
Lab acquired infections
Central nervous system infections,
Biosafety cabinets
Tuberculosis, Menengitis
Measuring immune functions
CSF analysis,
Polymerase chain reaction
Table: 6.Topics that can be integrated with Forensic medicine
Toxicology
Biochemical changes after death
Measurement of toxin levels
Alcohol measurement in breath and blood
86
Vittal et al.,
Table: 7.Topics that can be integrated with Community Medicine

Mechanism, screening and diagnosis of Non Genetics and health
communicable diseases
Population genetics
Diabetes
mellitus,
Hypertension,
Environmental health
Obesity, Cardiovascular diseases
-Wateranalysis
Nutrition and health
-Air analysis
Diet planning, balanced diet,
Micro and macronutrients
Table: 8.Topics that can be integrated with General Medicine
Nutrition andxenobiotics
Balanced diet, Protein energy
Cardiac enzymes,
malnutrition.
C-reactive protein
Diet planning, Obesity
Lipidprofile, Vanillylmandelicacid assay
Vitamins
Hormone assay,
Fluid and electrolyte balance
Arterial blood gas assay and electrolyte
Alcohol metabolism and
analysis
Blood alcohol levels
Homocysteine assay
Haematology
Gastrointestinal tract
Haemoglobinopathies
and
Liver function tests, stool analysis
Haemoglobin variants
Gastric Juice analysis
Bleeding time, Clotting time
Blood ammonia
Respiratory system
Metabolic diseases
Mediators of allergy, asthma
Endocrine disorders
Arterial blood gas analysis,
Hormones: structure, mechanism, assay.
surfactant,
Molecular mechanism of diseases
Pleural fluid analysis
Laboratory diagnosis of all diseases
Genetics
Table: 9.Topics that can be integrated with Surgery
Neoplasia
Acid base homeostasis
Tumour markers, genetic
Water electrolyte homeostasis
basis of disease
Diagnostic support with ABG, electrolytes, point of
Hepatobiliary system:
care testing
Cholelithiasis, Cholecystitis,
Gall stone, analysis
Ascites,
Table: 10. Topics that can be integrated with Obstetrics and gynaecology
Diagnosis of pregnancy:
Diagnosis of pre, intra, peri, and post natal
Screening for genetic disorders
disorders.
Screening
for
metabolic
Gestational diabetes
Iron and Folic acid
disorders.
Neoplasia
Hormones of menstrual cycle
Tumour markers, genetic basis
Water electrolyte homeostasis
of disease
Infertility workup with hormones analysis
Topics that were not amenable for integration with other subjects are shown below. (Table11)
87
Vittal et al.,
Table: 11.Topics that cant be integrated with other subjects of MBBS.

Hydrogen ion concentration; Acids, bases and Buffers. Henderson Hasselbalch equation
Isotopes, radioactive isotopes and their application in medicine.
Chemistry of carbohydrates
Chemistry of lipids
Chemistry of aminoacids and proteins
Chemistry of nucleic acids
Enzymes: Chemistry, classification, specificity, cofactors, activators, Km value, Mechanism of action
of enzymes.
Intermediary metabolism
Biological oxidation and electron transport chain.
Quality control and standardisation in laboratory
Calorific value, Respiratory quotient, Specific dynamic action
Metabolic changes in starvation.
For teaching of biochemistry syllabus, MCI has stipulated 120 lecture classes. Nearly 30 classes (25%) are not
amenable for integrated teaching and are to be taught in isolation; while rest of the topics (75%) can be integrated
with other subjects.
DISCUSSION
Biochemistry is taught to I-MBBS students with little
emphasis on its correlations to diseases. It makes the
subject less relevant and less interesting to students.
To overcome this deficit, impetus has been given to
integrated teaching.
Graduate medical education regulations -2012 framed
by MCI outline the plan for integration without
defining the subject areas or topics for integration.
Our study has identified the areas of Biochemistry
subject that can be integrated with all major subjects
of MBBS. Our study is the first of its kind and is a
small beginning in this direction.
Many studies have shown the usefulness of
multidisciplinary, integrated teaching by case based
learning and problem based learning in Indian
medical schools.
Problem based learning, a type of integrated teaching
was found to be effective in analysing and
understanding clinical problems and also was found
to arouse interest and enthusiasm in teaching learning
activity.6Integrated teaching splits the complicated
areas into easy small blocks that can be understood
by learner easily.7Students preferred integrated
teaching over conventional methods as they found it
to be useful and interesting.8, 9, 10,11,12.System-based
learning modules for integrated teaching were
developed by some researchers and found to be useful
than conventional teaching methods.13 Problem
based learning in biochemistry was found to be
associated with learning gains and development of

skills, values and attitudes.14
Hurdles are many for implementation of integrated
teaching in medicine, but its benefits outweigh the
difficulties of implementation in Indian scene.15
Limitations of the study: Study considered opinions
of only two subject experts per each speciality. Study
did not take into account of learners opinion
regarding choosing topics for integration. Temporal
integration and assessment that pose major challenge
for integrated teaching were not considered for study.
CONCLUSION
Majority of Biochemistry subject (75%) can be
integrated with other subjects for multidisciplinary
integrated teaching to make it more interesting and
relevant for the learners. This study provides the
outline of Biochemistry topics amenable for
integration to curriculum developers and subject
experts of MCI for integrating Biochemistry with
other subjects.
ACKNOWLEDGEMENT
Authors acknowledge the help of all subject experts
of different specialities for sharing their knowledge.
88
Vittal et al.,
REFERENCES
1. Harden RM. The integration ladder: a tool for
curriculum planning and evaluation. Med Educ.
2000;34(7):551-7.
2. Association of American Medical Colleges.
Physicians for the Twenty-First Century: Report
of the project panel onthe General Professional
Education of the Physicians and College
Preparation for Medicine. J Med Educ
1984;59,Part 2:1-208.
3. General Medical Council. Tomorrows Doctors
recommendations on undergraduate medical
education. London: GMC, 1993. p23. Available
online at www.gmcuk.org/Tomorrows_Doctors
_1993.pdf_25397206.pdf.Accessed 10 2014.
4. http://www.mciindia.org/RulesandRegulations/Gr
aduateMedicalEducationRegulations1997.aspx20
14 15:52:12
5. www.mciindia.org/tools/announcement/Revised_
GME_2012.pdfAccessed on 10.09.2014.
6. Dinesh Puri. An integrated problem based
curriculum for biochemistry teaching in medical
sciences. Indian J ClinBiochem. 2002; 17(2): 52
59.
7. Ramesh R, Niranjan G, Srinvasan AR, Satish
BM. Planning an objective and need based
curriculum: The logistics with reference to UG
medical education in biochemistry. J ClinDiagn
Res. 2013; 7(3): 58994.
8. Kalpanakumari MK, Vijaya KM, Seema R.
Students perception about integrated teaching in
UG medical education. J ClinDiagn Res. 2011;
5(6):1256-9
9. KadamSwapnali, Sane Kavita. Integrated
teaching tool for reformation of curriculum.
Indian Journal of Applied Basic Medical
Sciences.July2013.Available online http:/ /www.
themedicalacademy.in/fxconsult1/userfiles/Dr_%
20Kadam%20Swapnali%20%20&%20%20Dr_%
20Sane%20Kavita.pdf
Accessed
on
10
September 2014.
10. D'Souza J, Raghavendra U, D'Souza D, D'Souza
N. Teaching Learning in Biochemistry: Medical
College Students Perceptions and Opinions.
Education in Medicine Journal 2013; 5(2):e47e53.
11. Madhuri SK, Ujjwala JK, Avinash S,
DeshmukhYA.Introducing Integrated Teaching in
12.
13.
14.
15.
Undergraduate
Medical
Curriculum.
2010;1(1):18-22.
Vyas R, Jacob M, Faith M, Isaac B, Rabi S, et
al.An effective integrated learning programme in
the first year of the medical course. Natl Med J
India. 2008;21(1):21-6.
Vijaya SD. Curriculum development for
integrated teaching (module)-MBBS phase-I
students. Asian J ExpBiolSci 2011; 2(3): 474-81
Vella, F. Biochemistry teaching in integrated
curricula. Biochemical Education, 1997; 25: 75
77.
Haranath PS .Integrated teaching in medicine Indian scene.Indian J Pharmacol. 2013;45(1):1-3.
doi: 10.4103/0253-7613.106425.
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DOI: 10.5958/2319-5886.2015.00015.6

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Coden: IJMRHS
th
Research article
Copyright @2014
ISSN: 2319-5886
DHAT SYNDROME AND ITS ASSOCIATION WITH SEXUAL BEHAVIOR AND PYSCHIATRIC
COMORBIDITIES IN MALES: A CASE CONTROL STUDY
*Sahu RN1, Sharma VK2, Ashutosh Kumar3, Chintan Bavishi4, Balaji More5
1
Head and Professor, 3Lecturer, Department of Psychiatry Gandhi Medical College, Bhopal, Madhya Pradesh,
India
2
WHO Fellow (USA), Head and Professor, Department of Medicine, Gandhi Medical College, Bhopal, Madhya
Pradesh, India
4
Lecturer, Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal
University, Manipal
5
Assistant Professor, Department of Pharmacology, Krishna Institute of Medical Sciences, Karad, Maharashtra
*Corresponding author email: as.anju@yahoo.in
ABSTRACT
Background: Dhat syndrome is often taken as culture bound syndrome (CBS) of Indian subcontinent. There are
many misconceptions which form base of symptoms and co morbidities. Aim: Dhat syndrome is reported on basis
of self diagnosis. The study aims to study associated symptoms, sexual behavior and co morbidities in Indian
population. Material and Methods: This cross-sectional and case-control study was carried with help of trained
local interviewers at Department of Psychiatry and Medicine, Gandhi Medical College (GMC), Associated
Hamidia Hospital, Bhopal, India. Cases were compared to healthy matched controls. The study was conducted
using clinical interview, physical examination and other necessary investigations like urine analysis and
microscopy. Results: Of the 50 cases and control, each, age group was 21 to 25 years (48%) and education
upto12th class (60%). 20% cases reported history of Masturbation. Extramarital or premarital sexual contact was
found to have little significance on the syndrome. 76% of the patients met DSM-IV Diagnostic Criteria for
Anxiety and 56% patients met for Depression. 23 patients (46.3%) were having a co-morbid somatic complains
like body ache, weakness and fatigue. Erectile dysfunction by 34% & premature ejaculation by 8% was reported.
In Urine routine analysis and microscope no oxalates or phosphates were noted. Conclusions: Dhat syndrome is
more common among low educated young population. Laboratory evidence of any pathological cause was not
found. Contrary to popular belief, it had no direct correlation with masturbation and pre and extra marital sexual
contact.
Keywords: Dhat Syndrome, Semen, Sexual behavior, Somatic symptoms, Erectile dysfunction
INTRODUCTION
Dhat syndrome is a Culture bound syndrome1. But it
has been mentioned in medical history and reported
by population worldwide. The culture has a profound
impact on the mental status of an individual.
According to International Classification of Diseases

(ICD) 10 had classified Dhat syndrome had been
classified in both neurotic disorder (F48.8) and into
culture specific disorder caused by undue concern
about the debilitating effects of the passage of
90
Sahu et al.,
semen. The cases are always self reported and they

often report a set of symptoms. These vague somatic
symptoms are fatigue / bodily weakness, headache,
depression2, anxiety, loss of appetite, palpitation/
tachycardia, guilt, poor concentration, forgetfulness3.
Due to existing belief, it is often associated as a result
of masturbation and being sexually active outside
marriage. The co morbidities include erectile
dysfunction, premature ejaculation and impotence.
Patients reported semen loss in urine or involuntarily
outside (spontaneously; while sleeping; during
defecation; or while showering) of sexual relations4.
A typical profile of Dhat Syndrome patient has either
been a young man, unmarried or recently married,
less educated, and the one who holds strong
traditional beliefs5.
This category of disease involves mixed disorders of
behavior, beliefs, and emotions which are of
uncertain etiology and nosological status and which
occur with particular frequency in certain cultures.
The cultural belief and pattern associated with Dhat
syndrome make it different from delusional
disorder6,7.
The study is a case-control cross sectional study,
aimed to evaluate the symptoms, beliefs and co
morbidities related to Dhat syndrome. The study and
control group of 50 each was assessed.
The study was conducted at Gandhi Medical College
(GMC), Associated Hamidia Hospital, Bhopal, India.
Study group of 50 subjects was selected who had
Dhat syndrome without any other organic disorder at
OPD of Psychiatry Department. The control group of
50 patients was shortlisted from the Medicine
Department. They were not diagnosed as a Dhat
syndrome and were matched with the case group in
all aspects.
Inclusion criteria:
Case group: Complain of whitish discharge in the
urine and associating it with symptoms and co
morbidities, Fulfilled Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSMIV) TR criteria apart,8 Consenting to clinical
interview
Control group: In patients who were not suffering
from Dhat syndrome though they were suffering from
other medical ailments, matched in other aspects with

the case group, consenting to clinical interview
Exclusion criteria: Presence of Genitourinary
disorder, Testicular tumor, Varicocele, Organic
sexual dysfunction, Pelvic inflammatory disease,
Endocrine disorders, Spinal cord trauma.
On the persons enrolled for both study and control
group detailed case history, including past, medical,
family and sexual history was taken. General and
systemic examination were performed to rule out
other ailments before proceeding to laboratory
evaluation. Both groups were interviewed based on a
structured interview, which was prepared by the
investigator. The questionnaire included demographic
data, symptoms, past, medical, personal and sexual
history. The detail questionnaire can be accessed by
communication via Email with Corresponding author.
The laboratory parameters were evaluated for all the
participants of both the groups. These included
routine biochemical evaluation and urine analysis. To
exclude organicity Sonography, Hormone Assay and
semen analysis were performed on case group.
All interviewers were careful about ethical and legal
considerations. All identification information
including names, initials and hospital numbers were
avoided to keep the patient details in anonymity.
Ethics: Institutional review board and ethical
committee approval was taken from GMC, Bhopal,
India. All periodic adverse event reports were
reported to them and appropriate guidance was taken.
Written informed consent after the details of the
project were fully explained, was obtained from all
participants. There were no minors involved and
hence no paternal consent involved in this study.
Statistics: The data was analyzed by using statistical
tests of mean and standard deviation. (P>0.005)
RESULTS
Dhat syndrome is prevalent in younger age group.
Anxiety is most prevalent followed by depression.
They are related to sexual symptoms as ejaculatory
dysfunction, premature ejaculation and impotence.
(Fig. 1) Patients associated Dhat syndrome as a direct
result of excessive indulgence in sexual activity or
masturbation or to nocturnal emissions. (Fig. 2) Dhat
syndrome was prevalent in class of lower education,
below class 12.
91
Sahu et al.,
Routine biochemical and urine laboratory evaluation

was conducted for all 100 participants. Other
necessary investigations were carried out as per the
requirement of the subjects to exclude organicity
(Sonography and Hormone Assay).None of the
reports showed presence of oxalates or phosphates. A
semen analysis founded out only 1 patient had
azospermia and 2 were having oligospermia.
80% 76%
70%
56%
60%
44%46% 42% 44%44%
50%
34%
40% 30%
24%
30%
18%
10% 8%
20%
4% 0% 8% 0%8% 0% 0% 0% 6%
0% 0%2%
10%
0%
0%
STUDY GROUP
Fig 1: Co-morbid conditions associated with

patients in study group and control group
History of masturbation
25%
20%
20%
15%
12%
10%
5%
0%
STUDY GROUP
CONTROL GROUP
History of sexual contact

(extramarital or premarital )
14%
12%
10%
8%
6%
4%
2%
0%
12%
6%
STUDY GROUP
CONTROL GROUP
Fig 2: Sexual history of patients in study group

and control group
Sahu et al.,
DISCUSSION
As a Culture bound syndrome (CBS), Dhat syndrome
has been discussed for long time. Epidemiology and
prevalence are noted in history of medicine all over
the world1, 9. The Dhat syndrome is not limited to
Indian subcontinent. The origin of its name had a
strong relationship with Indian culture, history and
mythology 10, 11.
Dhat Syndrome forms an important health problem
and the magnitude is also very high. In view of this it
needs a proper attention and sensitization amongst the
healthcare providers for the proper treatment,
counselling of these patients and referring them to
related Specialty. The patient presenting with Dhat
syndrome is typically more likely to be recently
married; of average or low socio-economic status
(student, laborer or farmer by occupation), came from
a rural area and belonged to a family with
conservative attitudes towards sex12.
The exact pathophysiology of Dhat syndrome is not
known. The study demonstrated various other
symptoms and morbidities being involved along with
Dhat syndrome. The prevalence in a relatively
younger age group can be attributed to hormonal
rush13. Majority of these individuals visited selfclaimed sex specialists and traditional faith healers.
The contact with these health providers not only
strengthen their misconception and false beliefs, but
also compel the patients to pay a huge cost of
investigations and drugs which are not only noneffective but also hazardous.
Among other studies the relationship between marital
status and sexual contact outside marriage and Dhat
syndrome is not discussed. This study establishes
contrary to the popular belief that no such causeeffect relationship exists. Dhat syndrome was most
common among illiterate patients and less educated
patients. There is a need for patient education and sex
education in the eradication of syndrome 14, 15. The
spread of disease in all age groups indicates towards
the need of patient education about the disease in
India. In many cases the syndrome is under diagnosed
in general, the deep-rooted misconceptions associated
with anatomical and physiological aspects of
sexuality are difficult to be correct with general
counseling sessions.
The further work in this field is required to know:
Whether Dhat is a Culture bound syndrome only in
92
India? What is the pathophysiology behind it? Is there

any relationship of it with depression, anxiety or
other mental health disorder? Whether there is any
relationship between puberty and Dhat syndrome.
9.
CONCLUSION
Thus to control the morbidity that arise out of cultural
Thus to control the morbidity that arise out of cultural
misconceptions like Dhat syndrome, the public
awareness and education should be done in young
adults. Those with actual azospermia or oligospermia
can be provided with proper counseling and
knowledge about assisted reproductive technological.
10.
11.
ACKNOWLEDGEMENT
We are thankful to all the interviewers who
conducted data collection.
REFERENCES
1. Sumathipala A, Siribaddana SH, Bhugra D.
Culture-bound syndromes: the story of Dhat
syndrome. Br J Psychiatry. 2004; 184: 200-9.
2. Bhatia M.S, Jhanjee A, Kumar P. Culture bound
syndromes- a cross-sectional study from India.
European Psychiatry. 2011; 26:448
3. Dhikav V, Aggarwal N, Anand KS. Is Dhat
syndrome, a culturally appropriate manifestation
of depression? Med Hypotheses. 2007; 69 (3):
698.
4. Mehta V, De A, Balachandran C. Dhat syndrome:
a reappraisal. Indian J Dermatol. 2009; 54(1): 8990.
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Bergamaschi V, Castelli F; Migration Health
Committee of the International Society of Travel
Medicine. Forty meals for a drop of blood. J
Travel Med. 2009; 16(1): 64-5.
6. Behere PB, Natraj GS. Dhat syndrome: the
phenomenology of a culture bound sex neurosis
of the orient. Indian J Psychiatry. 1984; 26(1):
76-8.
7. World Health Organization (1992) International
Statistical Classification of Diseases and Related
Health Problems (ICD-10). Geneva: WHO.
8. American Psychiatric Association. Appendix I:
Outline for cultural formulation and glossary of
12.
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14.
15.
culture bound syndromes. In Diagnostic and

statistical manual of mental disorders, 4th ed.,
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De Silva P, Dissanayake SAW. The use of semen
syndrome in Sri Lanka: A clinical study. Sex
Marital Ther. 1989; 4:195-04.
Malhotra HK, Wig NN. Dhat syndrome: a
culture-bound sex neurosis of the orient. Arch
Sex Behav. 1975; 4(5): 519-28.
Angst J, Gamma A, Gastpar M, et al. Depression
Research in European Society Study. Gender
differences in depression. Epidemiological
findings from the European DEPRES I and II
studies. Eur Arch Psychiatry Clin Neurosci.
2002; 252(5): 201-9.
Singh G. Dhat syndrome revisited. April
1985;27(2):119-22
Carroll BJ. Adolescents with depression. JAMA.
2004 Dec 1;292(21):2578
Tiwari SC, Katiyar M, Sethi BB. Culture and
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Avasthi A, Jhirwal OP. The concept and
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93
Sahu et al.,
DOI: 10.5958/2319-5886.2015.00016.8

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
PATTERN OF CARDIOVASCULAR FUNCTIONS, NUTRITIONAL STATUS AND OBESITY INDICES

AMONG BAIGA AND GOND TRIBES OF MADHYA PRADESH
*Monika Saini1, Kapoor AK2, Satwanti Kapoor2
1
UGC-JRF, 2Professor, Department of Anthropology, University of Delhi, Delhi-110007
*Corresponding author:mini.1901@yahoo.com
ABSTRACT
The Indian population is passing through a nutritional transition with a rise of non-communicable disease burden
like cardiovascular disease. Aims: The overall aim was to provide detailed information on the current
cardiovascular functions, nutritional status and obesity indices among Baiga and Gond tribes of Madhya Pradesh
and to compare with other population groups in India. Materials and Methods: A cross-sectional study was
carried out among 177 males of Baiga and Gond tribes of Madhya Pradesh ranging in range from 20-50 years.
Stature, Weight, circumferences, skin fold thicknesses, body fat percentage and physiological measurement were
taken. Obesity indices like body mass index (BMI), waist-hip ratio (WHR), waist-height ratio (WHtR), grand
mean thickness (GMT) were computed. Cardiovascular functions were assessed by taking systolic (SBP) and
diastolic (DBP) pressure, heart rate and pulse rate. Results: Gond males were found to be taller and heavier than
Baiga males. Upper arm circumference, waist circumference, hip circumference and chest normal circumference
were all found to be significantly higher among Gond males as compared to Baiga males. Among the adiposity
measurements only the body mass index (BMI) and Grand Mean Thickness were found to be more among Gond
males as compared to Baiga males. Diastolic blood pressure (DBP), heart rate (HR), pulse rate (PR) was found to
have greater mean value among Gond males but the differences were found to be statistically non-significant. All
India comparison on these variables has also been made. Conclusion: Subjects belonging to different population
groups of India showed marked differences in different body dimensions, adiposity indices and cardiovascular
functions. Gender differences were also seen with reference to adiposity measures.
Keywords: Nutritional transition, Cardiovascular functions, Adiposity indices, Populations.
INTRODUCTION
India is the second most populated country in the
world that consists of 17% of world population and
contributes 16% of worlds deaths. Cardiovascular
diseases and nutritional problems are prevailing cause
of death and disability in the Indian sub-continent.
Cardiovascular diseases (Ischemic Heart Disease,
Stroke and Congenital Heart Failure) are also
contributing towards an ever-increasing proportion of
the non-communicable diseases in the Indian
Population. The Global Burden of Diseases (GBD)
study reported the estimated mortality from coronary
Monika et al.,
heart disease (CHD) in India at 1.6 million in the year

20001. There are many factors which affect the
cardiovascular functions. Obesity is one of the most
ubiquitous causes. There are various anthropometric
indices which define obesity with relative ease and
accuracy like body mass index, waist hip ratio and
waist circumference. Obesity measured by any index
almost correlates with cardiovascular disease risk
(CVD) factors; there are differences in the
relationship of these anthropometric measures and
CVD risk factors in different ethnic groups2.
94
The Indian population is passing through a transition

phase where subsistence conditions are being
replaced by plentiful food but reduced physical work
and therefore, an understanding of the changing
nutritional scene is critical3. Nutritional status of the
Indian population also varies significantly across the
regions. Certain regions are associated with
extremely high rates of childhood undernutrition
(ranging from 20% to 80%), whereas others have a
high prevalence of adult undernutrition (>50%), and
some have both4.Anthropometric indices are essential
features of nutritional evaluation for determining
malnutrition, being overweight and obesity. The
present study evaluates the anthropometric
measurements nutritional status and cardiovascular
functions among different population groups of India.
Subjects and area: The Indian population is divided
into large number of endogamous groups consisting
of different castes, tribes, religions, minorities,
scheduled castes etc. The basis of isolation of these
populations is varied, but it is mainly geographic,
religious, ethnic or occupational5.
Populations of India can be broadly classified under
three categories: Urban Population, Rural Population,
Tribal Population
Mann6 identified eight characteristics which are used
as a means for comparing the urban and rural
populations. India as a country, mothers 8.43 crores
of tribal population, which constitutes 8.2% of the
total population. The tribes or aborigines were
ascribed the lowest position in the human civilization
of which the highest level was said to have been
achieved by the white men in the west7.
The present study was carried out among Baiga and
Gond tribal population in Madhya Pradesh, India.
The selection criteria for studying these tribes were
the lack of adequate literature and heavy
concentration of these tribes in the Madhya Pradesh
region. A cross sectional study was carried out in
three districts namely Anuppur, Dindori and Mandala
districts of Madhya Pradesh. Anuppur district is
situated in the northeastern part of M.P. The district
extends 80 km from east to west and 70 km from
north to south. It is a tribal dominated district.
Dindori district is part of Shahdol division. In 2006,
the ministry of panchyati raj named Dindori one of
the countrys 250 most backward districts (out of a
total of 640). Mandla is a tribal district situated in the
east-central part of M.P.
Monika et al.,
The Baiga are a munda or kolarian people (part of the

Baiga tribe) located in the central highland of India. It
is one amongst primitive tribes of India. The Baiga
houses are actually huts made of wood and bamboo
which are mud plastered. The number of rooms in a
house depends on their economic status and
requirement. The Baiga people are known for their
scanty use of cloth. They are short statured with dark
brown complexion. Their dress pattern, hair style and
jewelry are unique. They are very much fond of
tattoo. They are strictly endogamous. The Gonds are
among the largest tribal groups in south Asia and
perhaps the world. Gondi belongs to the Dravidian
family of languages and related to Tamil and
Kannada. They live in a hamlet of their own. The
hamlet is not a closed cluster of huts for the Gonds,
homesteads are spread over a large area within the
hamlet. They are also short statured with dark black
skin and fuzzy hair. These people are known for their
rich socio-culture life. Based on the ethnographic
study it was observed that Gonds practice clan
exogamy, considering intermarriage within a clan to
be incest.
A cross-sectional study was conducted in 3 districts
namely Anuppur, Dindori and Mandla of Madhya
Pradesh. A total 177 males between the age group 2050 yrs. were studied. Out of the total population, 88
males were Baigas and 89 males were Gonds.
Detailed information of the tribals were taken with
the help of schedule. Data was collected from
different villages of Amarkantak, Furrisemar,
Amanala,
Karanjia,
Chauradadar,
Ladwani,
Thadpathra, Malagaur, Kateltola, Lacchantola,
Bhangartola, Hurratolaetc by a door to door survey.
Fieldwork was conducted from 17th January 2012 to
20th Feb. 2012.Ethical clearance was taken from the
Department of Anthropology, University of Delhi,
Delhi. Subjects also gave their written consent to be
part of the study.
General information such as clans, household
composition, dietary preferences, health status,
demographic profile, various anthropometric and 4
physiological variables were taken on all the subjects.
Since the female members of the area were mostly
busy in the household work so they were excluded
and due to easy availability and positive response of
male members they were taken into consideration.
95
Transport bottleneck and sparsely populated villages

were the major limitations in the collection of data.
Subjects were measured for stature, body weight,
circumferences (minimum waist, mid upper arm,
normal chest, hip and calf), skinfold thicknesses
(biceps, triceps, suprailiac and subscapular).
Anthropometric and physiological measurements
were taken using standard protocols given by Weiner
and Lourie8 and Shaver 9. Stature was taken with the
help of anthropometer in the standard arm hanging
position; body weight was taken by spring balance
with minimum clothing; circumferences were
measured with the help of flexible steel tape.Skin fold
thicknesses were taken with Holtains skin fold
caliper which exerted a constant pressure of 10
g/mm2 over the contact surface.
Table 1: List of Variables Studied
Unit
Instrument Used
centimeters Anthropometer
kilograms(K Weighing Machine
g)
Circumferences in centimeters (cm)
Minimum Waist Circumference
Flexible Steel Tape
Mid Upper Arm Circumference
Normal Chest Circumference
Hip Circumference
Calf Circumference
Skin fold Thicknesses in millimeters (mm.)
Biceps
Skin fold Caliper
Triceps
Subscapular
Supra iliac
Physiological Measurements
Systolic and
mmHg
Sphygmomanometer
Diastolic Blood
Stethoscope and
Pressure
Stopwatch
Heart Rate
beats/min.
Stethoscope and
Stopwatch
Pulse Rate
pulse/min.
Stopwatch
Measurements
Stature
Body Weight
Cardiovascular functions were assessed by taking

Systolic (SBP), Diastolic (DBP) blood pressure, heart
rate(total number of the heart beat per unit time) and
pulse rate(the frequency of blood pressure wave
propagated along superficial, periphery arteries such
as
carotid
and
radial
artery)
using
sphygmomanometer, stethoscope and stopwatch
whereas nutritional status was assessed by BMI
(Body Weight (Kg)/
(m)), body
circumferences and skin fold thicknesses. Obesity
indices which include body mass index (BMI), grand

mean thickness (GMT), waist-hip ratio (WHR) and
waist-height ratio were computed statistically.
Waist circumference (WC) was categorized
according to the Dobbelsteynet. al 10. Males and
females whose waist circumferences are more than 90
and 80 centimeter were at risk. The classification of
BMI was done according to the WHO expert
consultation 11. BMI less than 18.5 as underweight
and more than 24.9 as overweight. WHtR cut off
points followed for males was 0.5012.
Blood Pressure was classified in different categories
according to JNC7 (Joint National Committee)13.
Subjects were divided into three classes:
normotensive, prehypertensive (120-139 mm Hg
systolic; 80-89 mm Hg diastolic), and hypertensive
(140/90mm Hg).
The data were analyzed using SPSS version 16.0 and
window 7.0. Statistical variables such as arithmetic
mean, Std. Deviation, std. Error of mean, t-test and
correlation coefficient were calculated. Data were
also analyzed for the computation of adiposity indices
such as Body Mass Index (BMI), Waist-Hip ratio,
Waist height ratio and Grand mean thickness.
RESULTS
Table 2 shows mean, std. deviation and std. error for
various anthropometric, skin folds and physiological
measurements and adiposity indices, body fat
percentage of Baiga and Gond males of Madhya
Pradesh. Gond males were found to be taller and
heavier than Baiga males. upper arm circumference,
waist circumference, hip circumference and chest
normal circumference were all found to be
significantly higher among Gond males as compared
to Baiga males. Only triceps and suprailiac skin fold
thickness were found to be significantly more among
Gond males as compared to Baiga males. Only the
systolic blood pressure (SBP)was found to be greater
among Gond males as compared to Baiga males
(p<0.01). diastolic blood pressure (DBP), heart rate
(HR), pulse rate (PR) was found to have greater mean
value among Gond males but the differences were
found to be statistically non-significant. Among the
adiposity measurements only the body mass index
(BMI) (p<0.01) and Grand Mean Thickness were
found to be more among Gond males as compared to
Baiga males. Body fat percentage was also found to
96
Monika et al.,
be more among Gond males as compared to Baiga

males (-2.11*).
Table 2:
Anthropometric and Physiological
Variables among Baiga and Gond Males
Measurement
Stature(cm.)
Body weight(Kg.)
Mid upper arm
circumference (cm)
Minimum waist
circumference (cm)
Maximum hip
Chest normal
Maximum calf
Biceps
Triceps
Subscapular
Supra iliac
SBP (mmHg)
DBP (mmHg)
Heartrate(beats/mi
n)
Pulserate(pulse/mi
n)
BMI(kg/m2)
WHR
WHtR
GMT (mm)
Body fat
percentage
MeanSD MeanSD t
(Baiga)
(Gond)
values
160.26.07 162.85.30 2.99**
48.35.21 52.16.20 4.39***
23.41.80 24.21.70 2.91**
69.65.80
71.86.06
2.47*
80.64.27 83.24.33 4.20***

81.43.60 84.34.50 4.69***
30.02.33 30.52.01
1.65
3.10.90
3.00.90
0.273
5.01.60
5.72.30
2.164*
9.02.20
9.73.06
1.62
4.81.52
5.42.60
2.11*
127.911.6 128.413.3 2.82**
85.09.72 87.09.50
1.38
76.010.80 81.386.60 0.581
75.810.20 73.010.90
18.81.72 19.72.20
0.90.80
0.90.70
0.40.03
0.40.03
5.51.10
6.01.90
11.313.10 12.524.38
1.805
2.87**
0.287
1.20
2.06
2.11*
*p<0.05,**p<0.01,***p<0.001
Table 3 depicts the distribution of Baiga and Gond
males according to their BMI. Most of the Baiga
males (52.3%),and Gond males (68.5%) were in the
normal category. 3.4% Baiga males and 2.2% Gond
males were severely underweight. 6.8% Baiga males
and 4.5% Gond males were in moderate underweight
category. 36.4% Baiga males and 23.6% Gond males
were mild underweight .Only 1.1% of Baiga males
and Gond males were overweight.
Table 3: Distribution of Baiga and Gond
MalesAccording to Body Mass Index
BMI
Baiga
Gond
Frequency
% Frequency
%
Severe UW
3
3.4
2
2.2
Moderate UW
6
6.8
4
4.5
Mild UW
32
36.4
21
23.
Overweight
1
1.1
1
1.1
Normal
46
52.3
61
68.5
Total
88
100
89
100
Table 4 displays the distribution of Baiga and Gond

males according to their blood pressure. For the SBP,
most of the Baiga males (67.0%) and almost half of
the Gond males (56.2%) were in pre-hypertensive
category. 18.2% Baiga males and 18.0% Gond males
were normal. Rest 14.8% Baiga males and 25.8%
Gond males were Hypertensive.
For the DBP, 44.3% Baiga males and 38.2% Gond
males were pre-hypertensive. 20.5% Baiga males and
19.1% Gond males were normal .Rest 35.2% Baiga
males and 42.7% Gond males were hypertensive.
Table 4: Distribution of Baiga and Gond Males
According to Blood Pressure
Blood
pressure
Baiga
Gond
SBP
DBP
N % N
%
16 18.2 18 20.5
N
16
DBP
% N
%
18.0 17 19.1
44.3
50
56.2 34
38.2
35.2
100
23
89
25.8 38
100 89
42.7
100
Normal
Pre59 67.0 39
hypertensive
Hypertensive 13 14.8 31
Total
88 100 88
SBP
*Systolic (SBP), Diastolic (DBP) blood pressure

Table 5 presents the best predictor (value) of
cardiovascular health from various anthropometric
indices.It is clear from table that BMI is better
predictor of cardiovascular risk in Baiga males
(=.223) for SBP and in Gond males (=.216) for
DBP. Waist height ratio is a predictor of
cardiovascular risk in Gond males (=.245) for DBP.
Waist circumference is a predictor of CVR in Baiga
males (=.206) for SBP and (=.258) for DBP. Waist
circumference is also a predictor of CVR in Gond
males (=.211) for SBP and (=.277) for DBP.
Table 5:
Predictors of Cardiovascular Risk
Among Baiga and Gond Males
Adiposity Indices
Baiga
SBP
DBP
General adiposity measures
Body Mass Indexkg/m2
.136
.223
Grand Mean
.183
.113
Thickness(mm)
Fat percentage
.202
.171
Regional adiposity measures
Waist height ratio
.160
.178
Waist circumference(cm)
.258
.206
Waist hip ratio
.148
.121
Gond
SBP
DBP
.113
-.036
.216
.046
.031
.151
.156
.211
.098
.245
.277
.117
(p<0.01), *Systolic (SBP), Diastolic (DBP) blood

pressure
97
Monika et al.,
DISCUSSION
The present study clearly represents the double stress
of under-nutrition and hypertension among the tribal
population of Madhya Pradesh i.e. Baiga and Gond
males. The prevalence of both under nutrition and

pre-hypertension was quite high which is
contradictory
to
many
other
studies14.
Table 6: Comparison with different region of Indian Population (Published)

Area
Population Sex
Groups
Age
Khatri
F
M
M
F
F
F
M
F
M
F
F
M
F
M
M
M
20-30 156.56.6
167.27.1
30-34 167.07.4
30-34 155.35.0
21-50 154.05.5
20
154.76.2
167.67.2
50
149.86.8
164.86.7
16-32 152.06.
20
153.65.6
20
165.37.8
50
151.95.7
50
160.09.5
20-50 160.26.0
20-50 162.85.3
F
M
F
M
20
20
50
50
20-25
M 50-55
55-60
F
20-30
Tangkhul
Naga
M
20-30
(Tribe)
M
20-70
20-70
149.54.2
161.15.6
148.54.9
158.05.3
163.15.5
158.44.7
159.94.8
153.05.6
164.85.7 59.18.3
162.05.9 54.97.4
151.35.5 48.77.4
21.72.6
20.92.3
21.22.7
20-29
30-39
40-49
155.65.0
154.05.9
153.55.6
163.46.0
21.32.7 0.80.0
22.22.8 0.80.0
21.93.0 0.80.0
18.82.0
-
Delhi
Baniya
Punjabi
H.P.
Rajput
Haryana
Rajput
Rajput
(Caste
Group)
Baigas (Tribe)
Gonds (Tribe)
Tadavi
(Tribe)
Meena
(Tribe)
Manipur
Assam
Kalita
(Caste
Group)
Brahmin
Kalita
Jogis
Kaibartas
Ahoms
Kochs
Rajbasnhis
BoroKacharis
Lalungs
Mechs
Miris
Pnars
M 18-62
Stature
Weight
52.09.52
61.513.6
68.715.6
62.910.1
64.912.9
47.68.22
56.310.8
45.99.59
58.49.62
42.06.0
44.27.38
48.06.83
40.14.85
45.23.55
48.35.2
52.16.2
BMI
21.23.6
21.93.9
24.625.1
26.154.4
27.35.1
19.82.9
19.92.6
20.54.0
21.42.8
18.2 18.72.5
17.62.3
17.42.1
17.93.5
18.81.7
19.72.2
40.43.1
18.11.3
50.511.2 19.54.7
41.99.6
18.93.5
44.86.8
17.92.3
47.13.3
17.71.1
43.83.9
17.51.4
45.15.5 17.72.6
49.67.4 21.12.2
51.77.5
52.97.7
51.97.9
50.36.1
163.05.7 50.56.7
WHR
0.70.0
0.80.0
0.90.6
0.70.0
0.80.0
0.70.0
0.80.0
0.80.0
0.80.0
0.7 -0.70.0
0.80.0
0.80.0
0.80.0
0.90.8
0.90.7
WHtR
SBP
0.40.0
0.40.0
0.90.0
0.40.0
0.50.0
0.40.0
0.40.0
0.40.0
0.40.0
0.40.0
0.40.0
0.40.0
0.40.0
0.400.0
0.400.0
104.19.1
119.79.3
125.29.6
114.88.4
117.512.0
131.512.6
124.118.4
136.829.7
113.619.0
120.414.2
122.918.0
125.919.0
127.911.6
128.413.3
0.80.0 0.410.0
0.80.0 0.410.0
0.80.0 0.440.0
0.80.0 0.440.0
0.80.0 0.410.0
0.80.0 0.440.0
0.80.0 0.410.0
0.70.0 0.450.0
113.710.5
118.15.8
124.57.1
126.37.4
121.36.8
125.67.8
135.516.0
106.79.7
0.80.0 0.430.0
0.80.6 0.470.0
0.80.7 0.510.0
0.40.0
0.40.0
0.40.0
-
DBP
70.76.9
83.49.3
89.610.0
81.044.3
76.09.8
84.88.2
79.911.5
82.522.8
74.89.3
76.510.9
80.210.8
81.28.8
85.09.7
87.09.5
76.05.8
76.45.4
85.09.7
82.93.5
78.96.6
82.37.1
89.713.0
70.28.2
121.212.8 75.410.0
126.317.6 80.013.1
119.818.9 75.213.2
GMT
Reference
14.45.0
10.45.1
19.558.
26.16.1
23.29.5
5.51.1
6.01.9
Mungreiphy et
al21
Mishra 22
Kapoor et al23
Kapoor et al.16
Kapoor 24
Kapoor et al.16
Present Study
Present Study
Kapoor et al 16
6.980.7 Kapoor et al.25
7.400.4
7.080.5
13.43.7 Mungreiphy21
9.864.
7.52.8 Mungreiphy26
10.73.2
118.715.5 74.411.8 120.913.6 77.610.4 132.220.0 82.110.9 -
18.92.1
164.05.6 50.25.62 18.62.01
160.06.4 47.06.6
18.32.0
162.05.5 49.275.5 18.71.5
162.56.1 50.697.7 19.12.5
161.35.9 51.17.6
162.25.3 52.15.6
19.62.6
19.81.8
160.16.4 49.26.1
19.11.3
160.34.4 52.74.2
20.41.1
159.35.7 49.65.0
19.51.9
157.65.6 49.34.5
19.81.4
Bordoloi 27
Khongs
Dier28
98
Monika et al.,
Population Sex
Groups
Area
Andaman
Nicobar
Car(Tribe)
Nicobarese
Orissa
Nolia
Kerala
Ezhava
Age
F
M
M
F
M
F
Andhra Ural
Pradesh population
Urban
population
Stature
Weight
160.11.7
158.13.7
162.31.8
160.02.1
155.95.3
170.65.9
166.311
158.29.4
166.510
157.89.8
55.51.4
57.02.2
50.21.4
48.31.6
47.58.1
56.910.3
68.915.3
64.914.9
73.015.9
69.213.1
BMI
21.70.8
22.80.9
19.00.4
18.80.2
19.52.7
19.53.05
24.94.9
25.96.10
26.45.81
27.85.7
WHR
WHtR
SBP
DBP
GMT
Reference
0.70.0 0.400.0 107.510.2 72.310.3 14.33.5

0.70.0 0.390.0 121.210.2 81.68.8 10.13.7
123.016.8 82.08.9
0.90.0
0.80.0
119.922.2 81.68.2
0.90.0
128.118.3 83.399.4
0.80.0
128.413.5 82.048.1
-
Table 7: Comparison of various parameters with different region of Indian Population (Published)
Delhi
Population
Groups
Sex
Age
Khatri
F
M
M
F
F
Baniya
Punjabi
(Khatri&A
rora)
H.P.
Chopal
F
(Shimla)
Baigas
M
M.P.
Gonds
M
Meena
Rajasthan
M
Manipur
Tangkhul
Naga
F
M
M
F
Kalita
Assam
Andaman Car
Nicobar
Nicobarese M
Orissa
Nolia
Kerala
Ezhava
F
M
Andhra
Rural
M
Pradesh
Population F
(Chittoor) Urban
M
Population F
Waist
Circumfer
ence
Hip
Upper
Circumferen Arm
ce
Circumfer
ence
Calf
Biceps
Circumfe Skin fold
rence
Triceps
Skin fold
Subscapular Supra-iliac Reference

Skin fold
Skin fold
20-30 67.38.0
76.38.5
30-34 83.211.5
30-34 74.57.2
21-50 80.711
91.07.3
90.37.7
91.77.8
96.510.2
100.310.
3
28.33.0
27.52.5
-
33.33.4
33.63.2
-
7.63.3
12.04.3
11.84.9
12.55.4
24.78.1
21.310.
3
23.810.8
27.98.1
29.730.3
16-32 63.25.0
84.24.9
22.12.3
5.02.3
20-50
20-50
20-25
50-55
55-60
20-30
20-30
20-70
20-70
20-29
30-39
40-49
20-25
50-60
20-25
50-60
20-30
20-30
30-70
30-70
30-70
30-70
80.64.2
83.24.3
78.62.8
81.35.5
82.05.0
89.45.5
89.84.2
86.95.0
88.15.9
84.97.9
87.79.8
87.610.4
84.05.39
85.16.83
96.013.0
97.912.8
97.013.7
99.614.8
23.41.8
24.21.7
23.61.9
23.81.5
23.71.6
26.02.8
25.32.4
25.50.4
26.00.9
23.40.9
23.21.4
-
30.02.3
30.52.0
28.93.4
30.64.1
30.14.0
33.72.5
32.33.5
-
3.10.9
3.00.9
8.61.8
10.22.3
10.72.2
3.51.3
5.42.2
-
69.65.8
71.86.0
67.44.4
69.53.4
66.26.2
69.77.2
72.28.7
76.68.1
76.89.5
67.587.3
70.369.1
70.578.9
62.56.4
68.07.0
86.911.1
87.010.4
88.212
86.710.7
The main reason for this opposite trend is the high

prevalence of under nutrition in the studied
population groups. Both Baiga and Gond males had
subsistence economy. These ethnic groups with
deprived economic resources had high prevalence of
Monika et al.,
26.29.8
26.98.9
27.79.4
Mungreiphy et
al.21
Mishra22
10.73.3 10.43.5
11.45.1
Kapoor24
5.01.6
5.72.3
4.71.1
5.21.4
5.61.4
6.12.3
11.64.1
-
4.81.5
5.42.6
4.31.5
5.11.4
4.81.3
11.55.9
15.15.8
-
Present Study
Present Study
Kapoor et al.25
9.02.2
9.73.0
7.71.4
9.51.6
7.71.3
10.53.7
12.04.0
-
Kapoor et al.23
Mungreiphy et
al.26
Bordoloi27
Kapoor et al.29
Basa30
pre-hypertension and under nutrition. The strenuous

habitual physical activity, difficult terrain and limited
and irregular food supply may be the reasons for
underweight as also reported among Raji males15.
The prevalence of pre-hypertension in CED
99
categories was highest among Tadvi, Rajis, Bhotias

and DesiaKhonds16.
Among Baigas, body mass index and waist
circumference, predicted SBP and only Waist
circumference was found to predict DBP. Whereas
among Gonds, Waist circumference predicted SBP
among Gonds while Body Mass Index. Waist Height
Ratio and Waist circumference predicted DBP. Waist
circumference was the predictor of blood pressure
both systolic and diastolic in both Baigas and Gonds.
Some previous studies showed that waist
circumference had the strongest association with
blood pressure among Asian population17,
Americans18or European19. A recent meta-analysis
indicated that the waist to height ratio (WHtR) is a
best predictor of cardiovascular disease risk factor20.
Tables 6 and 7 display a comparison of various
anthropo-physiological variables, cardiovascular
functions, nutritional status and obesity indicating
variables among different population groups. Data
was collected from various states from secondary
sources during literature review.It is seen that
Ezhavamales of Kerala were found to be tallest
whereas Tadavi females of Gujarat were shortest.
Males of the urban population of Chittoor (Andhra
Pradesh) were found to be heaviest with highest BMI
and WHR. Maximum of WHtR were seen in Punjabi
females of Delhi whereas lowest was seen in males of
the Ezhava group of Kerala. The highest SBP and
DBP were seen in Rajaput males of Himachal
Pradesh and Meena males of Rajasthan whereas
lowest SBP and DBP were found in Khatri females of
Delhi and Tangkhul Naga tribal females of Manipur
which may be due to their low physical activity,
dietary intake and sedentary lifestyle as compared to
Rajputs and Meenas. The lowest GMT was reported
in Baiga males of Madhya Pradesh and highest was in
Baniya females of Delhi.
With reference to circumferences and skin folds,
highest of waist, hip, upper arm and calf
circumferences were noted in males of the urban
population of Chittoor, Punjabi females of Delhi,
Baniya males of Delhi and Tangkhul Naga males of
Manipur whereas lowest was seen in Ezhava females
of Kerala, Baiga males of Madhya Pradesh, Rajput
females of Himachal Pradesh and Meena males of
Rajasthan. Baiga males of Madhya Pradesh were
found to be having lowest triceps, subscapular and
supra-iliac skin folds among all the reported
population groups of India whereas highest values of

biceps and triceps skin folds were found in Baniya
males of Delhi and highest subscapular and supraIliac were seen in Punjabi females of Delhi. These
Skinfold thicknesses at specific location on the body
estimates the percentage of body fat among different
population groups.
This comparative study shows that pre-hypertensive
category was prevalent among rural areas of
Rajasthan and Himachal Pradesh. Overweight and
obesity trend was more in urban population groups
(Delhi and Andhra Pradesh). Such scenario was also
reported by Shah and Mathur31. The rural population
(Haryana and Rajasthan) of India are particularly
vulnerable to malnutrition whereas semi-urban areas
lay in between the urban and rural populations but
more inclined towards urban trends. Under-nutrition
and pre-hypertensive categories were comparatively
high in tribal groups of India as compared to caste
groups. Similar trend was observed by Rao et
al.23This is because of their geographical isolation,
uncertainty of food supply, lack of adequate health
care facilities and due to certain traditional belief
systems and cultural practices. Being hilly area the
villages are sparsely populated which made data
collection a tedious task.
CONCLUSION
Subjects belonging to different population groups of
India showed marked differences in different body
dimensions, adiposity indices and cardiovascular
functions. Gender differences were also seen with
reference to adiposity measures. The double stress of
CVD and nutritional imbalance in India is epidemic.
It is thus suggested through present study that more
efforts should put in place an intervention programme
which should be complemented with a robust
surveillance mechanism so as to monitor, evaluate
and guide policies and programmes.
ACKNOWLEDGEMENTS
The authors are thankful to all the subjects and
District Magistrate for their cooperation and patience.
Monika Saini is also grateful to UGC for providing
financial support in the form of JRF and Anup Kumar
Kapoor and Satwanti Kapoor are thankful
toUniversity of Delhi for giving research grant to
conduct research work
100
Monika et al.,
Conflict of Interest: There is no conflict of interest

with any financial organization regarding the material
discussed in the research article.
14.
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Monika et al.,
DOI: 10.5958/2319-5886.2015.00017.X

&
Health Sciences
www.ijmrhs.com
Received: 4th Oct 2014
Research article
Volume 4 Issue 1
Coden: IJMRHS
Revised: 24th Nov 2014
Copyright @2014
ISSN: 2319-5886
FACTORS RELATED TO THE USE OF HOME CARE SERVICES BY STROKE PATIENTS UNDER
JAPANS LONG TERM CARE INSURANCE SYSTEM
*Kazuya Ikenishi
Lecturer, School of Nursing Aichi Kiwami College of Nursing, 5-4-1 Jogan-dori, Ichinomiya, Aichi, 491-0063,
Japan
*Corresponding author email: k.ikenishi.t@aichi-kiwami.ac.jp
ABSTRACT
Introduction: As the population aged 65 years or older in Japan grows, the number of people who receive
long-term care is increasing. Amongst the various disease groups, stroke sufferers are currently the largest group
who use home care nursing services. This study explores the factors that affect the insurance systems home care
services use rate among stroke patients and their main caregivers in Japan. Aims: This study aims to identify the
key factors of stroke patients and that of their main caregivers to determine their relationship with the use
situation of home care services under Japans long-term care insurance system. Methods: We enrolled 14 subjects
and their caregivers in the Tokai and Kinki regions of Japan. Questionnaires were used for the main caregivers
and survey forms were used for home care nursing center personnel. The data were analyzed by univariate
analysis. Results: Barthel Index (BI) score and the number of higher brain function disorders were found to be
relevant to the use rate of long-term care insurance:. As a result of removing an outlier, the rate of number of units
for home care increased as the BI score fell. Conclusions: Two characteristics of stroke patients were found
relevant to the use rate of long-term care insurance: BI score and the number of higher brain function disorders.
As a result of removing an outlier, the rate of the number of units for home care nursing increased as the BI score
fell.
Keywords: Family Nursing, Home Health Nursing, Home Care Services, Japan, Questionnaires, Stroke
INTRODUCTION
Since the introduction of Japans long-term care
insurance system in 2000, the number of recipients
who have received care services under the insurance
system has been increasing yearly. There were
4,450,000 recipients as of April 2000, which
increased to 1,490,000 by 20121. The care services
offered under this system can be classified into three
types: home services, facility services, and
community-based services. There are approximately
3,280,000 home service users; these users make up
the majority of long-term care insurance recipients.
They should pay 10% of the cost of those home
services.
Kazuya
Japans long-term care insurance system only

provides care services and includes a health care
service that encompasses home visits by nurses.
Based on disease type, stroke patients make up the
majority of certifications for long-term care2. It is
predicted that the number of elderly people will
increase in the future, and how Japan will pay for
care services for elderly stroke victims under
long-term care insurance is a serious problem.
In 2012, 24.0% of the population was aged 65 years
or older. In the long term, it is thought that increases
in public funding and premiums cannot be avoided,
especially if user pays levels remain at their present
103
amounts.
Necessary medical care and welfare services must
continue to be provided even if the financial means
become limited, and as a result, the effectiveness of
the system becomes the focus. To increase
effectiveness, it is necessary to clarify who needs
what service and how much it will cost. In this study,
to consider greater effectiveness, the focus is on the
user who receives home care services after suffering a
stroke. Stroke was chosen in this study because it
comprises the highest number of long-term care
insurance users.
According to a patient survey by the Ministry of
Health, Labour and Welfare2, the most common
disease type is hypertensive diseases, with
approximately 7,810,000 suffers, second is a
malignant neoplasm with 1,420,000, and fifth is
cerebrovascular diseases with 1,370,000. Strokes
represent 21.5% of main-cause diseases that require
care, as reported by the Ministry of Health, Labour
and Welfare3. Similarly, according to care service
facilities in an establishment investigation4, stroke
sufferers represent the largest group at approximately
28% the 68,895 people who use home care nursing
services under the long-term care insurance system.
Therefore, to ensure an increase in the level of
effectiveness, this study analyses the use situation of
long-term care insurance by focusing on strokes,
which represents the largest user group in the
insurance system. Kawate5investigated the use
situation of stroke patients in Japans long-term care
insurance system, but did not analyse related factors.
Furthermore, no studies to date have clarified those
factors that relate to the situation of stroke patients
under the long-term care insurance system.
However, Oura6, McCullagh7, and Franzen-Dahlin8
did analyze the association between the burden of
care and home help services. These studies reported a
significant relation between the reduction in the
burden of care or the mental burden and the use of
such services. McCullagh7 reported that stroke
patients living in their own home who received a low
level of home help had higher rates of readmission.
Although these results suggest that use of home care
service is concerned with the quality of life (QOL) of
the caregiver and caregiver burden, it seems that the
use of these social resources is not only influenced by
the caregivers situation but also by that of the stroke
Kazuya
patient and any changes in symptoms. Therefore,

based on the results of these previous studies, because
they do not state whether a home care service is
chosen only because of a caregivers feeling of
burden and QOL, it is necessary to analyze the other
factors at play.
In this study, to identify the factors related to the use
rate of home care services, it is necessary to focus on
the relationship between the level of use of home care
services and the stroke patients ADL and the
characteristics of the caregiver. Because of the
relevance of ADL and the use of home care services
can be assumed, it is necessary to analyze the
relationship between a patients ADL and the use of
home care services.
A number of studies have analyzed the use of home
care services6,7,11,12, with Oura6 and McCullagh7
reporting significant results. Although these studies
analyzed the use of various home care services and
the number of services, Oura6 did not analyze the
number of use units of long-term care insurance. It is
thought that situations of both the patient and
caregiver are major factors in the use of home help
services. In the present study, variables such as the
stroke patients age, ADL, and higher brain function
disorder are analyzed. Previous research has also
defined the use of home care services in terms of
individual use of these services6,7,9,11,12,14. However, in
the present study, it is defined as the number of units
used in total by all users. This is because this research
aims to clarify the characteristics of those people who
require a high level of in-home care services by
analyzing the actual number of units used. The aim is
not to identify the characteristics of people who need
individual services. As stated above, this study is
limited to that of stroke sufferers because stroke is the
condition that receives the most certifications under
the long-term care insurance system in Japan.
Therefore, the search for the effective supply of
insurance services for stroke sufferers has greater
significance than for other illnesses.
Study Purpose and Significance: Study purpose:
This study aims to identify the key factors of stroke
patients and that of their main caregivers to determine
their relationship with the use situation of home care
services under Japans long-term care insurance
system.
Significance: By clarifying the relevant factors in the
104
use of home care services by stroke patients under the

long-term care insurance system, the characteristics
of caregivers and stroke patients who need more
home care services can be identified. The results of
this study will assist in policy decisions regarding the
selection and use of future home care services. For
example, if a specific type of patient and caregiver
require more home care services, it is likely that the
system needs to be changed to increase the upper
limit of service use to ensure peoples needs are meet.
METHODS
Subjects: The subjects in this study were patients and
their main caregivers living in the Tokai and Kansai
areas in Japan. The patients main diagnosis was
stroke. After subjects received their care needs
assessment, they received home care services under
the long-term care insurance system. All subjects had
received the service(s) for at least 3 months. The
3-month (minimum) duration ensures that there is
enough time for a care manager to adjust the care to
an appropriate care plan to provide the patient and
his/her caregiver with home care services.
In this study, the main caregiver refers to the person
that spends the longest time in recuperation/care
activities at a patients home.
Investigation facilities: Home care nursing centers
(STs) in the Tokai and Kansai areas in Japan.
Investigation method: Questionnaire that were made
for this study were distributed to consenting main
caregivers of stroke patients that used ST services.
The questionnaires were returned via a self-addressed
envelope. ST staff completed a survey form. They
provided relevant medical information about the level
of care need, times units used, and diagnosis. This too
was returned via a self-addressed envelope.
Investigation items: Caregiver questionnaire:
caregivers age and sex, relationship with stroke
patient (e.g., parent, child, sibling), number of other
caregivers, and care situation (hours spent providing
care and hours of leisure time).
ST personnel survey form: diagnostic name (cerebral
infarction, cerebral hemorrhage, subarachnoid
bleeding) of stroke, level of care needed, number of
use units at the time of investigation, Barthel Index
(BI) score (which measures level of ADL), and
presence of higher brain function disorders (aphasia,
agnosia, apraxia, unilateral spatial neglect,
Kazuya
disturbance of attention, memory disorder).

Investigation period:
From June 1, 2012 to
January 31, 2013
Ethics approval: Approval was obtained from the
Ethical Review Board, Aichi Prefectural University.
Moreover, the researcher explained the investigation
to the ST managers, and then obtained consent.
Regarding 14subjects, the content of the investigation
was explained to them, and where consent could be
obtained, they signed a consent document. The ST
personnel survey form referred to individual patients,
and thus a list of stroke patients was made for the
reference. The list was managed by the ST managers.
When the survey ended, the manager destroyed the
list.
Analysis: Spearmans rank correlation coefficient was
used to clarify the relationship between the rate of the
number of use units under the long-term care
insurance system (the use rate) and the number of use
units of home care nursing (the use rate of home care
nursing) and the caregivers age, stroke patients age,
BI score, and the level of care needed. A
Mann-Whitney U test was also performed to
determine the relationship between the sex of the
caregiver, patients sex, hours of care time, hours of
leisure time, the number of care supporters, and the
number of higher brain function disorders. The hours
of care time and leisure time and the number of care
supporters were divided into two groups (using the
median to split the two). The number of higher brain
function disorders was divided into two groups: those
with fewer than three and those with three or more.
RESULTS
Of the STs that consented to participate in the
investigation, one was located in Kansai and four in
Tokai. Of the 16 users who agreed to participate, 14
were deemed suitable for the study (refer to Table 1).
Table 1: Number of users at investigation facilities
Visiting
Number
Number of
Number of
nursing
of users* stroke patients person for
station
(rate)
analysis
1
145
24(16.6%)
4
2
54
21(38.9%)
4
3
39
5(12.8%)
1
4
100
10(10.0%)
2
5
48
8(16.7%)
3
Total
386
68(17.6%)
14
105
*Number of users was it of results
Table 2: Characteristics of stroke patients(n=14)

Age [median(range)]
73(4689
Sex(male/female)
12/2
Stroke type infarct/ intracerebral 7/5/2
hemorrhage/subarachnoid hemorrhage
Level of care need(1/2/3/4/5)*
0/2/2/3/7
Use rate of long term care need 85.0%

[medianrange]
(42110)
Use rate of visting nursing [median 16.7%

range]
(8.330)
BI score [medianrange]
35(080)
Having highly advanced brain functional disorder
or not||
Aphasia
7
Agnosia
7
Apraxia
6
Unilateral spacial neglect
6
Attention disorder
8
Defects of memory
7
*Among subjects, there was no person of level of
support. It was calculated by [use number of units
of long term care insurance100/ceiling unit
according to level of care need]
It was calculated by [use number of units of visiting
nursing 100 / ceiling unit according to level of care
need] ||Multiple responses.
The results for the 14 stroke patients are shown in
Table 2. Those for the main caregivers are shown in
Table 3. Six people were reported to have three or
higher brain function disorders.
Seven patients required the highest level of care, level
5, and none required level 1. Of the seven patients,
the median use rate of long-term care insurance was
90.8%, with a range of 78.0%110.3%. The median
use rate of home nursing care was 16.6%, ranging

from 8.3% to 21.9%. The median BI score was 10
points, with a range of 035 points. There were six
patients with more than three higher brain function
disorders. The other patient had unilateral spatial
neglect and disturbance of attention.
Table 3: Characteristics of main caregivers (n=14)
Age [median (range)]
68(3087)
Sex(male/female)
2/12
Relationship to stroke patient : Spouse 11
Others (Brother or Sister, Child, 3
Brother-in-law)
No. of caregivers other than main 2(04)
caregiver [median(range)]
Hours spent caring per day: Less than 10
5
More than 10 5
Hours of free per day: Less than 2
8
: More than 2
6
Of the 14 caregivers, 12 were women, and 9 were the
spouses of patients. The results of the univariate
analysis are shown in Tables 4 and 5. There was no
significant relationship between the ages of the
caregivers and patients and the use rate of long-term
care insurance and the use rate of home care nursing
care. There was a significant positive correlation
between use rate and level of care needed, and a
significant negative correlation between use rate and
BI score. No significant relationship was found for
any variables and the use rate of home care nursing.
Caregivers sex, patients sex, number of caregivers,
hours of care time, and hours of leisure time had no
significant influence on the use rate of long-term care
insurance and the use rate of visiting nursing care.
The number of higher brain function disorders had a
significant influence on the use rate of long-term care
insurance. None of the variables had a significant
influence on the use rate of home care nursing.
Table 4: Analysis of relationship between use rate of long-term care insurance, use rate of home care
nursing and age, level of care need, BI score*
Use situation of long term Age of caregiver
Age of stroke Level of care BI score
care insurance / variable
patient
need
Use rate
-0.391(p=0.167)
-0.369(p=0.194)
0.646(p=0.013)
-0.623(p=0.017)
Use rate of visiting nursing -0.269(p=0.353)

-0.497(p=0.070)
-0.265(p=0.360)
0.209(p=0.472)
*Significant at the 0.05 level, use rate=use number of units of long term care insurance 100/ceiling unit
according to level of care need, use rate of visiting nursing=number of units of visiting nursing 100/ceiling
unit according to level of care need
Kazuya
106
Table 5: Analysis of relationship between use rate of long-term care insurance, rate of home care nursing and
sex, number of care supporters, hours of care, hours of leisure, number of highly advanced brain functional
disorder*(n=14)
variable/use situation of Sex
Number Use rate
p value Use
rate
of p value
long term care insurance

visiting nursing
Sex of caregiver
Male
2
0.465
75.6(61.789.5)
17.6(13.421.9) 1.000
Female
12
87.4(42.9110.3)
Male
10
81.2(42.9100.1)
Female
93.3(64.2110.3)
84.4(42.9100.1)
89.5(64.2110.3)
<8
64.2(42.9110.3)
10
89.5(61.7100.1)
<2
63.0(42.9110.3)
90.2(66.9100.1)
Number
of
highly 2
advanced brain functional 3
disorder
*Significant at the 0.05 level
65.5(42.9100.1)
93.5(78110.3)
Sex of stroke patient

Number of care supporter
Hours of care per day
||
Hours of leisure per day
16.7(8.330.4)
0.304
17.8(8.321.9)
0.559
14.8(0.240.31)
0.456
13.4(8.330.4)
1.000
18.7(11.821.9)
0.518
16.2(12.930.4)
1.000
16.8(8.329.3)
0.142
14.5(8.330.4)
0.592
17.6(11.829.3)
0.029
19.3(8.430.4)
0.592
16.4(8.318.7)
use rate=100number of use units/ceiling unit according to level of care need , median(maxmin) unit%
use rate of visiting nursing = 100number of use units of visiting nursing/ceiling unit according to level of care need ,
median(maxmin) unit%
The group of caregiver was divided into two except a main caregiver and the groups more than three.
||The group of caregiver was divided into the one within eight hours and the another where were more than it for ten hours.
There was not the person of 8-10 hours. The number of people in a list shows the number of people of the applicable
caregiver.
The group of caregiver was divided into the one less than two hours and others more than two hours. The number of people
in table5 shows the number of people of the applicable caregiver.
DISCUSSION
There was no significant relation between use rates
and the age of the caregiver and patient. Thus, these
results show a stronger relationship between patients
with a decrease in ADL or a higher brain function
disorder and the use of long-term care insurance
rather than the influence of the age. A number of
articles have reported a significant relationship
between growing older and a declining ADL16-18. The
results in the present study can be explained because
of the small sample and because the focus was not on
possible relationships with ADL; instead, the focus
was on the relationship with use rate.
The number of caregivers did not show a significant
relationship with use rate in this research; however,
Makizako9 found a significant relationship between
Kazuya
the number of care supporters and levels of caregiver

burden. Thus, caregiver burden may be reduced
where there are more care supporters. Kuwahara11
explained that caregiver burden may not decrease
with more helpers, because the main caregiver may in
fact have to give greater attention to all the other
caregivers involved. Similar to Kuwahara11, because
the present study includes the care burden of the main
caregiver, it is possible that her/his feeling of burden
has no relation to the use rate.
Concerning the hours of care and leisure activities,
eight caregivers provided care for 12 hours or more
per day. Of these subjects, seven had less than 2 hours
leisure time. It should be noted that time spent
sleeping were not included in this study. Furthermore,
there was no significant relationship between the
hours engaged in both care and leisure activities and
107
use rate. Previous studies on hours of care and the

burden of care6,11,13,14,15 reported a significant
relationship between the two. The lack of a
significant relationship between hours of care and use
rate in this study can be explained as follows: even if
a caregiver used a home help service, he or she would
not leave the patient unattended while they used the
bathroom. A significant relationship was found
between the use rate of long-term care insurance and
the number of higher brain function disorders: the
greater the number of higher brain function disorders,
more services required. There was no significant
relationship with the use rate of home care nursing
because the condition of the disease was stable.
Study Limitations and Future Research: As it is
difficult to identify the type and amount long-term
care insurance services required, future research
should investigate care plans. It is also necessary to
clarify the relationship between of the existence of a
disease and the use of long-term care insurance as it
relates to caregivers.
CONCLUSION
Two characteristics of stroke patients were found
relevant to the use rate of long-term care insurance:
BI score and the number of higher brain function
disorders. 2As a result of removing an outlier, the
rate of the number of units for home care nursing
increased as the BI score fell.
Acknowledgement: Nil
4.
5.
6.
7.
8.
9.
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seisakunitsuite/bunya/hukushi_kaigo/kaigokourei
sha/gaiyo/dl/hoken.pdf(Accessed 5 May 2014)
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Thegeneralcondition
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patient
survey.
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DOI: 10.5958/2319-5886.2015.00018.1

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Coden: IJMRHS
th
Received: 9 Oct 2014
Research article
Copyright @2014
ISSN: 2319-5886
VOICE RELATED QUALITY OF LIFE IN INDIVIDUALS WITH CHRONIC OBSTRUCTIVE

PULMONARY DISEASE
Anuradha Shastry1, *Radish Kumar Balasubramanium2, Preetham Acharya R3
1
Assistant Professor, 2Associate Professor, Department of Audiology & Speech Language Pathology, Kasturba
Medical College (Manipal University), Mangalore-1, Karnataka, India.
3
Associate Professor, Department of Pulmonary Medicine, Kasturba Medical College (Manipal University),
Mangalore-1, Karnataka, India.
*Corresponding author email: radheesh_b@yahoo.co.in
ABSTRACT
Background: Chronic Obstructive Pulmonary Disease (COPD) refers to lung diseases such as, Chronic
Bronchitis, Chronic Asthma and Emphysema. These diseases are characterized by obstruction to airflow that
interferes with normal breathing and they frequently co-exist. COPD can affect voice as respiration is a vital
subsystem for voice production COPD that have a significant voice impairment which might further impact the
quality of life. There are very few studies available in the voice literature on the assessment of quality of life in
individuals with COPD. In this regard, the study aimed to assess the voice related quality of life in individuals
with COPD and compare the findings with normal controls. Methods: 64 participants were considered for this
present study under two groups (Group 1: individuals with COPD, Group 2: normal individuals). The voice
disorder outcome profile (Voice-DOP), self-perceived severity of voice problem rating scale and the modified
medical research council (MMRC) dyspnoea scale were the quality of life measures employed in this study.
Results: There was statistically significant difference between the two groups on all the three measures at p <
0.05. Further, a positive correlation was found between all the three measures. Conclusions: These findings
indicate that COPD has an impact on the individuals quality of life. This could be attributed to the voice
deviations due to COPD itself or due to the effects of the medication that cause an impact the voice related quality
of life in these individuals.
Key words: Voice Related Quality of life, Voice disorder outcome profile, Self-perceived severity of voice
problem, Modified Medical Research Council dyspnoea rating scale, Chronic Obstructive Pulmonary Disease
INTRODUCTION
Chronic Obstructive Pulmonary Disease (COPD) is
an abnormality of the respiratory system in which the
swelling and inflammation of the lining of the airway
leads to airway obstruction due to narrowing of
airway. This kind of inflammation stimulates the
mucous (sputum) production excessively, which
causes further obstruction in the airway. COPD is a
broad term that covers several lung conditions which
include Chronic Bronchitis, Chronic Asthma and

Emphysema1.
COPD has various causes; one of the leading causes
is smoking / consumption of tobacco. Further,
environmental factors and genetic influences can also
heighten a persons likelihood of acquiring COPD.
Long-term exposure to lung irritants that damage the
lungs and the airway as a result of air pollution,
110
Anuradha et al.,
occupational dusts, second-hand smoke and

chemicals are some of the environmental
2
factors. Few might acquire COPD due to Heredity
factors which include a history of childhood
respiratory infections/COPD, while few others might
develop COPD due to low levels of alpha-1
antitrypsin (AAT) which is also known as the Lung
Protector is a protein made in the liver.
Few common symptoms of COPD are chronic cough,
shortness of breath (dyspnoea), Xerostomia, frequent
respiratory infections and dysphagia in severe cases.
COPD can affect voice production and quality,
directly - because it is associated with respiratory
decline, and indirectly - as associated with concurrent
symptoms or due to the side effects of medication.
Voice problems in these individuals have been
neglected and increased prominence is given to
assessment and treatment of the respiratory problem,
despite the fact that the respiratory system is the
source for voice production. These respiratory
conditions are known to cause adverse effects on
voice production.
There are few studies available in the voice literature
on individuals with asthma with very few studies that
have focussed on the voice measures in COPD.3-5One
such study was done by Shastry and
Balasubramanium6 where they studied the acoustic
and perceptual parameters of voice in 14 individuals
with COPD and compared the findings with the 14
normal individuals. The perceptual analysis was done
using CAPE - V and Acoustic analysis was
performed using CSL software. The results showed
that there was a significant difference between the
two groups on acoustic and perceptual measures. The
COPD individuals had a lower fundamental
frequency, increased pitch and amplitude perturbation
measures. The frequency range, intensity range, SPI
& NHR measures did not show any significant
difference across the two groups (COPD &Normal
Controls). Perceptual analysis results showed the
presence of slight hoarse component. They reported
that the respiratory obstruction resulted in inadequate
breath support due to which there was increased
aperiodicity in vocal fold vibration resulting in the
above findings. 6From this it is clear that individuals
with COPD have a significant voice impairment
hence this might further restrict the individuals
activity and limit the individuals participation.
Hence there is a need to evaluate the quality of life in

individuals with COPD.
Voice related Quality of life measurement is the
assessment of the overall outcome of the physical,
mental, and social well-being of an individual as a
result of a voice disorder. Currently, the voice related
quality of life measures such as Voice disorder
outcome profile7, Voice handicap index8 are available
to assess the effect of voice on the individuals
quality of life. Self-perceived severity of voice
problem rating scale is a general parameter of the
evaluation of subjective aspects regarding the voice
problems. This is helpful in assessing the quality of
life in individuals with voice abnormalities.
In a study done by Zeijger, Dejonckere and Wijnen
the voice related quality of life was assessed using the
Voice Handicap Index in 44 individuals with
obstructive pulmonary disease. Each patient also
filled in the MRC scale (Medical Research Council) a
scale for subjective assessment of the severity of
dyspnoea. Results of their study showed that globally
the VHI-scores of patients with chronic lung disease
are significantly higher than those of the normal
controls.9 There was no significant difference
between the median VHI score of asthma and COPD
individuals. Further, no statistically significant
correlation was found between the degree of
impairment of the respiratory function as measured
with the spirometric parameters - and the VHI-score.
However, the correlation between MRC and VHI
scores was found to be statistically significant.9
Similarly the present study was carried out with the
intention of assessing the voice related quality of life
in individuals with COPD. Hence this study was done
using the voice disorder outcome profile and the selfperceived severity of the voice problem as these
measures have been developed for the Indian
population. Also, these have good validity and
reliability. MMRC10 was also used in order to assess
the self-perception of the breathlessness of the COPD
individuals.
Need for the study: The respiratory system is
considered to be the base for voice production. As
COPD causes voice deviations, we have hypothesised
that there would be an impact on the quality of life in
these individuals. Hence, there was a need for
analysis of voice related quality of life in these
individuals so that a proper understanding about their
voice problems can be obtained. Hence, we planned
111
Anuradha et al.,
to investigate the voice related quality of life

measures in individuals with all types of COPD
Aim of the study: To assess the voice related quality
of life in individuals with Chronic Obstructive
Pulmonary Disease (COPD).
Objectives of the study: 1. To investigate the quality
of life measures in individuals with COPD, 2. To
compare the findings of quality of life measures in
COPD individuals along with that of normal
individuals.
Participants: The 64 participants (30 females & 34
males) were divided into two groups. Group 1
consisted of 32 individuals between 25 to 75 years of
age mean age = 43 years with the diagnosis of
COPD. The diagnosis of COPD was done by an
experienced physician in the field of pulmonary
medicine based on the signs, symptoms and lung
function tests. All the types of COPD were included
in this group. Group 2 consisted of 32 age and gender
matched normal controls. The exclusion criteria for
both groups included a history of vocal abuse/misuse,
professional voice users, history of surgery to the
laryngeal structures/voice therapy hearing impairment
and neurological problems affecting the voice
production.
Materials:
1. Voice Disorder Outcome Profile (VoiceDOP)7:This is a reliable and valid tool to measure
impact of voice disorder on the individuals
quality of life in the Indian population in English
& Kannada language.7This profile consists of 32
questions each requiring a response from the
participant on a visual analog scale of 100 mm
undifferentiated line with the extreme left end
marked as never and the extreme right end as
always. The questionnaire is used for selfassessment for quality of life ratings (VoiceDOP).7
2. Self - Perceived Severity of Voice Problem7: The
individuals were asked to rate the severity of their
voice problem along with the Voice-DOP. SelfPerceived Severity Rating is a single question and
it is also based on a visual analog scale of 100
mm with the left extreme edge marked as
normal and the right extreme as severe.
3. Modified Medical Response Council dyspnoea

scale: Modified Medical Research Council
(MMRC) Dyspnoea Scale uses a simple rating
system to gauge the patient's level of
dyspnea.10MMRC grading scale was also given to
the participants which consists of 5 point rating
scale that has to be rated based on the individuals
self-perception from 0-4. The participants had to
choose the Grade that best represents their
condition.
Procedure: The study was carried out in the
Department of Audiology and Speech Language
Pathology, Kasturba medical college hospital,
Attavar, Mangalore. This study followed a
comparative cross sectional study design, with the
Nonrandom Convenient Sampling procedure. Ethical
approval was received from Manipal Universitys
Institutional human research ethics committee. The
participants were comfortably seated and details
regarding the assessment procedures were explained
and assessment began only after obtaining the written
consent from the participants. The Voice Disorder
Outcome Profile, Self - Perceived Severity of Voice
Problem and MMRC were the scales employed to
assess the quality of life in this present study. The
clients were given the questionnaire for selfassessment for quality of life ratings (Voice-DOP).
The subjects had to rate their responses to each of the
32 questions under 3 domains (physical, emotional
and functional) on a visual analog scale which is a
100-mm undifferentiated line with the left extreme
edge marked as never and the right extreme as
always. Along with the Voice-DOP, the individuals
were also being asked to rate the severity of their
voice disorder as per the self-perceived severity of the
voice problem in the same manner with the left
extreme edge marked as normal and the right
extreme as severe. The subjects were asked to fill
the questionnaire without any assistance from the
clinician. In addition to these two measures the
MMRC grading scale was also given to the individual
which is a 5 point grading system with scores from 04. The participants were instructed in detail to fill in
each rating scale and instructions was repeated
whenever requires and clarification was sought as and
when necessary.
Data Analysis: The filled questionnaire was scored
based on the distance (mm) measured from the left
extreme end of the scale to the mark made by the
112
Anuradha et al.,
individual for each question of all the 3 domains. The

total Voice-DOP score was obtained by summing the
scores of all three domains (physical, emotional &
functional). The total Voice-DOP score for an
individual could be a maximum of 3200 (there are 32
items with 100 as a maximum for each item) and a
minimum of 0. The self-perceived severity scale was
scored in the same manner like that of the voiceDOP where the distance (mm) measured from the left
extreme end of the scale to the mark made by the
individual for his/her self-perceived severity of the
voice impairment. Thus, a maximum score for selfperceived severity was 100 and the minimum score
possible was 0. The MMRC is a 5 point rating scale
and the grade is chosen by the patients themselves
based on the description that represents their
condition and tabulated for analysis.
Statistical analysis: The self-perceived severity
ratings as well as the Voice DOP ratings of the
subjects of both groups were compared using
Independent-samples t-test. The Mann Whitney U

test was employed to compare the MMRC Dyspnoea
rating between the groups.
The Spearmans
correlation statistic was administered to check for the
association between the MMRC rating, self-perceived
severity rating and the voice DOP rating. Statistical
analysis was done using the statistical package SPSS,
version 17.0 at p < 0.05 considered as significant.
RESULTS
The responses were analysed for the voice related
quality of life and self-perceived severity of the voice
problem. The mean and standard deviation for each
domain was calculated for both the groups (Table 1).
As observed from the table, the COPD group had
higher mean scores on the voice disorder outcome
profile and self-perceived severity of the voice
problem rating scale in comparison to the normal
group.
Table 1: Descriptive statistics for voice related quality of life measures for both the groups
Voice related quality of life measures
COPD
Normal
T value
Physical
7.8
272.1194.7
0.6 3.8
Emotional
101.9 144.9
0.0 0.0
3.9
Functional Job
19.9 33.1
0.0 0.0
3.4
Functional Daily Communication
58.6 76.1
0.0 0.0
4.3
Functional Social Communication
13.0 29.9
0.0 0.0
2.4
0.6 3.8
Total QOL score
6.8
465.6 381.2
0.3 1.7
Self -perceived severity of the voice problem
8.4
31.1 20.5
The statistical analysis using Independent-samples ttest revealed a significant difference between the two
groups for voice disorder outcome profile and the
self-perceived severity of the voice problem rating
scale with the COPD group having significantly
higher scores at p< 0.05. The Independent-samples ttest showed that the COPD group had higher scores
on voice disorder outcome profile for the Physical
Domain at t (62) = 7.88, p = 0.00, Emotional Domain
at t (62) = 3.97, p = 0.00, Functional Domain (Job
Related) at t (62) = 3.40, p = 0.001, functional
domain (Daily Communication) at t (62) = 4.35, p =
0.00, functional domain (Social Communication) at t
(62) = 2.45, p = 0.017 in comparison to the normal
controls. The Total QOL score was also significantly
higher in the COPD group at t (62) = 6.899, p = 0.00
P value
0.000
0.000
0.000
0.000
0.000
0.000
0.000
As all domains had a higher score in the COPD

group. The Independent-samples t-test also indicated
that the self-perceived severity of the voice rating was
significantly higher in the COPD group in
comparison to the normal group at t (62) = 8.478, p =
0.00 also which suggests that these individuals have a
reduced voice related quality of life. The mean and
standard deviation for MMRC was calculated for
both groups. The COPD group had a higher mean
grade (Mean = 2.21, SD = 0.90) than the normal
group (Mean = 0.00, SD = 00.0).
The Mann Whitney U Test was performed to check
for the significant differences in MMRC across the
groups. Results revealed that there were statistically
significant differences between the groups with the
COPD group having a higher grade compared to the
113
Anuradha et al.,
normal group at z = -7.407, p = 0.00, suggestive of an

increased breathlessness in the COPD group.
Correlation between the Voice-related quality of
life measures and MMRC: The COPD Group had
higher values on the voice related quality of life
measures (Voice- DOP and self- perceived severity of
voice problem) as well as the MMRC dyspnoea rating
scale. Therefore, this study investigated the
association between these measures to know if the
level of dyspnoea correlated with the severity of
voice problem and the quality of life. For this purpose
a series of Spearman's rank correlation coefficient
was employed. A two-tailed test of significance
indicated that there was a significant positive
relationship between the voice DOP and the selfperceived severity of voice problem at rs (64) =
0.967, p = 0.00 (Figure 1). However, a similar two
tailed test of significance also revealed a positive
relationship between the voice DOP and the MMRC
dyspnoea rating scale at rs (64) = 0.964, p = 0.00
(Figure 2). Further, the MMRC dyspnoea rating scale
also showed a positive correlation that was significant
with the self-perceived severity of voice rating at rs
(64) = 0.961, p = 0.00 (Fig 3).
Fig 1: Scatter plot representing association between

Voice-DOP and Self-perceived severity of voice
problem

Voice DOP and MMRC

MMRC and Self-Perceived Severity of voice problem
These findings indicate that the individuals with

higher rating on the MMRC dyspnoea scale had an
increased voiceDOP score along with higher
perceived severity of the voice problem. All the
above findings indicate that COPD has a significant
impact on the voice related quality of life.
DISCUSSION
It is well known that the respiratory system serves as
the source for voice production. Hence a deviancy in
the anatomical or physiological aspect of the
respiratory system can have an undesirable effect on
voice production. Therefore, the present study was
carried out with the aim of assessing the voice related
quality of life in individuals with COPD. For this
purpose the quality of life measures (Voice-DOP,
self-perceived severity of voice problem and MMRC)
were measured in individuals with COPD and the
findings were compared with that of the normal
population.
Voice Disorder Outcome Profile: The present study
showed that the COPD individuals had a higher score
on this measure compared to a normal population
suggestive of an impaired voice related quality of life
in the COPD individuals. Further, the results of the
present study also revealed a statistically significant
difference between the groups on the all the domains.
Physical domain assesses the problems concerning
the voice output and voice usage due to the impact of
the voice disorder. The COPD group had a significant
impact of a mild to moderate degree on the physical
domain while normal group had no impact on
physical domain. The self-perception of the physical
domain indicates that the voice impairment also
correlates well with the findings of Shastry and
114
Anuradha et al.,
Balasubramanium who reported abnormal acoustic

and perceptual parameters in individuals with
COPD.6 This is attributed to the impact of the
respiratory abnormality on the laryngeal behaviour
that has also been reported in many studies done on
individuals with COPD,3,4,5thus resulting in the
restricted vocal behaviour due to which the overall
Quality of life is compromised in the individuals with
COPD. Further, the above findings may also be
attributed to the fact that individuals with COPD have
abnormal speech, breathing patterns 11,12resulting in
the abnormality in voice.
Emotional domain assesses the problems concerning
the psychological impact of the voice problems on the
individuals. The COPD group had a mild impact on
the emotional domain while the normal group had no
impact on the emotional domain. This finding
specifies that the voice impairment resulting from
COPD may have resulted in a small impact on the
personality and self-esteem of the individual. The
COPD also impacted the individuals concern and
emotional response. However the impact was not as
high as was present in the physical domain. This
finding was similar to the findings obtained by Zeiger
where in the emotional impact of the voice problem
in individuals with COPD is present but to a mild
degree.9
Functional Domain mainly assess the self-perception
of the impact of the voice problem on the
participation in daily routine activities, job related
activities as well as on an individual's ability to
socialise. The COPD group had a slight impact on the
functional domain when compared to the normal
group where there was no impact. This is due to the
impact of the COPD on the voice making it difficult
to communicate for purpose of daily communication,
job related aspects and social communication. The
results also showed that the daily communication and
job related aspect of the functional domain had a
higher impact than the social communication part of
the functional domain. Similar findings were obtained
by Zeijger, Dejonckere & Wijnen in their study on
individuals with chronic lung disease.9 The greater
impact of the voice problem on the functional domain
pertaining to the daily activities and job related
activities is due to the greater frequency of voice
usage during the daily activities and job-related
activities due to which the individuals with COPD
frequently encounter difficulty compared to social
communication aspect of the functional domain. All

these findings shows that the individuals having
COPD most often have voice abnormalities due to
which there is further limitation in activities and
participation restriction.
Self-perceived severity of the voice problem: This
particular scale assesses the individuals selfperception of the degree of voice abnormality/
impairment. Results revealed a statistically significant
difference across the two groups where the COPD
group had higher ratings ranging from a mild to
moderate degree while the normal group had no
perceived voice problems. These findings are also in
accordance with the findings obtained from the
physical domain on voice disorder outcome profile
from this present study. The findings are also in line
with findings reported by Zeijger, Dejonckere &
Wijnen where they found a significant impact of
voice problems in individuals with chronic lung
disease on the physical domain.9These findings are in
line with findings reported by Shastry and
Balasubramanium6. This finding could be attributed to
the respiratory insufficiency where in the chronic
lung disease restricts the source required for voice
production thus leading to an abnormality in the
functioning of the phonatory system that that further
affects the voice quality observed in individuals with
COPD. Similarly the abnormal speech breathing
patterns could also be the reason for the abnormal
voice11, 12. Further the voice problem is such that the
individuals themselves are able to perceive the voice
abnormality.
MMRC scale: This particular scale assess the
individuals self-perception about his dysnoea. The
results revealed that the individuals of the COPD
group had statistically significant higher grades when
compared to the normal group. This shows that all
individuals with COPD had breathlessness. In the
present study, it was observed that all individuals
with COPD had a score greater than two (indicating
that they had breathlessness after walking long on a
levelled ground at their own pace) while all normal
individuals scored 0 (indicating no breathing
difficulty). The higher score is due to the presence of
the reduced breath support due to the presence of the
obstructive pulmonary disease leading to the
increased MMRC score. There was no significant
gender differences observed for scores on this rating
scale.
115
Anuradha et al.,
Correlation between the voice related quality of

life measures and the MMRC scale: On clinical
observation of the raw scores, it was found that the
individuals with a higher score on MMRC scale had a
greater impact on the overall voice related quality of
life. The statistical analysis also revealed that there
was a positive relationship between the voice DOP
measure, self-perceived severity rating as well as the
MMRC grades. This means to say that the higher
level of breathing difficulty an individual exhibits, he
is at higher risk of having an impaired voice related
quality of life. This finding is interesting as it clearly
shows the relationship between the breathing
problem, the severity of the voice problem caused
due to COPD and its impact on the quality of life of
the individual. Zeiger, Dejonckere & Wijnen in their
study on individuals with obstructive pulmonary
disease also reported a similar finding where they
reported significant correlation between the MRC
scale and VHI.9 However, observation of raw data
showed that a few individuals with very mild form of
COPD had scores near to normal population
indicating that all individuals with COPD may not
have an equal degree of impaired voice related
quality of life.
The result of the present study provided an insight
about effect of COPD on the Voice related quality of
life. This brings the need for voice intervention in this
population so that quality of life may be improved.
The findings from this study will also guide us in
planning a good voice intervention program for these
individuals so that their problems specific to each
domain (physical emotional & functional) can be
appropriately addressed.
CONCLUSION
The present study aimed at assessing the voice related
quality of life. Voice Disorder Outcome Profile, SelfPerceived Severity of Voice Problem rating scale and
MMRC dyspnoea rating scale. The results disclosed
significant difference across the groups with the
Voice Disorder Outcome Profile, Self-Perceived
Severity of Voice Problem ratings and the MMRC
scores being higher in the COPD individuals in
comparison to the normal controls indicative of a
reduced quality of life. Further, statistical analysis
revealed a positive correlation between the three
voice related quality of life measures which showed
that the more severe dyspnoea the individual
exhibited, greater was the severity of the voice

problems and more is the negative impact on the
quality of life. All these findings indicate that the
COPD affects the respiratory capacity of the
individual which further causes voice problems that
impacts the overall activity and participation of the
individual. The findings of this study will help us in
planning a good intervention program for these
individuals so that their problems can be
appropriately addressed. Further research can also be
done to analyse the impact of the COPD types as well
as the severities of COPD on the quality of life so that
a clearer understanding about their impact on the
voices can be obtained. Further studies should
address the efficacy of the various voice treatment
approaches in individuals with COPD.
ACKNOWLEDGEMENTS: Our sincere thanks to
Manipal University for funding this study.
Conflicts of interest: Nil
REFERENCES
1. Asthma Australia: COPD [Internet]. Australia:
Asthma Foundation NSW; c1999-2014 [cited
2014, Jan 12] Available from: http://www.
asthmaaustralia.org.au/default.aspx
2. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist
SA, Calverley P, Fukuchi Y, Jenkins C,
Rodriguez-Roisin R, Van-Weel C, &Zielinski J.
Global strategy for the diagnosis, management,
and prevention of chronic obstructive pulmonary
disease: GOLD executive summary. 2007;
176(6): 532-555. doi: 10.1164/rccm. 200703456SO
3. Williamson IJ, Matusiewicz SP, Brown PH.,
Greening AP, & Crompton GK. Frequency of
voice problems and cough in patients using
pressurized aerosol inhaled steroid preparations.
Eur Respir J. 1995; 8: 590-592.
4. Dogan M, Eryuksel E, Kocak I, Celikel T, &
Sehito M. Subjective and Objective Evaluation of
Voice Quality in Patients with Asthma. J Voice.
2007; 21: 224-230. doi:10.1016/j.jvoice.2005.
11.003
5. Asnaashari AM, Rezaei S, Babaeian M, Taiarani
M, Shakeri MT, Fatemi SS, &Darban AA. The
effect of asthma on phonation: a controlled study
of 34 patients. Ear Nose Throat J. 2012; 91(4):
168-171.Retrieved from: http:// www.Thefree
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6.
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8.
9.
10.
11.
12.
library.com/The+effect+of+asthma+on+phonatio
n%A+a+controlled+study+of+34+patients.a0288872086
Shastry A & Balasubramanium RK. Acoustic and
perceptual analysis of voice in individuals with
Chronic Obstructive Pulmonary Disease.
Proceedings of 43rd Annual convention of Indian
Speech and Hearing Association (ISHCON 46).
2014; Feb 7-9,Kochi, Kerala, India.
Konnai RM, Jayaram M, & Scherer RC.
Development and validation of a voice disorder
outcome profile for an Indian population. J
Voice.
2010;
24:
206-220.
doi:10.1016/j.jvoice.2008.06.006
Jacobson, Barbara H., et al. The voice handicap
index (VHI) development and validation.
American
Journal
of
Speech-Language
Pathology. 1997; 6 (3): 66-70.
Zeijger R, Dejonckere PH, & Wijnen FNK. The
VHI in Patients with Chronic Lung Disease.
(Unpublished
masters
thesis),
Utrecht
University, Netherlands. 2012. Retrieved from:
http://dspace.library.uu.nl/bitstream/handle/1874/
254983/Thesis_Zeijger_3459985.pdf
Brooks S. Surveillance for respiratory hazards.
American Thoracic Society News. 1982; 8:12-16.
Lee L, Loudon RG, Jacobson BH, et al. Speech
breathing in patients with lung disease. Am Rev
Respir Dis. 1993; 147: 1199-1206.
Loudon RG, Lee L, Holcomb, BJ. Volumes and
Breathing patterns during speech in healthy and
asthmatic subjects. J Speech Hear Res. 1988; 31:
219-27.
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DOI: 10.5958/2319-5886.2015.00019.3

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 7 Dec 2014
INTRALESIONAL PLATELET RICH PLASMA vs INTRALESIONAL TRIAMCINOLONE IN THE

TREATMENT OF ALOPECIA AREATA: A COMPARATIVE STUDY
*Shumez H1, Prasad PVS2, Kaviarasan PK3, Deepika R1
1
Junior Resident, 2Professor, 3Professor & Head, Department of Dermatology, Venerology and Leprosy, Rajah
Muthiah Medical College and Hospital, Annamalai University, Tamil Nadu, India
*Corresponding author email: shumezh@gmail.com
ABSTRACT
Background: Alopecia areata (AA) is a chronic non-scarring alopecia that involves the scalp and/or body, and is
characterized by patchy areas of hair loss without any signs of clinical inflammation. Various therapies have been
proposed for their treatment. But none have been shown to alter the course of the disease. Platelet Rich Plasma
(PRP) is a volume of autologous plasma that has a high platelet concentration. Growth factors released from
platelets may act on stem cells in the bulge area of the follicles, stimulating the development of new follicles and
promoting neovascularization. Aim: To evaluate and compare the efficacy of intralesional injection of autologous
platelet rich plasma with intralesional injection of triamcinolone acetonide (10mg/ml) in the treatment of alopecia
areata. Methodology: 74 patients with alopecia areata were allocated into 2 groups and treated with triamcinolone
and PRP injections. Treatment outcome was measured by taking into account extent and density of regrowth of
hair and was expressed as a percentage of overall growth. Results: Forty eight patients were treated with
triamcinolone injections and 26 patients were treated with PRP injections. Patients treated with PRP had an earlier
response at the end of 6 weeks than patients treated with triamcinolone. However, this difference was statistically
insignificant. The overall improvement at the end of 9 weeks was 100% for all patients in both groups.
Conclusion: PRP is a safe, simple, biocompatible and effective procedure for the treatment of alopecia areata
with efficacy comparable with triamcinolone.
Keywords: Alopecia Areata, Platelet Rich Plasma, Triamcinolone
INTRODUCTION
Alopecia areata is a chronic, inflammatory disease
that involves the hair follicle and sometimes the nails.
It is characterized by nonscarring hair loss involving
any hair-bearing surface of the body. Alopecia areata
is often triggered by psychological stress and has
limited treatment options. Corticosteroids are the
most popular drugs for the treatment of this
disease.1 But localized atrophy is a common
complication, particularly if triamcinolone is used.2
Alopecia areata does not destroy hair follicles, and
the potential for regrowth of hair is retained for many
years, and is possibly lifelong.2 The current therapy
Shumez et al.,
for AA is not curative, but rather aimed at controlling

or limiting the pathogenic process. Most of the
effective
therapies
for
AA
are
either
immunosuppressive or immunomodulatory, which
are associated with varying side effects. Intralesional
corticosteroids are used frequently in AA3, although
other therapies like topical minoxidil, anthralin,
immunotherapy, systemic corticosteroids, cyclosporin
and PUVA (Psoralen and Ultra Violet-A Light
therapy) are also commonly used with varying
success. Platelet-rich plasma (PRP) is an autologous
preparation of platelets in concentrated plasma. PRP
118
has attracted attention in several medical fields

because of its ability to promote wound healing.4
Hence, promoting hair growth by application of a
blood extract - Autologous Platelet Rich Plasma is a
simple, yet effective procedure in the treatment of
alopecia areata with no danger of allergic reactions.
The objectives of our study were to evaluate and
compare the efficacy of intralesional injection of
autologous platelet rich plasma with intralesional
injection of triamcinolone acetonide (10mg/ml) in
the treatment of alopecia areata.
The present study was conducted in Department of
Dermatology, Venerology and Leprosy in our
hospital from August 2012 to July 2014. Ethical
clearance was obtained from the Institutional Ethics
Committee before the commencement of the study.
Written informed consent was taken from patients
before their participation in the study. It is a nonrandomized controlled study. In our study, 74 patients
were included with the following criteria.
Inclusion criteria: Patients with alopecia areata,
willing for the procedure, and those who have not
taken any form of treatment in the last 6 months.
Exclusion criteria: Patients with alopecia other than
alopecia areata, patients with active infection at the
local site and those with >25 % involvement of scalp
or facial hair.
Procedure: Detailed history and thorough
examination of the patches was done. A global
alopecia areata severity score Severity of Alopecia
Tool (SALT),5 based on the combination of extent
and density of scalp hair loss was determined by two
investigators.
Patients were randomly allocated into two groups:
Group 1: Triamcinolone acetonide (10 mg/ml) was
given intradermally into the lesion. It was
administered using a 0.5-inch long 30-gauge needle
in multiple 0.1 ml injections approximately 1 cm
apart.6
Group 2: PRP was prepared using a double
centrifugation technique. Under aseptic measures, 20
ml of blood was drawn and was centrifuged at 5000
rpm for 15 minutes. The first spin will separate the
red blood cells from the plasma containing the
platelets. Then the supernatant and the buffy coat
were centrifuged again at 2000 rpm for 5 - 10 min.
This soft spin produces the PRP. The bottom layer

was taken and 10% calcium chloride was added as an
activator (0.3 ml for 1 ml of PRP).7
Randomly allocated injections were given under
aseptic precautions. A total of 3 such sittings were
given to each patient at an interval of 3 weeks each
with a follow up at 3 months. No other treatment was
given during this period. Results were assessed based
on the Assessment of overall improvement scale.
This takes into account extent and density of
regrowth of hair and is expressed as a percentage of
overall growth. Serial photographs were taken and
dermascopic examination was done. The results were
analysed using Mann Whitney U test.
RESULTS
A total of 74 patients were included in the study, of
which 48 were treated with triamcinolone injections
and 26 were treated with PRP injections. The mean
age of the subjects in our study was 25.20 years (SD11.11). 47.34% of patients were aged between 19 and
30 years, followed by 27.08% of the patients aged
less than 18 years, and 21.66% of the patients
between 31 and 40 years of age. Males constituted
79.2% of the study population. The male to female
ratio was about 4:1. The duration of the disease was
between 1 and 6 months in 74.32% of the patients. In
the study population, 85.14% of the patients had an
insidious onset. 13.51% had associated stress and
8.11% were atopic. The most common area of
involvement on the scalp was the occiput (27.27%),
and on the face was the moustache region (27.27%).
The mean SALT score or percentage of involvement
of scalp was 5.945(SD-3.62). The mean SALT score
for face was 6.635(SD-3.29). The comparison of
overall improvement between groups was non
significant at 3rd week (p=0.688)(Fig 3). The
percentage of complete resolution (53.8%) was
higher in the PRP group than the triamcinolone group
(35.4%) at the end of the 6th week (Fig 4). Hence
there was comparatively higher percentage of
improvement in the PRP group than the
triamcinolone group at the end of 6th week. But this
difference was statistically insignificant (p=0.597).
The overall improvement at 9th week and 3rd month
revealed that all the subjects in both groups had
achieved complete regrowth of hair (Fig 1&2).
119
Shumez et al.,
1a
1b
1c
rd
Fig 1: Alopecia areata before treatment (1a), improvement at 3 week (1b), improvement at 6th week (1c),
with PRP
2a
2b
2c
rd
Fig 2 : Alopecia areata before treatment (2a), improvement at 3 week (2b), improvement at 6th week (2c),
with Triamcinolone
70
60.4
46.2
Percentage
50
46.2
Percentage
60
TRIAM
PRP
37.5
40
30
20
10
0
00
7.7
2.1
60
TRIAM
50
PRP
00
RG0 RG1 RG2 RG3 RG4 RG5

Comparison of overall improvement at 3rd
week
46.2
39.6
40
35.4
25
30
20
10
00
53.8
00
00
00
RG0
RG1
RG2
0
RG3
RG4
RG5
Comparison of improvement at 6rd week
Fig 3: Comparison of overall improvement at 3rd week Fig 4 : Comparison of improvement at 6rd week
RG Regrowth of Hair, TRIAM Triamcinolone, PRP Platelet Rich Plasma
RG0 - (no change), RG1 - (1-24% regrowth), RG2 - (25-49% regrowth), RG3 - (50-74% regrowth), RG4 - (7599% regrowth), RG5 - (100% regrowth)
DISCUSSION
Alopecia areata (AA) is a characterized by rapid and
complete loss of hair in one or more patches, usually
on the scalp, bearded area, and less commonly, on
other hairy areas of the body. It is a common form of

alopecia, accounting for about 25% of all the alopecia
cases.8
120
Shumez et al.,
Multiple therapies have been proposed for their

treatment. These include corticosteroids (topical,
intralesional and systemic), minoxidil, anthralin,
contact sensitisers, topical tacrolimus, PUVA
(Psoralen and Ultra Violet-A Light therapy),
cyclosporin
A,
etanercept,
methotrexate,
sulfasalazine, etc. But none have been shown to alter
the course of the disease.
PRP is a volume of autologous plasma that has a
platelet concentration five times more than normal
platelet counts.9,10 PRP enhances wound healing by
promoting the healing process by the growth factors
present in it.10 They are platelet derived growth
factor, fibroblast growth factor, vascular endothelial
growth factor, epidermal growth factor, transforming
growth factor.10,11
It is hypothesized that growth factors released from
platelets may act on stem cells in the bulge area of the
follicles, stimulating the development of new follicles
and promoting neovascularization.8
In addition to its proliferating-inducing effects, PRP
is also a potent anti-inflammatory agent, which can
suppress cytokine release and thereby limit local
tissue inflammation.12 As AA is characterized by an
extensive inflammatory infiltrate, responsible for
secretion of a variety of inflammatory cytokines, it is
probable that the anti-inflammatory effects of PRP
may be of great benefit in this condition.12
In spite of these previous studies, the precise
mechanism by which PRP promotes hair growth has
not been properly studied.
Intralesional corticosteroids are frequently used in
treating AA. Steroids with low solubility are
commonly used because of their slow absorbtion,
thereby minimising systemic effects.13 By exerting an
immunosuppressive effect, corticosteroids can
promote regrowth in AA.14 A study of intralesional
corticosteroids showed the time from injection to
visible hair growth was 2-4 weeks and subsequent
growth occurred at a constant linear rate.13 Any hair
regrowth is seen within 3 months but the therapy
should be stopped if there is no cosmetic response by
6 months, as such individuals may lack adequate
corticosteroid receptors in their scalp tissue. A
disadvantage of intralesional triamcinolone is that it
may induce slight transient atrophy and occasional
follicular atrophy.15
Intralesional corticosteroids are a time tested
modality of treatment for AA, in use from 1958.16
However, they are more suited for smaller, relatively

stable patches of alopecia areata.3 But depigmentation
and cutaneous atrophy are well documented
complications with intralesional corticosteroids.17
Allergic reaction18 and Cushings syndrome17 have
also been reported secondary to intralesional
triamcinolone. However, in our study, adverse effects
were not found with intralesional triamcinolone.
In 2013, Trink et al.12 performed a randomized,
double-blind, placebo and active-controlled, halfhead study on 45 patients and evaluated the efficacy
of PRP in patients with AA. Both triamcinolone and
PRP led to increased hair regrowth compared with the
untreated side of the scalp. Additionally, patients
treated with PRP had significantly increased hair
regrowth compared with those treated with
triamcinolone. 27% of patients treated with
triamcinolone achieved complete remission at 12
months, compared to 60% of patients treated with
PRP. No major side effects were observed during
treatment. PRP also decreased the percentage of
dystrophic hairs and burning or itching sensation. In
our study, a small percentage (11.53%) of the patients
treated with PRP had regrowth of gray hair. But PRP
may still serve as an effective and safer treatment
option in AA.
In our study, patients treated with PRP had an earlier
response than patients treated with Triamcinolone.
However,
this
difference
was
statistically
insignificant. Also, in our study, the overall
improvement at the end of 9 weeks was 100% for all
patients in both groups. This may be due to the fact
that our study was carried out in a small population,
with patches of AA involving less than 25% of the
total scalp area.
CONCLUSION
PRP is a safe, simple, inexpensive and biocompatible
procedure. Patients treated with PRP had an earlier
response than patients treated with Triamcinolone.
Though this difference was statistically insignificant,
it pushes the need for further clinical studies enrolling
a larger number of patients, using more sophisticated
techniques to arrive at a better and a definite
conclusion.
Acknowledgement: None
Conflict of interest: None
121
Shumez et al.,
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McMichael A. Alopecia areata. Int J Dermatol.
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2. Messenger AG. Disorders of Hair. In: Burns T,
Breathnach S, Cox N, Griffiths C, editors. Rooks
Textbook of Dermatology. 8th edition. UK:
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Shumez et al.,
DOI: 10.5958/2319-5886.2015.00020.X

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Received: 6 Nov 2014
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 16 Dec 2014
CLINICAL ISOLATES OF MECA, METHICILLIN, VANCOMYCIN RESISTANCE S. AUREUS; ESBLs

PRODUCING K.PNEUMONIA, E.COLI, P. AUREGENOSA FROM VARIOUS CLINICAL SOURCE
AND ITS ANTIMICROBIAL RESISTANCE PATTERNS
*Ismail Mahmud Ali1, Amirthalingam R2
1
Hospital Director, Head, Assistant Professor, Department of Surgery, Ibn Sina Teaching Hospital,
Specialist, Dept of Molecular biology, Ibn Sina Teaching Hospital, Sirt University, Libya, P.O. Box 705
*Corresponding author email: amrithrgenes@yahoo.co.in

ABSTRACT
Background and Objective: Antimicrobial resistance has turned into a key medical and public health crisis
globally since the injudicious use of magic bullets (drugs). Aim of this study is focused on the clinical isolate and
their percentages of resistant to antibiotics in gram positive bacteria such as MRSA, VRSA, and MSSA are
common causes of nosocomical, skin structure infections, bacteremia and infection of other systems; ESBLs
producing Enterobacteriaceae (E. coli, Klebsiella spp.) is common agent of urinary tract, bloodstream, pulmonary
and intra-abdominal infections and carbapenem resistant P. aeruginosa with its complete antimicrobial patterns
which are currently practiced in this population. Methods: There are one hundred and fourteen (114) various
clinical isolates, isolated from various clinical samples like throat swab, urine, pus, sputum, and blood culture,
identified as specific isolate with resistance patterns were analyzed by BD phoenix-100 the auto analyzer.
Results: Off 114 clinical isolate, 6 mecA-mediated resistance (cefoxitin>8mgc/ml), 11 methicillin resistance, 18
lactam/lactamase inhibitor, 12 methicillin sensitive and 3 vancomycin (>16g/ml) resistance S. aureus have
been isolated from overall 50 isolate of S.aureus. In addition, there are 27 P.aeruginosa, 15 ESBLs from overall
of 25 K. pneumoniae and 7 ESBLs out of 12 Escherichia coli species have been isolated. The resistance and
susceptibility pattern percentages have been graphically represented for each isolates. Conclusion: Current study
revealed that the drug classes of lactam/lactamase inhibitor having high resistance rate with S.aureus,
P.aureginosa, K. pneumoniae and E. coli isolate. Also, some of other drug classes such as cepham and
tetracycline having higher resistance rate with P.aureginosa and K.pneumoniae. In addition, the vancomycin
resistances S. aureus have been isolated and reported as first time in this population.
Keywords: Methicillin & Vancomycin Resistance, Methicillin Sensitive Staphylococcus aureus; extended
spectrum lactamases (ESBLs).
INTRODUCTION
A number of bacterial infections are caused by gram
negative aerobic and facultative anaerobic bacteria, it
belongs to the family of Enterobacteriaceae and nonEnterobacteriaceae. The gram positive bacteria
belong to the genera Staphylococcus, Enterococcus,
gram positive cocci and gram positive bacilli, all of
them are causative agents of nosocomial and
Ismail et al.,
community acquired infectious diseases in human

habitual life. Nearly 10 million children under the age
of 5 years have been died until the period of 2008 and
this effect enhanced the socioeconomic condition in
many developing countries, better management in
infection control, fast access immunization and
introduction of new vaccines against bacterial
123
infection diseases1-2. The aerobic and facultative

anaerobic gram negative bacterium such as K.
pneumoniae, E. coli and P. aeruginosa, and gram
positive bacteria like S. aureus are multi-drugs
resistance bacterium and currently it is very common
in this local population as well as Ibn Sina Teaching
Hospital setup. This antimicrobial resistance is a
natural biological phenomenon and it is operated by a
genetic material (Nucleic acid) of living microbes
such as plasmids, transposons and integrons, it has
major roles in extension of multi-drugs resistance in
all bacterium3. Staphylococcus aureus is an
opportunistic hospital associated (HA-MRSA) and
community associated (CA-MSSA) infectious
bacterium in human body. The one called methicillin
resistant Staphylococcus aureus (MRSA) contain a
mecA gene that makes resistance to all -lactam
antibiotics including penicillin and cephalosporin;
methicillin sensitive Staphylococcus aureus (MSSA)
susceptible to many antibiotics other than lactam,
and vancomycin resistance S. aureus (VRSA)
resistant to long time use of glycopeptides antibiotics.
It can cause soft tissue infection as well as
pneumonia,
endocarditic,
septic
arthritis,
osteomyelitis, meningitis and septicemia. Hence,
Hospital acquired MRSA isolates are major causes of
nosocomial infections. The community associated
MRSA strains are significantly associated with soft
tissue infection, it also causes sepsis, necrotizing
fasciitis, and necrotizing pneumonia. It is an epidemic
as well as endemic all over the world4. Extended
spectrum lactamases (ESBLs) are enzymes
produced by different types of Enterobacteriaceae
family including Klebsiella pneumonia, E. coli, and
non-fermentative gram negative bacteria, such as
Pseudomonas
aeruginosa
and
Acinetobacter
baumannii. It is derived from (Temoniera patients)
TEM or sulphydroxyl variable (SHV) enzymes (for
resistance of ceftazidime and ceftriaxone antibiotic)
types of plasmid mediated lactamases through gene
mutation (amino acid alteration). The CTX-M type
enzymes are replacing SHV and TEM types
enzymes in nosocomial and community acquired
infections caused by E. coli and K. pneumoniae5. The
K, pneumoniae carbapenemase (KPC) is an enzyme
of K, pneumoniae for resisting multi-drugs like
lactams, fluoroquinolones, and amino glycosides drug
classes. These types of KPC infection may cause high
therapeutic failure with 50% of mortality rates6-7.
Ismail et al.,
Current study mainly focused on the isolation of

resistant and multi-drugs resistant pathogenic
bacterium and its antimicrobial susceptibility
patterns. The ultimate goal of this study is to guide
the health care workers and specialists to manage
such type of infections in an ethical and scientific
way and also guide for the society of infectious
disease panel and Ministry of Health in Libya.
Clinical Samples: In the prospective analysis, a total
of 114 different bacterial isolates have been identified
from different clinical sources. The clinical sources
were sputum, urine, pus, wound & throat swabs, and
blood culture, received from Ibn Sina Teaching
Hospital and Out Patients during the years of 20132014. Although, some of exist datas during the years
of 2008 were integrated in this research for
highlighting the vancomycin resistance S.aureus have
been isolated previously by BD expert in this locality.
The dose of each drugs have been mentioned in all
graphs, because of the drugs concentration were
differed in each pathogenic bacterium so please refer
to the graphs. The drugs classes were included for all
clinical
isolate
such
as
5-fluoroquinolone
(Ciprofloxacin-CIP,
Norfloxacin-NOR,
Levofloxacin-LUX, Moxifloxacin-MXF) ; Amino
glycoside (Gentamicin-GM, Amikacin-AN);
lactam/beta-lactamase Inhibitor (Ampicillin AM,
Penicillin-G,-P,Oxacillin-OX,
Amoxicillin/
Clavulanate-AMC, Piperacillin-PIP); Carbapenam
(Imipenem-IPM,
Meropenem-MEM);
Folate
Antagonist (Trimethoprim/ Sulfamethoxazole-SXT);
Glycopeptides (Vancomycin-VA); Cephem (
Cephalothin-CF,Cefuroxime-CXM,CefoxitinFOX,Ceftazidine-CAZ,Cefotaxime-CTX, CefepimeCEP,
Ceftriaxone-CRO);
Lincosamide
(CCClindamycin);
Macrolide
(E-Erythromycin);
Nitro(FM-Nitrofurantion) ; Oxazolidine (LZDLinezolid) and Tetracycline. These are drugs names
with drugs classes have been applied according to the
gram stains concerns and rest of drugs classes have
been considered as exclusion criteria. The ethics
panel and internal review board of the organization
approved the procedure.
Culture Media preparation: There are some routine
mediums such as mac-conkey agar, nutrient agar,
blood agar (rest of clinical source and sensitivity),
chocolate agar (CSF), CLED agar for urine sample
124
(Cystine-Lactose-Electrolyte-Deficient) and blood

culture bottle Bactech for blood samples (aerobic &
an-aerobic) were been used in the department of
clinical microbiology laboratory. These are all
powdered form except blood culture bottle and it has
been diluted according to the manufacturers
guidelines in the individual conical flask and further
autoclaved at 125 psi for 30 minutes, then it has been
cooled to room temperature and dispensed the liquid
substance with slightly lukewarm condition on
culture plates. Day by day the samples were received;
cultured, isolated, gram stained and applied as diluted
samples to the auto-microbial analyzer for further
confirmatory reasons. Hence, the culture medias are
recommended by manufacture to use in ID and AST
(antimicrobial susceptibility test) broth in system
analysis such as trypticase soy agar with 5% sheep
blood, bromthymol blue (BTB) lactose agar, BBLTM
chromagar TM orientation; chocolate agar; columbia
agar with 5% horse blood; columbia agar with 5%
sheep blood; cystine-lactose-electrolyte-deficient agar
(CLED); dey/engley (D/E) neutralizing agar; eosin
methylene blue; hektoen enteric agar; macconkey
agar; trypticase soy agar without blood; trypticase soy
agar with lecithin and tween 80 and xylose lysine
desoxycholate agar. Hence, dey/engley (D/E),
neutralizing agar; hektoen enteric agar; trypticase soy
agar without blood; trypticase soy agar with lecithin
and tween 80 and xylose lysine desoxycholate agar
are not recommended to use for AST broth in the
system analysis.
Bacterial Culture Isolation: The Major clinical
isolate have been confirmed with gram stains to get
verification of weather gram positive or negative
bacterium. After that, the clinical isolate have been
specified the bacteria, biochemical tests, and its
multi-drug susceptibility tests were performed
through BD-Phoenix-100, the microbial auto
analyzer.
BD Phoenix Panel: There are three more BD
phoenix panel kits have been introduced by
manufacturer to screen bacterial pathogens and each
panel has its own specific pathogenic identification
with drugs sensitivity and resistance patterns. Such as
PMIC/ID-69, PMIC and PID panels (Gram positive
pathogenic), NMIC/ID-94, NMIC and NID panels
(Gram negative pathogenic organisms) and special
panels only for SMIC/ID-11 panels (Streptococcus
species). The system can perform at least100 bacterial
identification with antimicrobial susceptibility at a

time. It utilizes an optimized colorimetric redox
indicator for AST, and a diversity of colorimetric and
fluorometric indicators for ID. The AST broth is cat
ion (Ca++ and Mg++) adjusted to optimize
susceptibility testing performance8.
Bacterial Identification: The ID portion of the
Phoenix panel utilizes a series of conventional,
chromogenic, and fluorogenic biochemical tests to
determine the identification of the organisms. The ID
broth contains 45 wells with dried biochemicals
substrate and two fluorescent control wells. Both
growth-based and enzymatic substrates are employed
to cover the different types of reactivity in the range
of taxa. The tests are based on microbial utilization
and degradation of specific substrates detected by
various indicator systems. Acid production is
indicated by a change in the phenol red indicator
when an isolate is able to utilize a carbohydrate
substrate. The chromogenic substrates produce a
yellow color upon enzymatic hydrolysis of either pnitro phenyl or p-nitroanilide compounds. Enzymatic
hydrolysis of fluorogenic substrates results in the
release of a fluorescent coumarin derivative.
Organisms that utilize a specific carbon source reduce
the resazurin-based indicator. In addition, there are
other tests that detect the ability of an organism to
hydrolyze, degrade, reduce, or otherwise utilize a
substrate9-10.
Antimicrobial Susceptibility Testing: The BD
Phoenix AST method is a broth based micro dilution
test. It contains 84 wells with dried antimicrobial
agents and one growth control well. The Phoenix
system utilizes a redox indicator for the detection of
organisms growth in the presence of an antimicrobial
agent. Continuous quantification of changes to the
indicator as well as bacterial turbidity is used in the
determination of bacterial growth. Each AST panel
configuration contains several antimicrobial agents
with a range of two fold doubling dilution
concentrations. Organism identification is used in the
interpretation of (the lowest concentration of an
antimicrobial agents in which no visible growth occur
is called minimal inhibitory concentration) MIC
values of each antimicrobial agent producing
Susceptible, Intermediate, or Resistant (SIR) result
classifications11.
BD Phoenix-100 Methods: BD Phoenix is an
automated microbiology system utilized for
125
Ismail et al.,
recognition of pathogenic bacteria from pure culture

of different clinical samples. The pathogenic
organisms include the species of Staphylococcus,
Enterococcus, Gram positive bacilli and cocci, Gram
negative aerobic and facultative anaerobic bacteria
the family of Enterobacteriaceae and nonEnteterobacteriaceae. Also, it is future for in vitro
quantitative
determination
of
antimicrobial
susceptibility by minimal inhibitory concentration
(MIC).
The pure culture isolates have been tested with a
gram stain to assure the appropriate selection of
Phoenix panel type. Using aseptic technique, bacterial
colonies were picked from culture plate by sterile
swab and suspend the colonies into 4.5 ml of ID
broth. The BD Phoenix Spec Nephlometer has been
used to make inoculums densities purposes. There are
two types of inoculums density have been applied
(0.25 &0.5McFarland) for the panel type being run,
and then it ranges of 0.20 -0.30 to 0.50-0.60 was
acceptable. If the density of organisms is low then it
needs addition of bacterial colonies. Later on one
drop of AST indicator solutions was added to AST
broth solution (8.0ml); then 25l or 50l of bacterial
suspension were transferred from the ID tube into
AST broth tube according to the density of
suspension. These panels have been loaded into the
Phoenix instrument and continuously incubated at
35C until 16 hrs for the results gaining. There are
three different antibiotic methods (PMIC, NMIC and
SMIC) were been utilized in BD Phoenix-100 system
and the results were been reported as 95%
confidence automatically according to the
biochemical reaction the report have been released
with pathogenic names. Statistical analysis was done
by using micro software excel 2007.
RESULTS
There are 50 different types of S. aureus have been
isolated from various clinical samples with different
drug resistance patterns. Among fifty isolate, 6 mecA
mediated
resistant
staphylococcus
(MIC=
cefoxitin>8mcg/ml), 11methicillin (resistance of
ampicillin,
pencillin,
oxacillin
and
amoxicillin/clavulanate), 18 lactamase producing
staphylococcus aureus (susceptible to oxacillin and
amoxicillin), 12 methicillin sensitive (ampicillin,
oxacillin and amoxicillin/clavulanate) 3 vancomycin
(>16g/ml) resistance S.aureus and some of
heterogeneous vancomycin intermediate isolate have

been differentiated through auto analyzer from
various clinical samples .The selective antibiotic
usages have been graphically explained as
percentages with susceptible and resistance patterns
for S.aureus (refer to Fig-1). The most drug resistance
such as ampicillin (94%), penicillin (100%), oxacillin
(70%) and amoxicillin/clavulanate have been
observed as high resistance radio in among isolate of
S .aureus. The methicillin resistances S.aureus are
reported as high resistance to penicillin, lactam/lactamase inhibitor combinations, cephalosporins
and carbapenem because of ineffectiveness in clinical
usage but in this study carbapenem (imipenem 56%
and meropenem66%) is susceptible for S.aureus.
Fig 1: Antimicrobial resistance patterns for

S.aureus
Non-fermentative isolate such as Pseudomonas
aeruginosa is most frequently isolated as multidrug
resistance gram negative bacilli in routine clinical
microbiology laboratory. In current analysis, there are
twenty seven selective isolate have been isolated
from different clinical sources. The multidrug
resistance patterns have been observed as high in
lactam/ lactamase inhibitor (96-100%), folate
antagonist (100%), cephem (96-100%), and
tetracycline (100%). Hence, the moderate resistance
patterns also observed in 5-fluoroquinolone, amino
glycoside and carbapenem (Fig-2). Generally,
P.aeruginosa is intrinsically resistant to tetracycline;
primary quinolones, first generation and second
generation cephalosporin, amino penicillin/betalactamase inhibitor combinations, ertapenem,
ceftizoxime,
cefotaxime,
ceftriaxone,
chloramphenicol,
trimethoprim,
trimethoprim/
sulfamethoxazole and kanamycin were been
126
Ismail et al.,
mentioned by BD expert. P.aeruginosa may develop

resistance during prolonged antimicrobial therapy
with all antibiotics. Norfloxacin and Tetracycline are
drugs of choice for urinary tract infection.
susceptibility rate was high in carbapenem than other

drug classes (Fig-4).
Fig 4: Antimicrobial resistance patterns for E.coli

Fig 2: Multidrug resistance patterns for
P.aeruginosa
Enterobacteriaceae family, mainly Klebsiella
pneumoniae and Escherichia coli are producing
lactam/ lactamase enzymes are able to deactivate the
antibiotic like lactam/lactamase drugs classes and it
also found in Pseudomonas aeruginosa. The current
analysis revealed that, more than 25 isolates from
different clinical samples such as sputum, urine, pus,
and throat swab. The resistance patterns of Klebsiella
pneumoniae have been graphically explained (Fig3).The highest resistance patterns were observed in
lactam/ lactamase and 5-fluoroquinolone drug
classes. The highest susceptibility prevalence was
observed in the drug class of carbapenem (88%).
Fig 3: Multidrug resistance patterns for

K.pneumoniae sp
Finally, the extended spectrum lactamase producing
E. coli isolate were observed among twelve isolates.
The highest drug resistance patterns were observed in
lactamase and tetracycline drugs classes and
Ismail et al.,
DISCUSSION
Resistance to antimicrobial drugs is a major health
crisis in Libya like others developing nations because
of lack of antimicrobial resistance survey and
improper management of drugs. Generally,
Staphylococcus aureus is well recognized as
causative agent of hospital-and community acquired
infections in this locality and it was first isolated as
MRSA in Benghazi in the year of 1972 by Goda12.
Later on it was reported in different Cities13, 14, 15.
Also, vancomycin resistance (MIC 16g/mL),
intermediate (4-8g/mL) and heterogeneous (14g/mL) S. aureus have been reported in US, Europe,
and Asia 16-17.However, there is no VRSA, VISA and
hVISA cases were reported in Libya by using
standard CLSI methods until 2011. Whereas in
present study, MRSA, MSSA, ESBLs producer and
vancomycin resistance S. aureus (MIC 16g/mL)
have been isolated and in brief high lightened with
resistance patterns in results division. Hence, some of
isolates were found with vancomycin sensitive,
heterogeneous and intermediate S. aureus.
Enterobacteriaceae
spp
mainly
Klebsiella
pneumoniae and E. coli bacterium are gram negative
bacterium. The K. pneumoniae OXA-48 producing
strains have been reported mainly from North African
countries, the Middle East, Turkey, India and other
European countries18-19. This bacterium steadily in
advance to resistance against -lactam antibiotics like
penicillin and cephalosporin by the assembling of
extended-spectrum lactamases (ESBLs) or
carbapenem-hydrolyzing enzymes for K. pneumoniae
20
. The another mobile metallo -lactamases enzymes
127
produced by Pseudomonas aeruginosa spp in the

course of multidrug resistance activity and this type
of enzymes synthesis could be assorted from nation to
nation 21. Previous study of E.coli drugs resistance
pattern have been reported from Sirt, Tripoli and
Benghazi, during the years of 2002-2008.The
resistance pattern were ampcillin (49%,59%,57%);
chloramphenicol
(23%,21%,14%);
gentamicin
(9%,10%,7%); nalidixic acid (28%,28%,23%);
ciprofloxacin (2%,14%,17%) and trimethoprimsulfamethoxazole (36%,24%, 31%).22,23,24. Similarly,
the K. Pneumonia isolates proved to be resistant to all
broad-spectrum
cephalosporin
and
to
fluoroquinolones and susceptible to tigecycline were
reported from Italy during the Libyan conflict25.
Regarding resistance pattern in present study
(K.pneumonia & E.coli) were differed slightly from
previous report and should target more scientific
research on carbapenem and metallo -lactamases
producing isolates by molecular analysis in this
locality in feature.
The antibiotic resistance pattern in developing
countries like Iran, nearly 33% of ESBLs producing
K. pneumoniae causing major curative troubles and it
resistant was to ciprofloxacin and amino glycosides26;
though in India ESBL isolate drugs resistance were
amoxicillin (93.3%), gentamicin (70%), ciprofloxacin
(10.4%) and amikacin (26.1%)27. Likewise in present
study, lactam/lactamase drug class having high
resistance followed by cepham drug class for
K.pneumoniae and susceptibility ranges was higher in
carbaphenem drugs class. But in E .coli, lactam/
lactamase drugs class having high resistance followed
by tetracycline drug class and it susceptibility pattern
were 5- fluoroquinolone aminoglycoside and
carbapenem drugs class than nitrofurantoin and
cephem drugs class. The superior antimicrobial
resistance rates in current study could be attributed to
the resource of the clinical isolates being from
multispecialty setup and recurrent usage of broad
spectrum antibiotic. Also study might be helpful to
control of infectious diseases in public as well as poor
setup of hospitality.
CONCLUSION
Present study highlighted that the drug classes of
lactam/lactamase inhibitor having a high resistance
rate with S. aureus, P.aureginosa, K. pneumoniae and
E. coli isolate. Hence, some of other drugs classes
such as cepham and tetracycline also having higher

resistance rate with P.aureginosa and K.pneumoniae.
In addition, the vancomycin resistances S. aureus
have been isolated first time in this region by BD
phoenix expert and the clinical specialists should
concentrate much more in these cases. As a result,
superior antibiotic policy and hospital infection
management assessment can be making the first
move to prevent the emergence of multidrug resistant
clinical isolates.
ACKNOWLEDGEMENT: We would like to
convey our honest gratitude to microbiology teams.
Conflict of interest: None
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infection
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Nordmann P, Naas T, Poirel L. Global spread of
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19. Poirel L, Bonnin RA, Nordmann P. Genetic

features of the widespread plasmid coding for the
carbapenemase OXA-48.Antimicrob Agents
Chemother.2012;56:559-562.
20. Harris AD, Perencevich EN, Johnson JK,
Paterson DL, Morris JG, and Strauss SM et al.
Patient to patient transmission is important in
extended spectrum beta-lactamase producing
Klebsiella pneumoniae acquisition. Clin. Infect.
Dis.2007; 45: 134750.
21. Poirel
L,
Pitout
JD,
Nordmann
P.
Carbapenemases: Molecular diversity and clinical
consequences. Future Microbiology.2007; 2: 50112
22. Bgar SR, Hussein AA,Elahwel AM,Alani
SMH.Antibiotic resistance pattern of urinary tract
isolates. Jamahiriya Med J.2007; 7:116-21
23. Ghenghesh KS,Elkateb E,Berbash N, Nada RA,
Ahmed SF,and Rahouma A et al. Uropathogens
from diabetic patients in Libya: virulence factors
and phylogenetics groups of isolated E.coli. J
Med Microbiol. 2009; 58: 1006-14.
24. Buzayan MM, Tobgi RS,,Taher I. Detection of
extended spectrum -lactamases among urinary
E.coli and K.pneumoniae from two centers.
Jamahiriya Med J.2010;10: 10-6.
25. Kocsis E, Savio C, Piccoli M, Cornaglia G, and
Mazzariol A
et al. Klebsiella pneumonia
harbouring OXA-48 carbapenemase in a Libyan
refugee in Italy. Clin MicrobiolInfect.2013; 19:
E409-E411.
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Chiu CH. Characterization of Plasmids encoding
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DOI: 10.5958/2319-5886.2015.00021.1

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Volume 4 Issue 1
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Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 8 Dec 2014
A SHORT TERM OUTCOME OF STANDARD CRUCIATE RETAINING ARTHROPLASTY IN

PRIMARY OSTEOARTHRITIS OF KNEE
*Sankarlingam P1, Raja Pandian R2, Vijayaragavan N3
1
Professor & Head ,2Final year postgraduate ,3Asst. Professor of Department of Orthopaedics, Meenakshi Medical
College and Research Institute, Enathur, Kancheepuram, Tamil Nadu
*Corresponding author email: sanklink@yahoo.com
ABSTRACT
Total condylar prosthesis, which was developed in 1974, was subsequently modified to a posterior cruciate
substituting the posterior stabilized version in around 1978 for the purpose of improving stair climbing, better
range of knee motion, prevention of posterior subluxation and more conforming knee kinematics. But, this
prospective study was performed in our institute, to assess the clinical and functional outcomes of standard
cruciate retaining arthroplasty in primary osteoarthritis of knee. Methods: 29 patients who are diagnosed primary
osteoarthritis knee underwent Cruciate retaining knee arthroplasty and followed up for a period of 2-3 years.
Results: In our study patients were evaluated according to Knee society scoring system, which showed
preoperatively poor grade and post operatively showed 73% excellent, 17 % good and 10% fair results with no
poor results. Conclusion: We concluded from our study that cruciate retaining knee arthroplasty provides pain
relief, good range of motion, deformity correction, no instability and no other complications.
Keywords: Total knee arthroplasty, Cruciate retaining, Posterior cruciate ligament, Knee Society Scoring.
INTRODUCTION
Total knee arthroplasty (TKA) has provided pain
relief and improved knee function for a variety of
arthritic conditions with good long term results. 1-12
However, one of the most commonly cited reasons
for retaining the PCL is to preserve femoral rollback,
which improves extensor efficiency by lengthening
the moment arm and improves the range of flexion by
minimizing the potential for impingement of the
femur on the tibial component. 13-21
Physiologic rollback in the normal knee is a complex
combination of rolling, gliding and rotation of the
femoral condyles relative to the tibial plateau that
results in a net posterior movement of tibiofemoral
contact in flexion.14,15,17,22-24 Normal rollback is
dependent on the integrity of the cruciate ligaments,
which form a four-bar planar linkage between the
femur and tibia that constrains the relative
movements of the articular surfaces.23-25 During TKA,

the ACL is resected and the complex complementary
geometry of the articular surfaces is altered.
Therefore, the normal interaction of the four-bar
linkage mechanism and the articular surface is lost
and rollback cannot occur. However, under these
circumstances, if appropriately tensioned, the retained
PCL can exert a beneficial checkrein effect to
counteract the naturally occurring shear forces which
would otherwise result in anterior translation of the
femur on the tibia in flexion.26 This prospective study
was performed to assess the clinical and functional
outcomes of Cruciate retaining TKA.
This study was started after the approval of Ethics
Committee of Meenakshi Medical College Hospital
130
Sankarlingam et al.,
And Research Institute. The prospective study

conducted on 29 patients with 30 symptomatic
Tricompartmental OA knees in the Department of
Orthopedics at Meenakshi Medical College Hospital
and Research Institute, Kanchipuram. Patients aged
between 45-70 years presented with symptomatic
knees who are not relieved by conservative
management underwent Cruciate retaining TKA
during the period of June 2011 to June 2014. There
were 18 females and 11 male patients were evaluated
pre operatively and post operatively according to
knee society scoring33. There were 14 Type II
diabetic patients included in this study. All the cases
with primary osteoarthritis with joint space narrowing
were included in the surgery. Rheumatoid arthritis
with severe ligament damage of PCL and patients
who are unfit for surgery were excluded from our
study. Patients, prior to knee replacement, should be
clinically screened for active infection. After
obtaining informed consent from patients, they were
posted for surgery.
Surgical technique: Under strict aseptic precaution,
Combined spinal and epidural anesthesia were given
to all patients. Patient in supine posture, parts painted
and draped. All cases operated without using a
tourniquet. Prophylactic intravenous antibiotics were
used in all patients. Through midline skin incision,
medial parapatellar arthrotomy, all the knees were
exposed. PCL was retained and appropriately
tensioned by partially releasing from femoral
attachment especially anterolateral fibers. Tibial cuts
were made perpendicular to mechanical axis. Entry
point made in the distal femur, and distal cut made in
5degree/6degree valgus. Finishing cuts as per femoral
size required. After trail reduction, patellar tracking
were checked and final components were cemented.
Patients were operated by the same surgeon, using
instrumentation provided by the manufacturers
(genesis II - Smith & Nephew, AGC Biomet, &
Gemini Link). Since the tourniquet was not used,
majority of transfusions were administered
intraoperatively one unit and within 48 hours post
operatively one unit if required. There were no
adverse reactions.
Postoperatively, all patients received anticoagulation.
On 2nd post operative day, after drain removal
resistive quadriceps exercises, ankle pump exercises,
range of motion exercises and weight bearing were
done as tolerated. The patients were called back for
review at 1st month, 3rd month 6th, 1st year and 2nd
year (Short-term follow up study). Precautions to be
taken after surgery was deep knee bending after 110
degrees should be avoided. Sitting on floor with
crossed legs and squatting should be avoided.
1.1
1.2
Fig 1.1: Intra op PCL retained 1.2:Prosthesis

fixation (AGC-Biomet)
The knee society scoring33 was used for assessment
of preoperative and postoperative clinical and
radiological outcome at each follow up. This study
aims to assess the effectiveness and efficiency of a
Cruciate retaining TKA, and to evaluate clinical and
functional outcome.
RESULTS
In our study, there were 18 females and 11 males and
out of which bilateral TKA was done in 1 case at
same sitting. Maximum belonged to 60 69 years
with mean age 65.86 years and females are more for
surgery in the ratio of 3:1. Mean operating time was
1hour 30 min (range 1 hr 10 min to 1hr 50 min).
Average amount of blood in the drain post
operatively was 220 ml (range 150-280 ml). Mean
follow up duration was 2 yrs. Mean knee society
score preoperatively was 52 and postoperatively at 1st
month 68, 3rd month -74, 6th -78,1st year-81 and at
2nd year - 84. There were over 90% excellent results
according to knee society score33 in patients with
normal or weak quadriceps. There was
varus
deformities in all cases, with an average angle of 20
degrees (range 10-30 degree), which was corrected to
physiological valgus (2-7 degree). This was achieved
in 90% of cases (Fig.2.1-3.2). Range of knee motion
is considerably increased from a preoperative mean
of 60 degrees to a post operative mean of 100 degrees
at the end of two years. (Fig.4.1-4.2)
131
90
80
Mean knee society score
70
60
50
2.1
2.2
Fig 2.1: Pre Operative - Antero Posterior View Fig 2.2:

Lateral view
40
30
20
10
0
3.1
3.2
Fig 3.1: Post Operative Antero posterior View 3.2:

Lateral view
Though diabetes mellitus increases the chances of

infection, but no complication occurred in our study.
During the 2 year period of follow up there was no
case of loosening of tibial or femoral component. All
cases were having poor grade preoperatively
according to knee society scoring system and
postoperatively, there were 22 excellent, 5 good and 3
fair results in our study. (Fig.5)
4.1
4.2
Fig.4.1 Post operative-Sitting 4.2: Standing
Fig.5 Results graded according to Knee society score33

(Y axis mean knee society score)
DISCUSSION
Osteoarthritis causes a lot of physical and mental
trauma to the patient because of pain and deformity.
TKA has emerged as a boon for patients suffering
from osteoarthritis and other deformities of knee
when conservative treatments have failed. The
proponents of CR claim that it acts as a Biologic
stabilizer and is capable of absorbing the shearing
forces and reduces the stresses at the prosthesis-bone
interface5, 27-32. Andriacchi et al27, 30 demonstrated that
patients who received TKA with PCL preservation
were better at stair climbing than those who sacrificed
PCL.
According to this study, we were able to achieve the
physiological valgus of 2-7 degrees in all the cases.
We never used tourniquet. No cases were observed
with tibial or femoral component loosening. In our
study the follow up was done at 1st month, 3rd month,
6th month, 1st year and 2nd year. The results were
73% excellent, 17% good, 10% fair and no poor
results at the end of two years and these results are
obtained not only due to surgical skills but also
because of
better antibiotics, proper sterilized
environment, early ambulation and physiotherapy.
There were no major complications in our study.
Limitation of our study is short term follow up, where
long term study is required.
132
CONCLUSION
This study concludes that Cruciate retaining knee
arthroplasty in primary Osteoarthritis showed good
outcomes, good pain relief, good deformity
correction, good range of motion and no major
complications.
ACKNOWLEDGEMENT: This publication is the
result of three years of work whereby I have been
accompanied and supported by many people. I take
this opportunity to express my gratitude to our
beloved Chancellor, Vice Chancellor, Dean, Vice
Principal, Postgraduate Director for their guidance
throughout this work. I would like to thank my
assistants and postgraduates for helping me
throughout this study period.
Conflict of interest: Nil.
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DOI: 10.5958/2319-5886.2015.00022.3

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Volume 4 Issue 1
Coden: IJMRHS
st
Research article
Copyright @2014
ISSN: 2319-5886
ORAL CONTRACEPTIVES AS A RISK FACTOR FOR DEVELOPING BREAST CANCER IN

BREAST CANCER (BRCA) GENE CARRIER FEMALE IN- THE 30-60 YEARS AGE GROUP: A
META ANALYSIS
*Ghimire S1, Shrestha N1, BK Baral 2
1
Department of Public Health, Valley College of Technical Sciences (VCTS), Kathmandu, Nepal
Department of Biochemistry, Nepal Medical College & Teaching Hospital (NMCTH), Kathmandu, Nepal
*Corresponding author email: sarunaghimire@gmail.com

ABSTRACT
The literature linking breast cancer with oral contraceptives and BRCA mutation as possible risk factors is
equivocal. Hence, to account for these conflicting results in the existing literature and to observe the net effect,
this meta-analysis aims to investigate whether oral contraceptives are a risk factor for developing breast cancer in
breast cancer (BRCA) gene carrier female in the 30-60 years age group. Method: Systematic review of the
literature, both published and unpublished, and meta-analysis of relevant data. Results: Meta-analysis of data
from five relevant studies, with a total of 6682 BRCA carriers (3,269 BRCA1 carriers and 791 BRCA2 carriers),
revealed that use of oral contraceptives is associated with increased risk of breast cancer among BRCA mutation
carriers (OR=2.267; 95 % CI= 1.311, 3.919). When the same risk was stratified by mutation type, both BRCA1
and BRCA2 were at increased risk. However, BRCA2 carriers (OR= 3.060; 95% CI=0.951, 9.848) were found to
be at elevated risk compared to BRCA1 carriers (OR= 2.347; 95% CI=0.939, 5.865). Conclusions: This metaanalytical finding suggests that oral contraceptives are a risk factor for developing breast cancer in breast cancer
(BRCA) gene carrier females.
Key words: Oral contraceptives, Breast cancer, BRCA gene, Familial breast cancer and hereditary breast cancer.
INTRODUCTION
Breast cancer is a major global public health issue
and it is the most common cause of cancer death
among females1. It is also the second most commonly
diagnosed cancer in the world, after lung cancer, with
1.38 million cases2. Every woman is at the risk of
breast cancer and every 13 minutes a woman dies of
breast cancer in the world3.
The literature concerned with the association between
oral contraceptives and BRCA mutation as possible
risk factors for breast cancer is equivocal; as
numerous studies attempting to answer similar
questions about the association exists but the
individual studies show conflict in their estimation of
net association. Some studies demonstrate no

association between oral contraceptives use and
development of breast cancer among women with a
family history of breast cancer4-7. In contrast, others
reported an increased risk8-11. Instead of imposing
risk, there may be a protective effect of oral
contraceptive use for BRCA1 mutation carriers and
no effect for BRCA2 carriers12. A large retrospective,
population based International BRCA1/2 Carrier
Cohort Study (IBCCS) reported an elevated risk of
breast cancer among mutation carrier females (both
BRCA1 and BRCA2) who use oral contraceptives
(RR=1.47 95% CI 1.16-1.87)13. A meta-analysis
135
Ghimire et al.,
found no evidence of a significant increased breast

cancer risk in oral contraceptives users with germline
mutation in BRCA1/214. Hence, to account these
conflicting results in the existing literature and to
observe the net effect; this meta-analysis aims to
investigate breast cancer risk associated with oral
contraceptive use in BRCA carrier women of age 3060. Meta-analytical tool allows a more objective
appraisal of the evidence than traditional narrative
review, and hence contributes to resolve uncertainty
when original research, reviews and editorials
disagree15. Further this meta-analysis will also
examine the quantitative significance of this
association with respect to BRCA1 and BRCA2
individually.
field via emails. For computerized search, a list of

keywords
based
on
Reed
and
Baxter18
recommendation were developed. The following key
words combination was used: Oral contraceptives,
Breast cancer, BRCA gene/Breast cancer susceptible
gene, Women/ females, Familial/ Hereditary breast
cancer.
Studies that quantitatively estimate the association
between oral contraceptives and breast cancer and
providing sufficient statistical data to compute an
estimated effect size of the correlation between oral
contraceptive use and development of breast cancer
were included in this meta-analysis. Studies
conducted on breast cancer gene (BRCA) carrier
female only and not on general female population
were included. However, selection was not restrained
by demographic or other sample characteristics (such
as language, ethnicity etc.). Included studies should
report risk of oral contraceptive use for breast cancer
only and not on other types of cancer such as ovarian,
cervical cancer etc. If the study reports risk of various
types of cancer then the result of other types of cancer
apart from breast cancer will be excludes in this
meta-analysis. In this meta-analysis, studies will be
included irrespective of their result in order to avoid
inclusion criteria bias19. Similarly, studies with
qualitative design, those carried out in subjects such
as men, teenage female or women below 30 and
above 60 years or other than human subjects and
studies published in languages other than English
were excluded during the selection process. This
meta-analytical study was approved on 10th January
2011, by Centre for Health and Social care
Improvement (CHSI) in the University of the
Wolverhampton. The data was analysed by using
software for Meta-analysis called Metanalysis20.
An intensive database search, updated to September

2011, was carried out in Science Direct, Pub Med and
EBSCO Host. In EBSCO Host, only those databases
relevant to nursing and medicine were included.
These databases were AMED (The Allied and
Complementary Medicine Database), British Nursing
Index, and CINAHL Pus with full Text and
MEDLINE with full text. To minimize the problem
of publication bias or file drawer problem16, an
attempt was made to retrieve unpublished studies,
dissertation reports, thesis and scientific paper
presented in conferences. Search for such papers were
carried out in CINHAL Plus and national research
registers and Meta-register. Bibliographic search of
abstracts presented at top scientific events in the field
of breast cancer were also scrutinized. Further,
dissertation abstracts international17 was explored in
order to retrieve any of the dissertations. An attempt
was made to contact the leading researchers in the
Table 1. Search process
Search process
Exclusion
1068 Studies Resulted
433 excluded as the title and abstract analysis of these studies showed
(103 EBSCO Host + 238 Science Direct they were not relevant to aims and objectives of this meta analysis
+ 727 Pub Med)
427 paid and inaccessible articles
208 Further Screened
10 not reported in English
149 reviews and meta analysis
3 authors communications
2 study subjects were other than human
44 further screened to full text analysis
13 excluded as they did not consider oral contraceptive use
17 studies conducted on general females and not gene carriers
14 studies further screened
2 duplicates
7 studies had irrelevant data
5 studies included for the meta-analysis
136
Ghimire et al.,
Table 2 List of included studies

Author
Title of study
Study design
Country
Mutation status
No. of BRCA
carriers
No. Of BRCA
carriers
diagnosed with
BC
No .of BC
diagnosedBRCA carriers
using OCs
No.
of
BRCA1/
BRCA2
carriers
No.
of
BRCA1/
BRCA2
carriers
diagnosed with
BC
No. of BC
diagnosedBRCA1/
BRCA2
carriers using
OCs
Gronwald et al.
(2006)21
Haile et
(2006)7
al.
Brohet et al. (2007)13
Figueiredo
(2010)22
Phenocopies in
breast cancer 1
(BRCA1)
families:
implications for
genetic
counselling
BRCA1
and
BRCA2
mutation
carriers,
oral
contraceptive
use, and breast
cancer
before
age 50
Oral contraceptives and

postmenopausal
hormones and risk of
contralateral
breast
cancer among BRCA1
and BRCA2 mutation
carriers
and
noncarriers: the WECARE
Study
Matched
case
control
Multinatio
nal
Matched
control
Unmatched case
control
Oral
contraceptives
and breast cancer risk
in the international
BRCA1/2
carrier
cohort study: a report
from
EMBRACE,
GENEPSO,
GEOHEBON, and the
IBCCS Collaborating
Group
retrospective cohort
Multinational
Multinational
Multinational
Multinational
BRCA1 &
BRCA2
2622
BRCA1
BRCA1 & BRCA2
BRCA1 & BRCA2
1482
BRCA1
BRCA2
804
1311
348
914
56
Narod et
al.
(2002)5
Oral
contraceptiv
es and the
risk of breast
cancer in
BRCA1 &
BRCA2
mutation
carriers
case
&
et
al.
Population based case

control
1593
181
323
846
108
255
607
91
1181/412
109/72
597/249
67/41
436/171
59/32
497/307
195/128
146/109
Summary of the search and search results: The

search for relevant literature resulted in 1065 articles,
which were subjected to screening of titles, keywords
and abstracts. The inclusion, exclusion criteria were
used as a guideline to exclude or include a study
during the search process. The table 1 given below
outlines the detail of search process. Hence, finally 5
studies met the inclusion criteria of this meta-analysis
and were included for the process of data extraction.
Duplications were avoided through a careful

assessment of the abstract and full text of the two
studies20.
Data analysis: By using metanalysis programme,
heterogeneity was explored statistically in terms of
the I statistic. As, this meta-analysis includes only
five studies, use of Cochrans Q for assessing
heterogeneity was limited because Q has low power
when the number of studies is small.23 Due to the
presence of heterogeneity, the included studies were
137
Ghimire et al.,
assumed to have differences in study design,

sampling, and characteristics of subjects; and thus
were proceeded using a random effect model to
calculate the odds ratio by Dersimonian-Laird
method.20 Sub group analysis, stratified for BRCA1
and BRCA2 carriers, was performed to estimate any
difference in risk by type of mutation. Publication
bias was expressed and interpreted, in terms of
publication bias assessment (PBA), funnel plot and
the test of funnel plot asymmetry. Publication bias
assessment (PBA) is defined as a tool that helps to
assess the number of unpublished studies (similar to
those published and analysed) that are needed to
make the results of the meta-analysis not statistically
significant or meaningless.
RESULTS
The I2 value for this meta-analysis was 97.2 % (95%
CI = 99.4, 86.6), which suggest that maximum
variation exists between the included studies. In this
meta-analysis, oral contraceptive use was associated
with breast cancer risk (OR=2.267; 95 % CI= 1.311,
3.919) among BRCA mutation carriers, under random
effect model. Thus, a woman with BRCA mutation
carrier is two times more likely to develop breast
cancer, if she uses oral contraceptives; compared to
those who does not use it.
AUTHOR
YEAR
Breast
Cancer
Oral Contraceptive
Narod et al
2002
1311/2622
914/1311
Gronwald
2006
348/1482
56/348
Haile et al
2006
323/804
255/323
Brohet et al
2007
846/1593
607/846
Figueiredo et al
2010
108/181
91/108
Subgroup analysis:
The I2 value, for test of heterogeneity, for the metaanalysis of breast cancer risk associated with use of
oral contraceptives among BRCA1 and BRCA2
carriers was highly significant ( 97.7%;
95%
CI=99.7, 85.2 and 96.3%; 95% CI = 99.6, 64.2
respectively) and suggested the existence of
heterogeneity between the studies. The pooled odds
ratio for breast cancer risk associated with use of oral
contraceptives among BRCA1 and BRCA2 carriers
was 2.347 (95% CI=0.939, 5.865) and 3.060 (95% CI
= 0.951, 9.848) respectively, under random effect
model. Therefore, BRCA1 and BRCA2 carriers, who
use oral contraceptives, are more likely to develop
breast cancer than non carriers. Comparing the
findings for BRCA1 and BRCA2 carriers, it can be
interpreted that BRCA2 carriers are more likely to
develop breast cancer than BRCA1 carriers if they
use oral contraceptives.
AUTHOR
YEAR
Breast Cancer
Oral Contraceptive
Gronwald
2006
348/1482
56/348
Haile et al
2006
195/497
146/195
Brohet et al
2007
597/1181
436/597
Figueiredo et al
2010
67/109
59/67
1207/3269
697/1207
2.347(0.939/5.865)
Pooled (Random effect)
1923/2936
2936/6682
2.267(1.311/3.919)
Fig 2: Forest plot for pooled odds ratio for BRCA1

carriers
Fig 1: Forest plots for pooled odds ratio for BRCA

carriers
Publication bias assessment: In this meta-analysis,

publication bias assessment (PBA, table 3) is 335,
which denotes that 335 studies with null or negative
results are needed to make this meta-analytical result
meaningless. The funnel plot (figure 4) and test for
the symmetry of funnel plot (figure 5) does not
appear to have any significant relevance to this metaanalysis because both the tests are significant only in
those meta-analyses that includes a large number of
138
Ghimire et al.,
studies20,24,25, whereas, this meta-analysis includes

only five studies.
AUTHOR
YEAR
Breast
Cancer
Oral Contraceptive
Haile et al
2006
128/307
109/128
Brohet et al
2007
249/412
171/249
Figueiredo et al
2010
41/72
32/41
418//791
312/418
3.060(0.951/9.848)
Fig 5: The test for funnel plot asymmetry

DISCUSSION
Fig 3 Forest plot for pooled odds ratio for BRCA2

carriers
Table 3: PBA, NNT and the test for asymmetry

applied on the funnel plot.
PUBLICATION BIAS ASSESSMENT
(number of void or trials necessary to render
meaningless the meta analysis): 335
Number Needed to Treat (95% CI): 6 (5/7)
Number Needed to Treat (95% CI) (R.E.M.): 5
(3/21)
test of funnel plot asymmetry: =-0.01 95% CI= 12.28/12.26 p(z)= 1.00
Fig. 4 Funnel plot
In this meta-analysis, oral contraceptive use, among

BRCA mutation carriers, was associated with
increased risk of breast cancer. (OR=2.267; 95 % CI=
1.311, 3.919). The findings of this meta-analysis are
supported by many other evidences in the
literature.9,13 Oral contraceptive was classified as
group 1 carcinogens by World Health Organization
(WHO) in 2005. This means that oral contraceptives
confer high risk for development of various types of
cancers, including breast cancer. A womans
exposure to oral contraceptives contributes to the risk
of breast cancer in general population.26-28 Hence, it is
more likely that the same effect will be observed
among BRCA carrier females, who have already been
identified as at risk population for breast cancer due
to their mutation status. In addition, several other
histological, hormonal and genetic explanations also
support the findings of this meta-analysis.
It has already been established that exposure to
endogenous hormone (after Oophorectomy) confers a
substantial risk of breast cancer among BRCA
carriers.29,30 Hence, it is probable that exposure to oral
contraceptives
(exogenous
oestrogen
and
progesterone hormone) may induce similar risk. It is
also believed that the faulty germline in BRCA may
interact with oestrogen (a component of oral
contraceptives) in breast carcinogenesis and
participate in several cellular functions that are
important in carcinogenesis, including DNA damage;
repair and cycle checkpoint. 31
The next evidence to support the findings of this
study comes from the reports of in-vivo experiment
conducted on some animals. The carcinogenic effect
of hormones contained in oral contraceptives has
been well established in animals like rodents, dogs,
139
Ghimire et al.,
and monkeys.32,33 It would be unethical to experiment

the same in human subjects. However, in vivo
experiment conducted on these animals, closely
related to human, suggests a possibility of similar risk
in humans as well. Similarly, other experiments
conducted in animals have shown that the risk of
development of mammary glands (present in breast)
into cancerous tumour is directly related to the
proliferation rate of breast epithelial cells34 and it is
reported that the rate of breast epithelial proliferation
is increased by oral contraceptives or oestrogen and
progesterone.35
The increased susceptibility of BRCA1 and BRCA2
carriers to breast cancer is explained genetically on
the basis of the functions of these genes. BRCA genes
encode proteins that take part in the cellular response
to DNA damage; hence, inactivating mutations in
these genes enhance susceptibility to breast and
ovarian cancers.36 In the cells deficient in BRCA-1
and BRCA-2, double strand breaks are repaired in an
error-prone fashion which leads to chromosomal
rearrangements and instability, which is responsible
for carcinogenesis37. When cells are exposed to
radiation, BRCA-1 and BRCA-2 initiate homologous
recombination and double strand breaks repairing.
Hence, if a cell has mutated BRCA-1 and BRCA-2 it
is hypersensitive to radiation and causes error prone
repair of double strand breaks leading to faulty genes
and carcinogenesis.37 Hence, it is possible that
BRCA1 and BRCA2 carriers develop breast cancer
due to mutations in the gene, even if they are not
exposed to oral contraceptives. Therefore, it can be
said that if a woman carries a BRCA mutation or uses
oral contraceptives, each of these factors (genetic and
hormonal), individually impose risk of breast cancer
to her. Hence, a simple logic says that this risk must
be intensified among BRCA mutation carriers (who
are already at risk population for breast cancer) who
use oral contraceptives.
In the sub group analysis, the increased in breast
cancer risk associated with use of oral contraceptives
among BRCA1 and BRCA2 carriers is explained by
molecular signature and functions of BRCA1 and
BRCA2. BRCA1 is responsive to oestrogen levels
and the oestrogen-dependent and oestrogenindependent transactivational activity of oestrogen
receptor (ER) is repressed by BRCA1.38 Mutation in
BRCA1 may inhibit this regression process and
increase the epithelial proliferation of breast tissue
thus leading to breast cancer. Similarly the function

of BRCA2 is influenced by the presence of oestrogen
and leads to increased DNA repair responses in ER
positive breast cancer cells.39 These theories explains
the increased risk of breast cancer associated with
oestrogen exposure among BRCA1 and BRCA2 and
as oral contraceptives is a synthetic form of
oestrogen, the same explanation justifies the
increased risk found in this meta-analysis.
In this meta-analysis, it was observed that the risk of
breast cancer is higher among BRCA2 carriers who
use oral contraceptives, compared to BRCA1 carriers.
A distinct hormone receptor levels and a distinct
hormone receptor profile is observed between the
tumor by BRCA1 gene and tumour by BRCA2
gene.40 Similarly, BRCA1 and BRCA2 gene acts by
different pathways.41 BRCA1 associated breast
cancer are generally oestrogen-receptor/progesteronereceptor negative. While BRCA2 associated breast
cancer are progesterone-receptor positive.42 Hence
difference in breast cancer risk associated with use of
oral contraceptives among BRCA1 and BRCA2 may
be due to these differences in the hormone receptor
profile.
The heterogeneity or the variability between studies
may have occurred due to a number of characteristic
variations among the studies such as variation in
definition of breast cancer and definition of ever use
of oral contraceptives among the studies, different
level/duration of use of oral contraceptives, variation
in matching and adjustment factors as well as study
design and method of data collection. Similarly, age,
race, culture, ethnicity and geographical boundaries
of the subjects, age of female at diagnosis of breast
cancer, the womans age at the start and cessation of
use, type of breast cancer diagnosed and genetic
testing technique used for mutation detection varied
among all of the five included studies.
In this study, bias might have been introduced by the
biased studies or during the conduct of this metaanalysis. This meta-analysis may be prone to various
biases as it includes observational studies and most of
the observational studies are biased in themselves and
provide a challenge to investigators and readers to
scrabble out and judge about the result.43 As the
sample studies included in this Meta-analysis are only
the one published, so there might be sampling bias
and publication bias. The publication bias in this
study may be due to the fact that statistically
140
Ghimire et al.,
significant positive results are more likely to be

published. It is reported that 95% of the studies with
non significant results are found in the file drawers at
the laboratory and the studies published in the journal
include the remaining 5% of the studies with
significant results.44 Most of the studies presented at
scientific meetings, conferences and academic
dissertation are not always published in journals or
included in the reference list of database.20 It is
assumed that 16% of the total studies conducted are
not traced while doing a meta-analysis because either
the studies are not published for commercial
publishing interest or they are under review for
publication.20 As this meta-analysis is exclusively
based on English language reports it is subjected to
language bias45 because there are many investigators,
who work in non-English speaking countries and
publish their work in local journals in local language.
The next limitation of this meta-analysis is unable to
incorporate relevant data from two of the relevant
studies5,28 because both the studies reported data
indirectly in the form of hazard ratio28 and odds ratio5
with 95% confidence interval and a p value, which
was beyond the scope of the software used in this
meta-analysis. Another limitation of this metaanalysis is the use of crude odds ratios (ORs) instead
of adjusted ORs. Due to the lack of relevant data on
adjusted ORs, this meta-analysis has failed to adjust
for many potential confounders.
CONCLUSION
The finding of this meta-analysis is clinically relevant
as the understanding of the association between oral
contraceptives use and breast cancer risk among
BRCA carriers will guide future recommendations in
contraceptive health. To date very few published
studies have tried to intervene this association and
even the existing literature seems to be inconclusive
in estimating the net association. This clearly
demands the need of more studies and research in this
field.
CONFLICT OF INTEREST: None declared.
ACKNOWLEDGEMENT: We would like to thank
Mr. John Holmes for his constant supervision and
inspiration for conducting this study.
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DOI: 10.5958/2319-5886.2015.00023.5

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
th
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 6 Dec 2014
ASSOCIATION OF PREPROCEDURAL LEVELS OF MATRIX METALLOPROINASE-9, HIGH

SENSITIVE C-REACTIVE PROTEIN, SERUM AMYLOID A, AND NEOPTERIN WITH ANGIOGRAPHIC
IN STENT RESTENOSIS
*Muhsin Kalyoncuoglu1, Yasin Yuksel2, Alev Arat Ozkan3, Nafi Dogan4, Burak Ayca5, Sinan Varol5, Tevfik Gurmen3
1
Cardiologist, Instructor, Department of Cardiology, Safa Hospital Bagcilar, Turkey

Cardiologist, Instructor, Department of Cardiology, Istanbul Education and Research Hospital, Turkey
3
Professor , Department of Cardiology, Cardiology Institute of Istanbul University, Turkey
4
Cardiologist, Instructor, Department of Cardiology, Medikar Hospital Karabk, Turkey
5
Cardiologist, Instructor, Department of Cardiology, Bagclar Education and Research Hospital, Turkey
2
*Corresponding author eamil: mkalyoncuoglu80@gmail.com

ABSTRACT
Objective: Vascular inflammation induced by percutaneous coronary intervention (PCI) has an important role in
the pathogenesis of in-stent restenosis (ISR). Previous studies have addressed that serum amyloid A (SAA), high
sensitive C-reactive protein (hs-CRP), neopterin, and matrix metalloproteinase-9 (MMP-9) play an important role
in inflammatory process of development of ISR. Aim: We aimed to investigate the relationship of preprocedural
levels of these inflammatory markers and the development of ISR. Methods and Materials: This was a
prospective-case controlled study. 76 of 123 screened consecutive patients with stable angina who underwent
coronary angiography, were scheduled for bare metal stent (BMS) placement. Control angiography was
performed 6-12 months after the index intervention. Results: ISR was documented in the of 23 patients (30%), it
was not documented in the remaining 53 patients (70%). The basal serum neopterin level was 2.32 1.27 ng/ml
and 1.67 0.89 ng/ml, hs-CRP level was 9.16 8.73 mg/L and 5.855.59 mg/L, the serum basal SAA level was
18.28 39.84 ng/ml and 12.7723.67 ng/ml, the serum basal MMP-9 level was 75.06 35.05 ng/ml and
66.7838.32 ng/ml, in patients with and without restenosis, respectively. Neopterine and hs-CRP levels exhibited
a significant association with the ISR (p:0.01, p:0.04, respectively), SAA and MMP-9 levels did not (p:0.46,
p:0.36, respectively). Conclusions: In present study, serum baseline neopterin and hs-CRP concentrations were
predictive for the development of ISR. We also observed a significant correlation between the neopterin and hsCRP in restenosis group.
Keywords: In-stent restenosis, Matrix metalloproteinase-9, High sensitive C-reactive protein, Serum amyloid A,
Neopterin
INTRODUCTION
Percutaneous coronary intervention is the most
widely used revascularization technique to treat the
coronary heart disease.
But postinterventional
restenosis is a major long-term complication and the
main limiting factor to the long-term efficacy of the
procedure.1-2
Muhsin et al.,
Localized injury of the coronary artey wall induced

by coronary intervention is followed by a cascade of
complex molecular and cellular events.3,4 The role of
inflammation in the pathogenesis of ISR has been
displayed by previous studies.4,5 Measurement of
several markers in blood samples can provide
144
significant information about inflammatory process

triggered by PCI and its severity in developing ISR.
In previous studies that elevated baseline levels of
acute-phase proteins such as C-reactive protein
(CRP), SAA were associated with ISR.6,-8 SAA is an
acute-phase reactant and synthesized in the hepatic
and extrahepatic cells in response to infection,
inflammation, trauma, and neoplasia.9,10 It has been
reported that SAA inhibits platelet aggregation,
induces adhesion and migration of mononuclear and
polymorphonuclear leukocytes, binds to extracellular
matrix
proteins,
and
induces
matrix
metalloproteinases (MMPs).9
Neopterin is a pteridine derivative and produced by
activated monocytes/macrophages and has an
important role in athetrogenesis via impairing reverse
cholesterol transport, enhancing production of MMPs
and other proinflammatory cytokines.11-12 Matrix
metalloproteinases zinc-dependent endopeptidases
with proteolytic activity against extracellular matrix
proteins, have an important role in pathophysiology
of atherosclerosis, its complications and restenosis
via breakdown and reorganization of extracellular
matrix and so leading to inappropriate pathological
vascular remodelling.13-14
Although previous studies15,-19 indicated that SAA,
hs-CRP, MMP-9, and neopterin play an important
role in the development of ISR, little is known about
clinical significance of preprocedural levels of these
markers in patients underwent stent placement.
Because of that, we aimed to evaluate whether basal
serum levels of these inflammatory markers can
predict of the development ISR in stable patients
underwent elective BMS placement.
This was a prospective-case controlled study. From
October 2006 to December 2007, 123 consecutive
patients with stable angina, who underwent coronary
angiography and BMS placement were screened. A
detailed record of individuals current medications,
previous cardiac and noncardiac medical history and,
risk factor history was obtained. Physical
examination,
surface
electrocardiogram
and
transthoracic echocardiography performed in all
patients. And if required excercise or pharmacologic
stres test was performed. All participitants gave
written informed consents before being recruited into
Muhsin et al.,
this the study. The study approved by the local ethics

comittee.
Patients with acute coronary syndrome, those with
restenosis, those who underwent drug-eluting stent
(DES) placement, those who only underwent balloon
angioplasty, those with vascular aneurysm, those who
were directed to surgery as well as those with
apparent severe illnesses (cancer, hepatic or renal
disease with GFR < 30 mL/1.73 m/min, chronic
infections or inflammatory disease) , those who
withdrew their consent and refused to take control
angiography in the follow up period were excluded.
The present study included all patients with stable
angina, who underwent coronary angiography and
intended BMS implantation.
Blood samples to evalute lipid panels, fasting blood
glucose, blood urea nitrogen, serum creatinine, and
complete blood cell counts, hs-CRP, MMP-9, SAA
and neopterin were taken after 12 hours of fasting
from the antecubital vein directly before the
intervention. Blood samples were allowed to clot for
30 minutes before centrifugation and after
centrifugation (3500 rpm for 15 min). They were
stored as frozen at -20 C to-30 C. Prior to assay, the
frozen samples were brought to room temparature
and mixed gently. Serum hs-CRP level was measured
using the BN ProSpec nephelometric system
analyser (Dade Behring) and hs-CRP < 3.36 mg/L
were accepted as normal. Serum MMP-9 level was
measured by using competetive enzyme-linked
immunosorbent assay (ELISA) (MMP-9 ELISA A1030 kits, Bender MedSystems Campus Vienna
Biocenter 2, Vienna, Austria, Europe) with ranges of
9.6-87.3 ng/ml accepted as normal. Serum SAA level
was measured by using nephelometric metod (SAA38989 kits Siemens Healthcare Diagnostics Products
GmbH) with ranges of 0.0-5.0 ng/ml accepted as
normal. Serum neopterin level was measured by
using competetive ELISA (Neopterin ELISA EIA1476 kits, DRG nstruments GmbH) with ranges of
0.3-3.0 ng/ml for neopterin levels accepted as normal.
Glomerular filtration rate (GFR) calculated by using
modification of diet in renal disease (MDRD)
formulas.
PCIs were performed by a team of experienced
operators and size, length and type of the stent used
were left to the discretion of the operator. All subjects
enrolled in the study were prescribed with asetil
salisilic asid (ASA) indefinetely and with clopidogrel
145
for 12 months. In addition to this, dual antiplatelet

therapy beta-blockers, angiotensine convetring
enzyme inhibitors or angiotensine receptor blockers,
statins and nitrats were prescribed by attending to
physicians discretion. Control angiography was
performed 6-12 months after the index intervention.
Coronary angiograms were analyzed by two
experienced interventionalist blinded to clinical data.
Angiographically ISR was defined as the presence of
50% diameter narrowing either within the stent or
within 5 mm proximally or distally to the stent
margin.
Statistical Analysis: Continuous variables were
expressed as mean SD and percentage for
categorical variables. Nonnormally distributed
variables are given as medians. Arithmetic mean of
the demographic data were obtained and standard
deviation of the data were calculated (mean SD).
Comparison of two groups independently was
performed by independent samples t test for normally
distributed data and Mann-Whitney U test for
nonnormally distributed data. Group comparisons of
categorical variables were performed using the Chisquare or Fishers Exact test, as appropriate. Two
quantitative property relationships were analyzed by
the Spearman correlation coefficient. We performed

receiver-operating characteristic (ROC) curves to
identify spesific threshold concentrations of hs-CRP,
MMP-9, SAA, and neopterin for maximized
predictive value for the occurrence of ISR. Multiple
logistic regression analysis could not be performed to
identify factors related to in-stent restenosis because
of small volume of study. Values of p < 0.05 were
considered significant in all analyses. Statistical
analysis were performed using IBM SPSS (Statistical
Package for Social Sciences) for Windows version
19.0 (Chicago, Illinois, USA). The authors had full
access to the data and take responsibility for its
integrity. All authors have read and agreed to the
manuscript as written.
RESULTS
The median follow-up time was 7.17 months (2.01).
Study population was scheduled for routinely control
coronary angiography to determine the ISR. Figure 1
shows study flow chart. End of the follow up period,
seventy and six patients who were scheduled for
elective PCI and constituted the actual study
population.
Fig 1. Study Flow Chart

In the of 23 patients (30%), restenosis was
documented by coronary angiography, and restenosis
was not documented in the remained 53 patients
(70%). Table 1 compares the baseline clinical
characteristics of the patients who subsequently
developed restenosis and who did not. The
Muhsin et al.,
demographic characteristics were not different in

patients with and without restenosis. Table 2
compares the biochemical parameters of the patients
who subsequently developed restenosis and who did
not. The hs-CRP level was 9.16 8.73 mg/L and
5.855.59 mg/L, in patients with and without
restenosis, respectively. We observed an association
146
between hs-CRP levels and ISR (p:0.04). The SAA

level was 18.28 39.84 ng/ml and 12.7723.67 ng/ml
respectively (p:0.46). The MMP-9 levels was 75.06
35.05 ng/ml and 66.7838.32 ng/ml, respectively
(p:0.37). Neopterin level was 2.32 1.27 ng/ml on
ISR group and 1.67 0.89 ng/ml on the other group
(p:0,01). It was also found a significant association
between the neopterin concentrations and ISR (0.01).
Additionally, we performed receiver-operating
characteristic (ROC) curves to identify spesific
threshold concentrations of hs-CRP, MMP-9, SAA,
and neopterin for maximized predictive value for the
occurrence of ISR (Figure 2). While we found a
spesific threshold level for neopterin which was 2.29
ng/ml (AUC: 0.65; figure 3) and hs-CRP which was
5.79 mg/L (AUC: 0.63; figure 4), there werent any
threshold level for SAA and MMP-9. When we also
made the spearmans rank correlation coefficient
analyze, we found a significant correlation between
the neopterin and hs-CRP in restenosis group (rs:
0.574, p:0.004) but this relationship was not detected
in norestenosis group.
Table 1. Baseline Clinical Characteristics and
Association With ISR
Restenosis
No
P
(n=23)
restenosis value
(n=53)
Age
58.5 9.6
57.6 9.9
0.69
Male, n (%)
18 (78)
47 (89)
0.29
Medical history, n (%)
Current smoker
12 (52)
35 (66)
0.25
Hypertension
16 (70)
36 (68)
0.88
Diabetesmellitus
4 (17)
12 (23)
0.76
Dyslipidemia
11 (48)
36 (68)
0.98
Family history
11(48)
33 (62)
0.24
CAD or equivilant
6 (26)
22 (42)
0.20
history
Cardiovascular medications, n (%)
Asetil salisilicasit
23 (100)
52 (98)
1.00
Beta-blockers
21 (91)
48 (91)
1.00
ACE inhibitors
20 (87)
46 (87)
1.00
or ARBs
Nitrates
20 (87)
31(59)
< 0.02
Statins
14 (61)
47 (89)
0.01
Clopidogrel
22 (96)
48 (91)
0.66
Table 2. Biochemical Assays and Association

With ISR
Restenosis No
P
restenosis
( n=23)
value
( n=53)
Fasting
blood 105.423.7 105.527.3 0.98
glucose (mg/dl)
HDL(mg/dl)
47.439.6
43.57.2
0.06
LDL(mg/dl)
114.436.2 113 38.1 0.87
Triglyceride (mg/dl) 163 79.5
172.2 75.2 0.63
hs-CRP, (mg/L)
9.1 8.7
5.8 5.5
0.04
MMP-9(ng/dl)
75 35
66.7 38.3 0.37
Neopterin(ng/dl)
2.31.2
1.67 0.9
0.01
SAA(ng/dl)
18.239.8
12.7 23.6 0.46
GFR,mL/1.73m/min 88.119.7
89.2919.8 0.82
ISR indicates in-stent restenosis; HDL, High-density
lipoprotein ; LDL, low-density lipoproptein; GFR,
glomerular fitration rate, p<0.05 is significant, Mann
Whitney U Test
Table 3 summurize the interventional and
angiographic factors of the patients who subsequently
developed restenosis and who did not. The final
vessel diameter exhibited insignificant relation with
the ISR (p:0.06). while the others did not exhibit.
Table 3. Interventional and Angiographic Factors
and Association With ISR
Restenosis No Restenosis Pvalue
(n:23)
(n:53)
Stented vessel, n (%)

LAD & side branches
8 (34)
Uncountable
18 (34)
LCx &side branches
5 (20)
10 (19)
RCA & side branches

By-pass graft
9 (41)
1 (6)
22 (42)
3 (5)
Reference vessel
3.10.4
3.00 0.35 0.24
diameter mm
Final vessel diameter, 3.2 0.3 3.41 0.43 0.06
(mm)
Length of lesion
19.24.9 19.66 5.45 0.74
(mm)
LAD indicates left anterior descending artery; LCx,
circumflex artery; RCA, right coronary arter, p<0.05
is significant, uncountable because of small volume
ISR indicates in-stent restenosis; CAD, coronary

artery disease
p<0.05 is significant, *Pearson Chi-Square Test,
Fishers Exact Test
Muhsin et al.,
147
value for the occurrence of ISR (AUC: 0.63; 95% CI:

0.51-0.74; p: 0.05)
100
80
Sensitivity
DISCUSSION
60
hsCRP
MMP9ngml
Neopterin
SAA
40
20
0
0
20
40
60
80
100
100-Specificity
Fig 2. Comparison of ROC curves for hs-CRP, SAA,

MMP-9, and Neopterin
hs-CRP ROC Curve: AUC: 0.63; 95% CI: 0.51-0.74; p:

0.05
Neopterin ROC Curve: AUC: 0.65; 95% CI: 0.53-0.76;
p: 0.04
MMP-9 ROC Curve: AUC:0.61; 95% CI: 0.49-0.72; p:
0.13
SAA ROC Curve: AUC: 0.60; 95% CI: 0.48-0.71; p:
0.19
Neopterin
100
Sensitivity
80
60
Sensitivity: 52.2
Specificity: 79.2
Criterion : >2.29
40
20
0
0
20
40
60
80
100
100-Specificity
Fig 3: ROC curve of Neopterin exhibites the spesific

threshold value as 2.29 ng/ml, for maximized predictive
value for the occurrence of ISR (AUC: 0.65; 95% CI:
0.53-0.76; p: 0.04).
hsCRP
100
Sensitivity
80
60
Sensitivity: 47.8
Specificity: 79.2
Criterion : >5.89
40
20
0
0
20
40
60
80
100
100-Specificity
Fig 4: ROC curve of hs CRP exhibites the spesific

threshold value as 5.79 mg/L, for maximized predictive
Muhsin et al.,
In our study, while the serum basal neopterin and hsCRP concentrations showed significant association
with the development of ISR, SAA and MMP-9
levels did not. In previous studies, increased serum
neopterin level was predictor for adverse prognosis
for coronary artery disease,11,12 and was closely
associated with restenosis in patients with BMS15 and
with only percutaneous coronary angioplasty.16 There
are only two published studies15-16 with limited
number of patients assessing the association of basal
neopterin levels and restenosis after PCI at current
literature and their results are similar to our findings.
Recently in a study, Mizutani et al. investigated the
association of serum neopterin levels measured on
admission with ISR. ISR was occured in 123 patients
with stable coronary artery disease and 44 patients of
whom underwent BMS and the others underwent
DES implantation. They showed that neopterin was
closely associated with ISR in patients who
underwent BMS in contrast to patients underwent
DES implantation.15 We thought that, this result may
be related to the anti-inflammatory effects of drugs
released from DES. Because of this reason, we
primarily evaluated the markers in patients who
underwent BMS implantation. Whether neopterin
level is a useful marker of ISR in patients with DES,
more studies are needed. Although there are some
pathophysiological differences in developing
restenosis after balloon angioplasty and stent
implantation, inflammation has an important role in
the restenosis after both therapeutic approaches. In
another study Eber et al. found a correlation between
neopterin levels and restenosis in the patients
undergoing balloon angioplasty.16 While they did not
reported any cut-off level for neopterin for predictive
for ISR, we found spesific threshold by using ROC
analysis, that appears most predictive at neopterin
level > 2.29 ng/ml (AUC: 0.65; 95% CI: 0.53-0.76; p:
0.04).
Systemic and local vascular inflammatory status at
the time of PCI plays a pivotal role in the
development of ISR. In previous studies, it has been
showed that elevated baseline levels of acute-phase
proteins such as CRP, SAA were associated with
restenosis after coronary intervention.6,-8 In our study
148
we determined that any level of hs-CRP > 5.79 mg/L

was predictive for ISR (AUC: 0.63; 95% CI: 0.510.74; p: 0.05) and preprocedural baseline hs-CRP
level was associated with the development of ISR in
contrast to SAA. Data focused on the relationship
between inflammatory markers including CRP and/or
SAA, angiographic and clinical restenosis after PCI
have had conflicting results. 1,4,12,20,-22 Similar to our
study, Buffon et al. showed that baseline CRP level
was independent predictor of restenosis. However,
they found significant association between the
baseline SAA level and ISR.20 On the other hand,
Gomma et al. did not demonstrate any relationship
between the preprocedural CRP level and ISR in
stable angina patients undergoing elective coronary
stenting. Besides that they found similar finding that
preprocedural SAA level didnt show any association
with ISR.8 Additionally, Segev et al. and Rittersma et
al. did not find any association between preprocedural
plasma levels of CRP and ISR in patients undergoing
elective stent implantation for de novo lesions.4,23
Although it includes stable and unstable patients
undergoing balloon angioplasty, Blum et al.
demonstrated an association between the increase of
SAA by 100% 24 h after PTCA and restenosis rather
association between the preprocedural SAA level and
restenosis.18 When these findings included our study
and previous studies are evaluated together, the local
sustained inflammatory response after stent
placement may not be reflected by an increased
serum acute phase reactants such as hs-CRP and SAA
concentrations. They may be reflector for activation
of vascular inflammation as well as progression of
atherosclerosis. The extent of the inflammatory
process after PCI can be quantified by
postintervention measurement of acute-phase
reactants. There are few studies with limited number
of patients assessing the association of basal MMP-9
levels and ISR and their results are contradictory.
Similar to our findings in a small group of 56
patients, Ge et al. investigated the serial changes of
serum MMP-9 antigen levels and found similar
baseline, but increased 1st, 3rd and 7th day levels in
patients with and without restenosis after BMS.24 In
contrast to our study, Zemlianskaia et al. found an
independent correlation between pre-PCI MMP-9
antigen levels and development of ISR in a selected
patient population with BMS implantation.25 Gregory
et al. evaluated relationship between the ISR and
Muhsin et al.,
plasma levels of pro-MMP-9, latent MMP-9 and

active MMP-9 in patients who received BMS. They
reported that active MMP-9 exhibited strong
association with the ISR and appeared most
predictive at plasma concentrations >2 ng/ml.26 In
present study we evaluated only preprocedural basal
MMP-9 antigen level and changes in the serum
concentrations and serum activity of MMP-9 during
inflammatory period after procedural injury were not
measured. Because of that we thought that this
finding was insufficient to decide about relationship
between serum MMP-9 level and ISR and
postprocedural analysis of concentration and serum
activity of MMP-9 may be useful to decide about role
of MMP-9 in development of ISR as mentioned
study. In the present study, we demonstrated that
statin therapy reduced the rate of ISR as demonstrated
in the previous studies.19-27 It was thought that, this
finding appears to be dependent on their pleitropic
effects on vascular wall rather than lipid lowering
effects as known.
The clinical variables predicting restenosis were
diabetes, lesion complexity, reference vessel
diameter, final minimum vessel diameter, lesion
length, stent type, and intervention for saphaneous
venous bypass grafts and restenosis. 3,28,29 In contrast
to previous studies 28,29 diabetes mellitus,
interventional and angiographic factors were not
associated with ISR in present study. This finding
may be explained by small volume of in our cohort.
Because of that we overlooked this result.
The main limitation, we assayed only basal levels of
biomakers at only preprocedural time. Hence,
changes in the serum concentrations of markers
during inflammatory period after procedural injury,
were not measured. In another one, in this study we
evaluated the patients with stable angina pectoris
underwent only BMS for de novo lessions. Other, the
number of patients in the study was small.
Consequently, it should be questioned whether these
markers are indicator for activation of vascular
inflammation as well as progression of
atherosclerosis and/or reflector for vascular
inflammation induced by PCI. So that, larger studies
will be needed to determine the associaton between
the pre- and postprocedural levels of associated
biomarkers and in-stent restenosis in patients with
stable coronary artery disese or acute coronary
149
syndrome who undergoing BMS and/or DES

implantation.
CONCLUSIONS
In our study, we found that serum baseline neopterin
and hs-CRP concentrations were predictive for
development of ISR while SAA and MMP-9 levels
did not exhibit any association with ISR in patients
with stable angina pectoris who underwent elective
BMS implantation for de novo lesions. We also
determined a significant correlation between the
serum preprocedural levels of neopterin and hs-CRP
in restenosis group.
ACKNOWLEDGMENT
:
We
gratefully
acknowledge Dr Aysem Kaya, Biochemistry
Department, Cardiology Instute of Istanbul
University, for measuring biomarkers of levels.
Conflict of interest
No conflict of interest was declared by the authors.
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DOI: 10.5958/2319-5886.2015.00024.7

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Received: 12th Nov 2014
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
Revised: 8th Dec 2014
SEROPREVALENCE OF HEPATITIS B CO-INFECTION AMONG HIV INFECTED PATIENTS IN

GOVERNMENT MEDICAL COLLEGE, KOTA AND ASSOCIATED HOSPITALS
Vandana Meena1, Anita E Chand2, *Harshad Singh Naruka3
1
PG Student, 2Professor & Head, 3Senior Demonstrator, Department of Microbiology, Govt. Medical College
Kota, Rajasthan, India
*Corresponding author email: narukaharshadsingh@gmail.com
ABSTRACT
Introduction Human immunodeficiency virus (HIV) shares routes of transmission with Hepatitis B virus
(HBV), so HIV patients have more chance to get co-infected with HBV and this type of concurrent infection
with both viruses may alter the disease progression, natural history and treatment response. Material & Method
The study was carried out at the Integrated Counselling and Testing Centre (ICTC) of Department of
Microbiology, MBS Hospital, Government Medical College, Kota. The present study included 100 patients,
diagnosed as HIV positive. Results Among the 100 HIV positive patients we found 35 patients co-infected with
HBV. Among the 100 cases of HIV, 65 (65%) were male, 34 (34%) were female and 1 (1%) was intersexual. In
HIV +HBV co-infected cases 22 (62.8%) were male and 13 (37.1%) were female. Of the 100 HIV patients most
were married 73 (73%) followed by unmarried 16 (16%), widow 7 (7%), separate 4 (4%). Among HIV+HBV
co-infection most was married 28 (80%) as compared to separate 3 (8.5%), unmarried, 2 (5.7%) and widow 2
(5.7%). Among the HIV patients route of transmission was mainly sexual 69 (69%).
Keywords: Human immunodeficiency virus, Hepatitis B virus, Integrated Counselling and Testing Centre, Co
infection
INTRODUCTION
Human
immunodeficiency
virus (HIV)
is
a lentivirus (a member of the retrovirus family) that
causes acquired
immunodeficiency
syndrome
(AIDS), and Hepatitis B virus (HBV) is
Hepadnavirus
which
cause
hepatitis
and
hepatocellular carcinoma. As both viruses share
routes of transmission, HIV positive patients have a
high probability to get co-infected with Hepatitis B
virus (HBV). 1-4
In HIV positive patients liver disease is one of the
leading causes of morbidity and mortality. The
development of highly active antiretroviral therapy
(HAART) in 1996 has completely modified the
pattern of hepatic events in HIV infection, and the
liver is now one of the most important organs to
consider when treating HIV-infected patients as

approximately one-third of the deaths of patients
with HIV infection are in some way related to liver
disease.4,5,6
In HIV positive patients, concurrent infection with
Hepatitis B viruses may alter the natural history and
treatment response of both diseases. In particular
those patients who are receiving antiretroviral
therapy (ART) Hepatitis B Virus (HBV) have
become major risk factors which are associated with
an increase in mortality.
HIV alters the disease progression of HBV by an
increase in persistence of HBV, increase in HBV
viral load and increase in the incidence of HBV
reactivation and reinfection.3,7 Thus the natural
152
Vandana et al.,
course of acute HBV infection may be altered in the

presence of HIV infection, with a lower incidence of
icteric illness and lower rates of spontaneous
clearance of HBV. Chronic HBV infected patients
with HIV shows lower rates of clearance of the
hepatitis B e antigen (HBeAg) and higher levels of
HBV DNA. On the other hand, most of studies
shown that HBV does not play a significant role in
the progression of HIV infection to AIDS.1, 8,9,10
The present study is conducted to check
seroprevalence in population to appraise the
immensity and effect of disease transmission and for
its prevention and control.
most were married 28 (80%) as compared to separate

3 (8.5%), unmarried 2 (5.7%) and widow 2 (5.7%).
Fig. 4
Among the HIV patients route of transmission was
mainly sexual 69 (69%).
In HIV+HBV co-infected patients route of
transmission was also mainly sexual 23 (65.7%), in
present study no one found positive in intra-venous
drug users (IDUs). Fig. 5
MATERIAL & METHOD

The study was carried out at the Integrated
Counselling and Testing Centre (ICTC) of
Department of Microbiology, MBS Hospital,
Government Medical College, and Kota. From the
period from July 2012 to Feb 2014. The present
study included 100 patients (n=100) of all age group
both male and female, diagnosed as HIV positive as
per WHO Testing Strategies III 11 (SD Bio line HIV1/2 3.0, TRIDOT & HIV Comb) at ICTC, Dept. Of
Microbiology, MBS Hospital, Government Medical
College, Kota. The ethical clearance was taken from
ethical committee of Govt Medical College Kota for
study purpose.
Serum of 100 HIV positive cases diagnosed at ICTC
centre Govt. Medical College Kota by three different
testing kits mentioned above were subjected for
Hepatitis B surface antigen (HBsAg) by SD Bio line
HBsAg rapid test and confirmed by Enzyme-linked
immunosorbent
assay
(ELISA)
HBsAg
TM
Microscreen ELISA Test Kit thereafter.
Fig: 1. HBV Prevalence among HIV patients

No of patients
35 35
35
30
25
20
14
15
10
13
2
Fig 52: Age Distribution
(Year) of 2patients
among
1
0
HIV0 and HIV+HBV
Numbers of patients
HIV
HIV+ HBV
RESULTS
Among the 100 HIV positive patients we found 35
patients co-infected with HBV (35%) and among
them maximum i.e. 13 (37.1%) were in the age
group 21-30 years. Fig.1 & 2
Among the 100 cases of HIV, 65 (65%) were male,
34(34%) were female and 1(1%) was intersexual. In
HIV+HBV co-infected cases 22 (62.8%) were male
and 13 (37.1%) were female. Fig. 3
Of the 100 HIV patients most were married 73 (73%)
followed by unmarried 16 (16%), widow 7 (7%),
separate 4 (4%). Among HIV+HBV co-infection
Fig 3: Sex Ratio of HIV and HIV+HBV
153
Vandana et al.,
No of patients
Fig 4: Marital status of HIV and HIV+HBV

patients
Fig 5: Routes of Transmission in HIV and

HIV+HBV patients
DISCUSSION
High risk group people who can acquire HIV
infection are also at risk to get other infections which
shares the route of transmission. Among them
Hepatitis B virus (HBV) infection is easier to acquire
because of very low infective dose. There is a high
degree of epidemiological similarity between these
two viruses (HIV and HBV) in terms of routes of
transmission, associated risk factors and the presence
of these viruses in various body fluids. With
changing trends in treatment with introduction of
new drugs, specially in HIV infected patients who
acquire various other infections, in their treatment
and in treatment of HIV itself with high affinity antiretroviral therapy (HAART), the liver is the organ
which got affected mostly and in person co infected
with HBV the condition gets worse so HBV has
emerged as a major cause of mortality and morbidity.
The present study supports the mandatory practice
to screen all the HIV positive patients for HBV. This
study is a retrospective study that included 100 HIV
positive cases at ICTC, Department of Microbiology,
MBS Hospital, Government Medical College, Kota.

In the present study, the age of the HIV patients
ranges from 2-70 years with mean age of 34.48
years. The average of the male patients is 34.81 years
and of female patients is 34.02 years. This correlates
with other studies.1,3,4,5
In this study the maximum numbers of HIV patients
were in age group 21-40 yr reflecting that sexually
active young adults are affected more. The result of
present study correlates with the findings of other
similar studies done.4,5,7
The more cases of HIV among younger age groups
may be due to their risk behaviours like intravenous
drug use, sexual behaviour and exposure to infection
like health care workers, accidents etc.
In present study the maximum number of cases of
HIV+HBV co-infection were seen in the age group
of 21-30 yr {13/35 (37.1%)} followed by 31-40
yr{10/35(28.5%)}. The earlier studies based on the
age groups, showed maximum co-infection of HBV
in the age group 31-40yr.3,4,8 In the present study
among the 100 HIV patients 65 (65%) were male, 34
(34%) were female and 1 (1%) was intersexual.
Thus, the male: female ratio of the study group was
1.9:1. This is almost similar to the studies.1,4,9,10
Table no-1. In present study HIV+HBV co-infection
was predominantly seen in males 22/35(62.8%) than
females 13/35 (37.1%). M:F ratio was 1.7:1 which
correlates with other study done. Table no-2.
This reflects that HIV, HIV+HBV are most prevalent
in males in comparison to females because in India,
the majority of the women are in a monogamous
relationship with their husbands and usually acquire
HIV infection from their spouse and they are
generally tested, after the diagnosis of their
husbands.
Table 1: Comparison of male: female ratio of HIV
patients in other studies:Author
Male Female M:F
1
Sud A et al 2001
56
24
2.3:1
14
Shazia M Ahsan et al 2002
130 70
1.8:1
Swati Gupta et al 20063
345 106
3.2:1
5
Jain A. et al 2007
123 42
2.9:1
S. Saravanan et al 20074
346 154
2.2:1
7
SU Munshi et al 2008
7
0
7:0
13
SPD Ponamgi et al 2009
915 572
1.6:1
Ataei B et al 201011
128 2
64:1
Present study
65
34
1.9:1
154
Vandana et al.,
Table: 2. Comparison of M:F ratio of HIV+HBV

co infected patients in studies
Author
Male Female M:F
1
Sud A et al 2001
23
4
5.7:1
3
23
1
23:1
39
6
6.5:1
7
5
0
5:0
Padmapryadarsini200615
46
15
3:1
Present study 2012
22
13
1.7:1
In present study out of 100 HIV patients maximum
were married 73/100 (73%) followed by unmarried
16/100(16%),
widow
7/100(7%),
separate
4/100(4%). In other studies also maximum HIV
patients were married. 7,12,13,14 HIV+HBV coinfection was maximum in married 28/35 (80%)
whereas in separate 3/35 (8.5%), unmarried, 2/35
(5.7%) and widow 2/35 (5.7%). This reflects that
HIV, HIV+HBV are common in married persons.
In present study out of 100 HIV-positive cases 35
(35%) are co-infected with HBV. Similar results
were found in other study.1,2 But a study done by A
Pal et al at Kolkata shows very high prevalence of
co-infection i.e. 66.67% because in this study HBV
is detected by HBsAg and HBV DNA. Other studies
show very low seroprevalence of HIV+HBV coinfection Table no-3 and 4.
Table 3: Comparison of co-infection of HBV in
HIV cases in various studies in India:Author
Place
Sud A et al 20011
Chandigarh
HIV+HBV
33.8%
S S Tankhiwale et al 20032
Nagpur
30.9%
3
New Delhi
5.3%
Chenni
9%
5
Jain A. et al 2007
Delhi
10.7%
Saroj Hooja et al 20126
Jaipur
10.5%
8
Sandhya Sawant et al 2010
Mumbai
16.7%
Shazia M Ahsan et al 200214 Mumbai
3.5%
15
Padmapriyadarsini 2006
Chenni
6.4%
A. K. Tripathi et al 200718
Lukhnow
2.25%
Present Study 2014
Kota
35%
In present study the predominant mode of acquiring
HIV infection was sexual contact 69/100 (69%). This
correlates with the finding of other similar studies in
which the main route of transmission of HIV was
sexual transmission. 2,3,5,10,12,13 Second most common
mode of transmission of HIV in our study was blood
transfusion 15/100 (15%) and this is similar to other
studies.3,10
Table 4: Comparison of co infection in studies did

out of India:HIV+HBV
Author
Place
7
Bangladesh 4.24%
19
C Larsen et al 2008
France
7%
Modou Jobarteh et al 201020 Gambia
12.2%
Olanisun olufemi Adewole Nigeria
11.5%
200921
Darunee et al 201022
Bangkok
8.2%
11
Ataei B et al 2010
Iran
11.5%
Present Study 2012
Kota
35%
In HIV+HBV co-infected patients main route of
transmission was sexual 23/35 (65.7%), followed by
blood transfusion 3/35 (8.5%), MTCT 1/35 (2.8%),
unknown 8/35 (22.8%). Similarly sexual contact was
the main route of transmission in HIV+HBV coinfection in other studies done.2,5,14-16 As blood is
being screened for HIV and HBV before transfusion,
so now the main route of transmission is sexual
contact for both.17-19
Due to declining opportunistic infections as a result
of highly active antiretroviral therapy (HAART), life
expectancy of patients with HIV has increased. In the
post-HAART era, with increased survival of HIV
infected patients, HBV induced liver disease has
emerged as a leading cause of morbidity and death in
this population.
There is also evidence that HIV may modify the
natural history of HBV infection. HIV positive
subjects have higher rates of HBV chronic carriage,
higher HBV replication and lower rates of
seroconversion to anti-HBe and anti-HBs antibodies.
There is a rapid progression of liver fibrosis and an
accelerated progression towards decompensated
cirrhosis in HIV co-infected subjects.
Hence all HIV positive cases and especially
receiving HAART should be screened for HBV.
CONCLUSION
In present study the age groups 21-40ys and 21-30ys
are high risk groups among HIV infection and
HIV+HBV co-infection respectively. So still it is
necessary to make more focus on these age groups to
prevent them from acquiring infections by providing
education and general awareness about HIV and
HBV.
As HIV infected persons who receives HAART and
lead a disciplined lifestyle, live longer, but in
155
Vandana et al.,
HIV+HBV co-infected individuals HBV induced

chronic liver disease are becoming more prominent
and worsen the condition and an important cause of
the increase in mortality among HIV infected
patients. So HIV patients should be screened for
HBV, which aids in early detection of co-infections
and thus initiation of prompt treatment would help to
decrease the further progress of these chronic viral
infections to liver fibrosis, cirrhosis, liver failure and
hepatocellular carcinoma.
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DOI: 10.5958/2319-5886.2015.00025.9

&
Health Sciences
www.ijmrhs.com
Volume 3 Issue 4
th
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
THE LEVEL OF PEOPLE'S AWARENESS OF OSTEOPOROSIS IN ARDABIL CITY: A SURVEY

BASED STUDY
FirouzAmani1, *Azam Ghorbani2, Sima Ghezelbash2, Manouchehr Barak3, Esmaeil Frazaneh4
1
Assistant professor in Biostatistics, Ardabil University of medical science, Ardabil, Iran

MSc in Nursing, Ardabil University of medical science, Ardabil, Iran
3
Associate professor in Pediatrics, Ardabil University of medical science, Ardabil, Iran
4
Associate professor, Department of Forensic Medicine and Toxicology, Ardabil University of Medical
Sciences, Ardabil, Iran
2
*Corresponding author eamil: a.ghorbani@arums.ac.ir

ABSTRACT
Introduction: Osteoporosis is a skeletal disease which is characterized by a decrease in bone mass which can
lead to increasing the risk of fracture. The present study aimed at assessing the level of people's awareness of
osteoporosis in Ardabil city. Materials and Methods: This is a cross-sectional study conducted with the purpose
of investigating the level of individuals' awareness of osteoporosis in Ardabil in 2013. The number of participants
in this investigation was 250 including both sexes. And the instrument used for data collection was a researchermade questionnaire which included 30 questions. Reliability and validity of the questionnaire were estimated, and
the Cronbach's alpha coefficient was 0.78. Data were analyzed through SPSS.16.Results: 46.4% of respondents
were male and 53.6% were female. The largest number (34.8%) of participants was from 15-25 age range. The
mean awareness score was 13.322.93 out of 23, and 73% of the cases were at a moderate level of awareness. In
this study, there was a significant relationship between the level of awareness on the one hand and the level of
education (primary level, diploma, university) or economic class (weak, moderate, good, very good) on the other
(p<. 001), but there was no such relationship between level of awareness and gender (p=0. 69), or age (p=0. 24).
Conclusion: According to the results of this research, a high percentage of individuals had a moderate level of
awareness. It is essential that health authorities and healthcare providers plan some programs for prevention and
control of disease, while taking into account the level of individuals' awareness.
Key Words: Osteoporosis, Awareness, Fracture, Ardabil.
INTRODUCTION
According to the definition proposed by the National
Osteoporosis Foundation (NOF) and National
Institute of Health (NIH), osteoporosis is a skeletal
disease which is characterized by defects in bone
strength and endurance, and as a result, increased risk
of fracture. It is a chronic disease with high
prevalence worldwide, especially in the U.S. The
Firouz Amaniet al.,
prevalence of osteoporosis in Europe has been

estimated about 27.6 million persons in 2010.1
According to estimations, approximately 10 million
persons in the U.S. suffer from osteoporosis, and
about 34 million suffer from low bone mass.2 It is
expected that this number to rise to 14 million until
2020.3In a study in Iran the prevalence of spine
158
osteoporosis in Tehran city was9/4% male and 32/4%

female in 20-69 age group.4
The most serious adverse effect of osteoporosis is
fracture. In 2005, more than 2 million cases in the
U.S. had fractures due to this disease.3Such fractures
reduce individuals' quality of life and are considered
huge economic burdens.5 Knowledge and control of
risk factors of osteoporosis are crucial to its
prevention. Some osteoporotic risk factors are
genetics (white race), female sex, menopause,
skeleton size, cigarette-smoking, alcohol and caffeine
intake, malnutrition, vitamin D and calcium
deficiency, low estrogen, early menopause (before 45
years of age), and a sedentary lifestyle.6-7 One
important key to the success of prevention programs
is raising awareness and knowledge of individuals
about this disease, especially awareness of diet, sport,
and issues relevant to inappropriate lifestyle which
hasten the progress of disease.3 But, unfortunately
people are seldom aware of osteoporosis, and even if
they are aware, rarely does such awareness induce a
higher
probability
of
taking
preventive
7
measures. Most studies conducted in this area have
pointed to low and unsatisfactory levels of awareness.
For instance, Jalili et al. found that mean score of
knowledge, attitude, and function was low for female
participants.8Gammage et al. also reported a low level
of awareness, perceived sensitivity, and intensity for
their targeted group.9Such low level of awareness is
also reported in studies of Mirza-aqa'ei et al 4,
Hazavahi and Saeedi10, Xu et al., and Gemalmaz and
Oge11.
Since osteoporosis is a disease which depends on age,
and the mean age of Iran's population is growing day
by day, the level of individuals' awareness of this
disease takes on utmost importance in our country.
Therefore, before making any interventions for
controlling and preventing a disease or a special
problem, it is necessary to obtain enough information
about the level of individuals' awareness of the
problem, so that strengths and weaknesses of the
community as well as areas requiring intervention can
be identified. The purpose of this investigation was to
examine the level of individuals' awareness in
Ardabil city.
This study is a cross-sectional one aimed at

estimating the level of people's awareness of
Firouz Amaniet al.,
osteoporosis disease in Ardabil in 2013. For the

purposes of the study, 250 individuals were
selected through completely random methods,
from 3 hospital, universities and bus stop of 5
town of Ardabil, from June to November 2013.
A consent form signed by the participants and
Then, they were interviewed by the researchers.
Exclusion criteria were disability to answer to
questions (e.g. deaf, dumb). Data were collected
through administrating the researcher-made
questionnaire to participants. The questionnaire
was developed through reference to various
reliable sources and articles. To ensure validity,
the first version of the questionnaire was handed
to 10 university professors in medical faculty on
the basis of whose evaluations the necessary
modifications were made. At the next stage, to
estimate the reliability of the questionnaire, the
questionnaire was piloted among 20 persons and
a Cronbach's alpha of .78was gained. Finally,
this researcher-made questionnaire consisted of
30 questions, which 5 questions concerned
demographic information, 23 questions were
related to the level of awareness, and 2 questions
pertained to the participants' perceptions. After
collecting the questionnaires, in scoring,
researcher was assigned the 1 for any correct
answer, and 0 for any false answer. It should be
noted to facilitate interpretation of the results, total
score of awareness (0-23) were classified into three
levels by researchers, includes weak awareness (score
0-7), moderate (score 8-15), and good awareness
(scores more than of 15). 2 questions of
participants' perceptions (22, 29) wasnt

calculated in total score.
To analyze and
interpret the data, SPSS 16 analytical tests
involving both descriptive and inferential
statistics were used.
RESULTS
46.4% of the cases were male and 53.6% were
female. Most subjects (34.8%) were of15-25 age
range. With regard to level of education, most
participants (45.2%) had college or university
degrees. Concerning job distribution, the highest
percentage belonged to students (36.8%), and 44.8%
of subjects, with the highest frequency, were from an
average economic status (weak, moderate, good, very
good) (it was reported by participants). Mean
awareness score was 13.32 2.93 out of 23, and
159
73.6% were at an average level of awareness (Table

emphasized the key role of education administration
1). In questions of questionnaire, concerning the use
in this regard. Overall, 46.2%highlighted media;
of information sources on osteoporosis and
19.6%, the education administration; 14.4%, the
participants perceptions of it, 40% checked the
press; and 16.8%, internet and cyberspace as the key
option "read books", 31.2% chose "consult doctors",
factor in raising individuals' awareness- on
and 25.2% opted for browse websites". 52.8%
osteoporosis.
Table 1: Proportions (%) of Correct Responses for awareness questions
Questions
% of correct
responses
Consider the issue of preventing osteoporosis - important and necessary
83/2%
Aware of osteoporosis prevention methods employed for children
51/2%
Study any books or article about osteoporosis
40%
Media programs are appropriate ways to inform people about osteoporosis
44/4%
Consult with doctors about osteoporosis
31/2
Browse websites about osteoporosis
25.2%
Which exercises prevent the osteoporosis (yoga, go running, rotational movement, all the 32%
above)
Using higher calcium nutriments as influential in osteoporosis prevention during growth 88%
ages
Used to go running in order to reduce the risk of osteoporosis at higher ages
43.2%
Obesity and excess weight poses a higher risk of osteoporosis
78%
Vitamin D is useful in osteoporosis prevention
87/6
Which nutriments help increase body calcium level(meat; fibrous foods; caffeine, all the 33/6
above)
Using soy milk is beneficial for prevention of osteoporosis
13.6%
A higher dairy diet is effectual in osteoporosis prevention
70/8
Which age groups are at the highest risk of osteoporosis,(children, worker, elderly females 60%
adolescent)
Aware of the importance and purpose of Bone Mineral Density (BMD) test in measuring 55.6%
bone density and preventing osteoporosis
Easy fracture is a side-effect of osteoporosis
70%
Aware of the negative effect of smoking on osteoporosis
66.8%
Family history of osteoporosis is a risk factor for osteoporosis
65/2%
Replacing hormones after menopause can slow down bone loss
38%
Osteoporosis is complication of some diseases
32%
Bisphosphonate(Alendronate) a class of drugs is used to treat or prevent of osteoporosis
24%
Using Some drugs(i.e. body building drugs ) increase risk of osteoporosis in future
35/3%
Table 2: The rate of awareness in people
Rate
N
0-7
2
8-15
184
16-23
64
Total
250
MeanSD: 13.322.93Max:23Min: 0
%
0.8
73.6
25.6
100
Table 3.The rate of awareness by education

level
in peoplePrimary
Education
Diploma University
level
level
rate
0-7
n
0
%
0
n
1
%
50
n
1
%
50
8-15
16-23
53
7
29
9.4
60
16
32.8
25
70
42
38.3
65.6
ANOVA test : F = 9.19df = 4p= 0.001
Firouz Amaniet al.,
160
Table 4.The rate of awareness by economic level in people

Economic
Weak
Moderate
Good
level
Very good
Total
rate
0-7
8-15
16-23
0
28
4
0
15.2
6.2
2
91
19
100
49.5
29.7
0
51
21
0
27.7
32.8
0
14
20
0
7.6
31.2
2
184
64
100
100
100
ANOVA test
F = 7.859, df = 6, p= 0.001
The question as to which nutriments help increase

body calcium level. 39.2% chose meat; 33.6%,
fibrous foods; 4.4%, caffeine; and 22.4%, all the
above. Concerning age groups at the highest risk of
osteoporosis, the option of elderly females was
checked by 60% of the subjects, and children by only
9.6% (the lowest). In this study (Table 2), there was a
significant statistical relationship between level of
awareness and level of education and economic status
(p<001) (Tables 3&4). However, there was no
significant relationship between level of awareness
and gender (p= 0.69) on the one hand, and age
(p=0.24) on the other.
DISCUSSION
In the present study, the general level of individuals'
awareness of osteoporosis disease and factors
affecting it was 13.32 2.93, and 73.6% of
participants had a moderate level of awareness.
Forouzi et al., in a similar study, over the population
of female teachers, reported the level of awareness
62%.12InYeap's study, in Malaysia, 87.1% of
individuals
had
heard
the
word
osteoporosis.13However, Mirzaaghaeeet al. estimated
this number to be about 40.8% in female high school
students.4In the present study, 83.2% of cases
acknowledged the importance of osteoporosis
prevention. This finding was similar to that of
Hazavahi and Saeedis which indicated that 82.7% of
secondary school students referred to educating
public on osteoporosis as an important measure.10
This is in contrary to Edmond et al.'s findings which
showed that only 45% of subjects considered the
issue of suffering from osteoporosis seriously.7In the
present study, the relationship between overall
awareness score and level of education was of
statistical significance (p<.001). Likewise, Forouzi et
al. found significant relationship between level of
Firouz Amaniet al.,
education and knowledge and attitude of

participants.12It seems that well-educated individuals
have more access to information and show more
willingness to obtain information regarding health
issues. In the present research, of statistical
significance was also the relationship between
economic class and level of awareness (p<.001). This
is in opposition to the findings of Ghaffariet al.14 and
Mirzaaghaee et al. which showed no such significant
relationship.4 The existence of this significant
relationship in the present study may be attributed to
the presence of a high percentage of the individuals
with above-average economic status in this study.
Regarding the diet relevant to osteoporosis
prevention, in this study, 70.8% believed that a higher
dairy diet is effective. This finding was in line with
those of Forouzi (98.4%) 12 and Dehghan Manshadi
(86.4%).15 Furthermore, 88.4% stated that high
calcium foods contribute to osteoporosis prevention.
This finding was in line with that of Mirzaaghaee
(77.4%).4 Hazavahi and Saeedi found that 77.5% of
students were aware of the role of nutrition and
exercise in osteoporosis prevention.10Since most
people are aware of the influential role played by
dairy in osteoporosis prevention, presenting enough
information about the exact and correct amount of
daily intakecan play a pivotal role in the prevention
of this silent disease. In this study, only 33.6%
assumed that fibrous foods are effective in boosting
body calcium level. This is against the findings of
Forouzi's study which showed that 97.3% considered
regular intake of vegetables and fruit helpful in the
prevention of osteoporosis.12 Regular intake of fruits
and vegetables can improve bone mass and prevent
osteoporosis in all age ranges.16In the present
research, 87.6% of the cases were of the opinion that
vitamin D is useful in osteoporosis prevention. This is
not in concordance with that of Hazavahi and
Saeedis who reported that only 38% of subjects
161
pointed to the benefit of vitamin D in better

absorption of calcium and negative effects of sour
foods. 10
In this study, only 43.2% of individuals used to go
running in order to decrease the risk of osteoporosis,
and only 32% assumed that running is helpful in
osteoporosis prevention. This finding conforms to
that of Larkey et al. who showed that there was a low
level of awareness of the variety of exercises
effective in osteoporosis prevention 17, but against
that of Edmond et al. who found that 76.8%
considered running and jumping as useful in the
prevention of this disease.7
CONCLUSION
According to high prevalence of osteoporosis, it is
essential, via school systems, media, especially visual
media, and treatment centers and clinics, to provide
people with accurate and complete information on
what osteoporosis is, what its risk factors and adverse
effects are, and what prevention and control methods
of this silent disease are?. In addition, studies
targeting the level of community's awareness create
an opportunity to provide guidelines for educating
health issues. Such guidelines can be used by
organizations in charge of health and treatment. It is
suggested that future studies address open questions
with larger samples in order to be able to present
more accurate information regarding the level of
individuals' awareness.
Acknowledgment: This result of this study was from
a student project had been done in Ardabil society
and we are thanking all peoples tended to response
our questionnaire.
Conflict of Interest: No conflict of interest.
REFERENCES
1. Hernlund E, Svedbom A, Ivergrd M, Compston
J, Cooper C, Stenmark J ,et al. Osteoporosis in
the European Union: medical management,
epidemiology and economic burden. Arch
Osteoporos. 2013;8:136.
2. Curtis JR, Safford MM. Management of
Osteoporosis among the Elderly with Other
Chronic
Medical
Conditions.
Drugs
Aging.2012;29(7):549-64.
Firouz Amaniet al.,
3. Allison Ford M, Bass M, Zhao Y, Bai J-B, Zhao

Y. Osteoporosis Knowledge, Self-Efficacy, and
Beliefs among College Students in the USA and
China. SAGE-Hindawi Access to Research
Journal of Osteoporosis. 2011:1-8.
4. Mirzaaghaee F, Moinfar Z, Eftekhari S,
KarimiKhezri M, Mazidi M, Aliramezani M, et
al. Theamount of knowledge in Iranian female
adolescents student about osteoporosis and its
risk factors. Hayat. [Research]. 2006;12(3):43-50.
persian.
5. McLeod KM, Shanthi Johnson C. A Systematic
Review of Osteoporosis Health Beliefs in Adult
Men and Women. SAGE-Hindawi Access to
Research Journal of Osteoporosis. 2011:1-11.
6. Tavassoli E, Javadzade H, Reisi M, Mazaheri M,
Gharlipour Z ,ZamanianAzodi M, et al.
Knowledge and Perceptions of Prevention of
Osteoporosis Among Shahr-e-kord Female
Teachers. Scientific Journal of Ilam University of
Medical Science. 2013;21:136-42.
7. Edmonds E, Turner LW, Usdan SL. Osteoporosis
knowledge, beliefs, and calcium intake of college
students: Utilization of the health belief model.
Open Journal of Preventive Medicine.
2012;2(1):27-34.
8. Jalili Z, Nakhee N, Askari R, Sharifi V.
Knowledge, attitude and preventive practice of
women concerning osteoporosis. Iran J Public
Health. 2007;36:19-25.
9. Gammage KL, Francoeur C, Mack DE, Klentrou
P. osteoporosis health belief and knowledge in
college students: The role of dietary restraint.
Eat Behav. 2009;10:65-7.
10. Hazavahi SMM, Saeedi M. A Study of the
Knowledge, Atitude and Practice (KAP) of the
Girls students on Osteoperosis in Garmsar.
Toloo-e-behdasht. 2004;5(1):31-9. persian.
11. Gemalmaz A, Oge A. Knowledge and awareness
about osteoporosis and its related factors among
rural
Turkish
women.
ClinRheumatol.
2008;27(6):723-8.
12. Forouzi MAZ, Haghdoost AA, Saidzadeh Z,
Mohamadalizadeh S .Study of knowledge and
attitude of Rafsanjanian female teachers toward
prevention of osteoporosis. Journal of Birjand
University of Medical Sciences. [Experimental].
2009;16(1):71-7. persian.
162
13. Yeap SS, Goh EM, Das Gupta E. Knowledge

about osteoporosis in a Malaysian population.
Asia Pac J Public Health. 2010;22(2):233-41.
14. Ghaffari M, Niazi S, Ramezankhani A, Soori H.
Knowledge of Female Students of Kalaleh city
about Osteoporosis, calcium intake and physical
activity: An Unacceptable Status. Iranian Journal
of Nutrition Sciences & Food Technology.
2013;7(5):319-26.
15. Dehghan Manshadi F, Naeme S, Makan M. Study
of knowledge, attitude, and practice of
osteoporosis. J Allied Health SciShahidBeheshti
Med Univ. 2003;1(1):23-30. persian.
16. Sutcliffe A. Osteoporosis: A Guide for
Healthcare Professionals. 8 ed. London: Whurr
Publisher; 2006.
17. Larkey LK, Day Sh, Houtkooper L, Renger R.
Osteoporosis Prevention : Knowledge and
behaviour in south western community. J
community Health. 2003;28(5):377 - 88.
Firouz Amaniet al.,
163
DOI: 10.5958/2319-5886.2015.00026.0

&
Health Sciences
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Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 7 Nov 2014
ACUTE EFFECT OF FLUCONAZOLE, ITRACONAZOLE AND VORICONAZOLE ON BLOOD

GLUCOSE IN NORMOGLYCEAMIC & DIABETIC RATS: AN EXPERIMENTAL STUDY
*Jadhav Amol, Nayak BB, Vakade Kiran P, Sanghishetti Vijay Prasad, Vijay Kumar AN, Vrushali Nibrad, Raul AR
Department of Pharmacology, Padmashree Dr. Vithalrao Vikhe Patil Foundations Medical College,
Ahmednagar, Maharashtra
*Corresponding author email: dramoljadhav1@gmail.com
ABSTRACT
Anti-fungal and antimicrobials are frequently co-prescribed either to manage or treat either the secondary
complications or other diseases. Among antifungal drugs Fluconazole, Itraconazole & Voriconazole are most
commonly used. The present study was undertaken to further confirm the effect of Voriconazole as well as other
antifungal drugs on blood Glucose level. Aim & Objectives: 1. To Study the effect of Fluconazole, Itraconazole
& Voriaconazole in Normoglycemic & Diabetic Rats on Blood Glucose. 2. To compare the effects between all
drugs. Material & Methodology: Grouping: Animals divided into 8 groups in each group 6 animals. Group 1- 4:
Normoglycemic rats, Group 5-8 Diabetic rats (alloxan induced) Group 1,5: received vehicle (Normal saline)
Group 2,6: received Fluconazole (18mg/kg BW), Group 3,7 received Itraconazole (18mg/kg BW) Group 4,8
received Voriconazole (18mg/kg BW). The glucose levels were estimated by Glucometer method (Accu-check
active) at the interval of 0, hr, 1hrs, 2hrs & 4hrs after drug administration. Results: Effect on blood glucose in
Normoglycemic Rats: Voriconazole had a significant hypoglycaemic effect which appeared after 1 hr (p value=
0.0102) of administration & persisted up to 2 hrs (p value=0.0001). However effect of Voriconzole was found to
be declined after 2 hrs. There was no significant change in blood glucose in normoglycemic rats with Fluconazole
& Itraconazole. Effect on blood glucose in Diabetic Rats: (Table 2): Voriconazole had a significant
hypoglycaemic effect which appeared after 1 hr (p value=0.013) of administration & persisted up to 2 hrs (p
value=0.001) in acute studies. However effect of Voriconzole was found to be declined after 2 hrs. There was no
significant change in blood glucose in diabetic rats with Fluconazole & Itraconazole treated. Conclusion:
Itraconazole, Fluconazole can be safely used in diabetic with fungal infections. Voriconazole should be avoided in
diabetics to minimise the further hypoglycaemia.
Keywords: Fluconazole, Itraconazole, Voriaconazole, Normoglycemic, Alloxan induced Diabetic rats
INTRODUCTION
Diabetes mellitus (DM) is a clinical syndrome
associated with deficiency of insulin secretion or
action. It is considered one of the largest emerging
threats to health in the 21st century. It is estimated that
there will be 380 million persons with DM in 20251.
DM has been associated with reduced response of T
cells, neutrophil function, and disorders of humoral
Jadhav et al.,
immunity. Consequently, DM increases the

susceptibility to infections. Diabetics are immunocompromised; they are easily susceptible to a number
of opportunistic fungal infections, which potentially
increases their morbidity & mortality. The greater
frequency of infections in diabetic patients is caused
by the hyperglycemic environment that favours
164
immune dysfunction, micro- and macro-angiopathies,

neuropathy, and decrease in the antibacterial activity
of urine, gastrointestinal and urinary dysmotility, and
greater number of medical interventions in these
patients. The infections affect all organs and systems.
In addition to the increased morbidity, infectious
processes may be the first manifestation of diabetes
mellitus or the precipitating factors for complications
inherent to the disease, such as diabetic ketoacidosis
and hypoglycaemia2,3.
Anti-fungal and antimicrobials are frequently coprescribed either to manage or treat either the
secondary complications or other diseases. Among
antifungal drugs Fluconazole , Itraconazole &
Voriconazole are most commonly used. Voriconazole
is the newest agent in the armamentarium against
fungal infections. It is a triazole antifungal with a
structure related to that of Fluconazole and a
spectrum of activity comparable to that of
Itraconazole. Voriconazole is indicated for the
treatment of invasive aspergillosis and for the
treatment
of
fungal
infections
caused
by S.apiospermum and Fusarium spp that are
refractory to other antifungal agents.3
There are some case reports suggesting Voriconazole
have some effect on blood glucose in diabetic
patients. Since Literature on this information is very
scanty, the present study was undertaken to further
confirm the effect of Voriconazole as well as other
antifungal drugs on blood Glucose level in
normoglycemic as well as diabetic rats4,5.
Aim & Objectives: To Study the effect of

Fluconazole, Itraconazole & Voriaconazole in
Normoglycemic & Diabetic Rats on Blood
Glucose. 2. To compare the effects between all
drugs.
MATERIAL & METHODS
Six to eight weeks old male Wistar rats weighing
250280grams were housed in polypropylene cages
with stainless steel top grill containing autoclaved
rice husk at an ambient temperature of 22 3 C and
relative humidity of 55 10%. They were exposed to
12:12 light-dark cycle and had free access to food and
water ad libitum. Animals were fed standard
laboratory diet.
The methods and procedures described in the present
study have been reviewed and approved by the
Jadhav et al.,
Institutional Animal Ethics Committee (IAEC) and

experiments were performed in accordance with the
guidelines by CPCSEA.
Grouping: Animals divided into 8 groups in each
group 6 animals.
Group 1-4: Normoglycemic rats
Group 1: Normoglycemic rats received vehicle
(Normal saline)
Group 2: Normoglycemic rats received Fluconazole
(18mg/kg BW)
Group 3: Normoglycemic rats received Itraconazole
(18mg/kg BW)
Group 4: Normoglycemic rats received Voriconazole
(18mg/kg BW)
Group 5-8 Diabetic rats
Induction of Diabetes: Diabetes was induced by using
freshly prepared solution of Alloxan monohydrate
dissolved in normal saline. (Procedured from Sd fine
Chem Limited, Mumbai ) Animals were fasted for 18
hrs before administration of Alloxan (100mg/kg I.P.
Single dose). Hyperglycemia was confirmed by
elevated glucose level determined at 48 hrs after I.P.
injection of alloxan. Rats with blood-glucose levels
above 250 mg/dl were considered as diabetic and
selected for the study.
Group 5: Diabetic rats received normal saline
Group 6:
Diabetic rats received Fluconazole
(18mg/kg BW)
Group 7:
Diabetic rats received Itraconazole
(18mg/kg BW)
Group 8:
Diabetic rats received Voriconazole
(18mg/kg BW)
(All the above drugs are dissolved in normal saline
and administered via Oral route with the help of
feeding needle)
Glucose estimation: The glucose level was estimated
by Glucometer method (ACCU-CHECK ACTIVE
MODEL: GC) at the interval of 0, hrs, 1hrs, 2hrs &
4hrs after drug administration. Blood glucose levels
were expressed as mg/dl of blood. After the
experiment blood sugar level of alloxan induced
diabetic rats had been normalised with I.P. injection
of insulin, if found elevated.
Statistical Analysis: Data obtained were subjected
to computerized Graph pad version 3.06. Paired t
test is used for group comparison. P < 0.05 was
accepted as statistically significant.
165
RESULTS
Table 1: Showing effect various drugs on blood glucose level in Normoglycemic rats $
Drugs
0hour
hour
1hour
2 hours
Control
88.5 4.7
87.6 3.8
87.7 4.02
86.84.61
Fluconazole (18mg/kg bw wt)
87 2.9
94.3 2.44 98.3 2.5
96.2 3.49
Itraconazole(18mg/kg bw wt)
92.24.52
95.2 4.8
101.7 6.17 102 4.3
Voriconazole (18mg/kg bw wt)
87.83.17
83.2 3.38 76.7 1.9** 61.82.37***
4 hours
88.8 3.6
101 2.2
98.5 4
74 2.35
Where, P value of Paired t test is expressed as p<0.05 *, p<0.01 ** & p<0.001 *** (values expressed mg/dl, MeanSEM)
Table 2: Showing effect various drugs on blood glucose level in Diabetic rats$
Drugs
0 hour
hour
1 hour
2 hours
Control
47025.05
Fluconazole (18mg/kg bw wt) 519.3 18.6
Itraconazole(18mg/kg bw wt)
484.3 29.5
Voriconazole(18mg/kg bw wt) 468.510.33
466.824.5
518.2 19.4
482.7 28.8
440.811.2
467.324.0
522.3 19.9
486 27.9
374.729.4**
468.225.5
522.2 20.6
485.8 28.9
33427.9***
4 hours
47026.84
518.5 17.8
489.3 29.4
401 19.9
Where, P value of Paired t test is expressed as p<0.05*, p<0.01** & p<0.001*** (values expressed mg/dl, MeanSEM)
$
All are compared with their respective zero hour readings
Effect on blood glucose in Normoglycemic Rats

(Table 1): Voriconazole had a significant
hypoglycaemic effect which appeared after 1 hrs (p
value= 0.0102**) of administration & persisted up to 2
hrs (p value=0. 0001***) in acute studies. However
effect of Voriconzole was found to be declined after 2
hrs & there were no significant hypoglycaemic effect
at 4 hrs. There was no significant change in blood
glucose in normoglycemic rats with Fluconazole &
Itraconazole treated.
Effect on blood glucose in Diabetic Rats: (Table
2): Voriconazole had a significant hypoglycaemic
effect which appeared after 1 hrs (p value=0. 013***)
of administration & persisted up to 2 hrs (p value=0.
001***) in acute studies. However effect of
Voriconzole was found to be declined after 2 hrs &
there were no significant hypoglycaemic effect at 4
hrs. There was no significant change in blood glucose
level in diabetic rats with Fluconazole & Itraconazole
treated.
DISCUSSION
Hypoglycemia is a potentially fatal, condition.
Common causes of hypoglycaemia in non-diabetics
include drugs, chronic renal failure, alcohol
intoxication, liver failure, sepsis, cancer and
endocrine disorders. Drug-induced hypoglycemia can
be severe and may cause significant morbidity.
Voriconazole is a triazole antifungal agent. The
Jadhav et al.,
primary mode of action of Voriconazole is the

inhibition of fungal ergosterol biosynthesis.
Voriconazole has an oral bioavailability of 96%. In
addition, there are reports indicating that
Voriconazole a relatively newer antifungal agent to
inhibit human cytochrome P450 enzyme system. The
most important CYP isoenzyme that are inhibited or
affected by antifungals like ketoconazole, and
Voriconazole are CYP1A2, CYP3A4, CYP2C8,
CYP2C9, CYP2C19, CYP2D6. There is a possibility
that drug-drug interaction may occur between the
antifungals and the drugs metabolized by these
enzymes6,7.
A previous study has shown that the major
metabolite, Voriconazole N-oxide, inhibits the
metabolic activity of these enzymes and increases
Voriconazole level.
Toxicity reported with Voriconazole includes
changes in vision, hepatotoxicity, cognitive
dysfunction and rash.8
This study is planned to study the effect of
Voriconazole along with other commonly used
antifungal drugs like Itraconazole & Fluconazole
which belongs to the same triazole group in
normoglycemic and alloxan-induced diabetic rats.
The normoglycemic rat model served to quickly
identify the effect and the diabetic rat model served to
validate the same response in patho-physiological
condition where this all antifungal drugs are most
commonly used.
166
Sometimes, Polypharmacy is needed in some patients

to treat disease conditions. When multiple drugs are
used there are increased chances of drug-drug
interactions. These types of drug-drug interactions
occur more frequently in whom multiple drugs are
used chronically. In all such conditions, it is a needed
to make an attempt to readjust the dose &/or
frequency of administration of any one or both the
drugs.
Therefore, there is every possibility that drug-drug
interaction may develop and may pose problems of
either overdoses or ineffectiveness. So it is very much
essential to evaluate the drug-drug interaction in
those conditions. According to reports, the incidence
of interaction ranges up to 20% in patients receiving
more than 10 drugs. It is one of the leading cause of
death. 9
Earlier experiments have revealed that Voriconazole
pre-treatment has enhanced the hypoglycemic effect
of rosiglitazone and glipizide in both carnivorous and
herbivorous species.10-12 However, in the present
experiment the influence of Voriconazole pretreatment on the same drugs under pathophysiological
condition i.e. Experimentally induced diabetes in
albino rats was studied.13-15
We would like to place on record that the present
study is carried out in Normoglycemic rats and
diabetic rats. Therefore, we suggest that similar study
should be conducted in healthy volunteers and
diabetic patients to confirm the obtained results. It is
further required to establish the influence of
Voriconazole pretreatment on the pharmacokinetic
parameters of oral antidiabetic agents in human
volunteers.
CONCLUSION
Itraconazole, Fluconazole can be safely used in
diabetic associated with fungal infections.
Voriconazole should be avoided in diabetics to
minimise the further hypoglycaemia.
Limitation the study:
1. Small Sample size, animal study only
2. Seen only acute effect (up to 4 hrs),
3. For the confirmation of above results requires
further clinical trials
4. Interaction study to be done with known standard
anti diabetic drugs
Jadhav et al.,
ACKNOWLEDGMENT: Our sincere thanks to

management for providing the necessary facilities.
Source of founding: Nil
Conflict of interest: None declared by the authors
REFERENCES
1.
Bjrnar Allgot, Delice Gan, Hilary King, Pierre

Lefbvre, Jean-Claude Mbanya, et al., Diabetes
Atlas
committee.
http://www.idf.org/sites/default/files/IDFDiabete
s_ Atlas_ 2ndEd. pdf
2. Geerlings SE, Hoepelman AI. Immune
dysfunction in patients with diabetes mellitus
(DM) FEMS
Immunol
Med
Microbiol. 1999;26:25665.
3. Muller LM, Gorter KJ, Hak E, Goudzwaard WL,
Schellevis FG, Hoepelman AI, et al. Increased
risk of common infections in patients with type 1
and type 2 diabetes mellitus. Clin Infect
Dis.2005; 41:2818.
4. Boyd AE, Modi S, Howard SJ, Moore CB,
Keevil BJ, Denning DW. Adverse reactions to
Voriconazole. Clin Infect Dis. 2004;39:12414.
5. Herbrecht R, Denning DW, Patterson TF,
Bennett JE, Greene RE, Oestmann JW, et al.
Randomized comparison of Voriconazole and
amphotericin B in primary therapy of invasive
aspergillosis. N Engl J Med. 2002;347:40815.
6. Nickie D. Greer. Voriconazole: The newest
triazole antifungal agent. Proc (Bayl Univ Med
Cent). 2003; 16(2): 241248.
7. Nelson, Koymans L, Kamataki, Stegeman J J,
Feyereisen R, Waxman DJ et al. P450 Super
Family: Update on New Sequence, Gene
Mapping,
Accession
Numbers
and
Nomenclature. Parmacogenetics 1996; 6:1 42.
8. Murad MH, Coto-Yglesias F, Wang AT,
Sheidaee N, Mullan RJ, Elamin MB, et al. Druginduced hypoglycemia: A systematic review. J
Clin Endocrinol Metab. 2009;94:741-5
9. Drug reactions a leading cause of death
Available
at:
http://www.rxmanagement.net/index.php/reasonone.html
10. Study the pharmacokinetic dug interaction of
voriconazole with oral anti-diabetic agents, H
Sarah Priya & etal, International Journal of
Pharmaceutical Sciences, May-August, 2011;3
(2): 1271-78
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11. Mendoza A, Kim YN, Chernoff A.

Hypoglycemia in hospitalized adult patients
without diabetes. Endocr Pract 2005;11:91-6.
12. Goodman and Gilmans, The Pharmacological
Basis of Therapeutics, 11th edition, McGraw
Hill, New York; 2006
13. Agarwal R, Singh N, Amphotericin B is Still the
Drug of Choice for Invasive Aspergillossis.
Voriconazole Versus Amphotericin B for
Primary Therapy of Invasive Aspergillosis. Am J
Respir Crit Care Med. 2006; 174 (1): 102.
14. Patterson T, Boucher H, Herbrecht R, Denning
D, Lorthalory O, Ribaud P, etal. Strategy of
following Voriconazole Versus Amphotericin B
Therapy with other licensed Antifungal therapy
for Primary Treatment of Invasive Aspergillosis:
Impact of Other Therapies on Outcome. Clin
Infect Dis. 2005; 41 (10): 1448-52.
15. Kullberg B, Sobel J, Ruhnke M, Pappas P,
Viscoli C, Rex J, et al., Voriconazole versus a
Regimen of Amphotericin B followed by
Fluconazole for Candidaemia in Nonneutropenic Patients: a Randomized Noninferiority trial. Lancet, 2005; 366 (9495): 143542.
Jadhav et al.,
168
DOI: 10.5958/2319-5886.2015.00027.2

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Volume 4 Issue 1
rd
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Revised: 8 Dec 2014
VALUE OF STUDYING THE TIME OF OCCURRENCE OF SUICIDE ATTEMPT IN PEOPLE

ATTENDING HOSPITAL FOLLOWING SUICIDE ATTEMPT
*Srinivasagopalan1, Nappinnai2, Solayappan3
1
Assoicate Professor, 2 Clinical Psychologist, 3Formerly Professor of Psychiatry, Department of Psychiatry,

Meenakshi Medical College & R.I., Enathur, Kanchipuram, Tamilnadu, India
* Corresponding Author email: drsrinivasagopalan1950@gmail.com
ABSTRACT
Background It is unclear whether any particular time of the day is Vulnerable for suicide attempts. Suicide
attempt is a known risk factor for future completed suicide. Aim To investigate the relationship between the time
of suicide attempt and the sociodemograpic and illness characteristics of suicide attempters. Method Time of
attempt, clinical and demographic data and illness variables of 74 patients presenting to hospital following suicide
attempt were analyzed. Results Our results showed 8.a.m. to 11.59 a.m. is the most preferred time of attempt and
it is statistically significant. Suicide attempt is significantly more in the day time (between 8 a.m. to 11.59 a.m.).
The above time period is significantly associated with place of attempt of the suicide attempters. This is the time
period where more young males (20 29 years) from rural back ground, married, illiterates and unemployed
(significant no. of house wives also) attempt suicide during this time. Depression is the common psychiatric
illness and pesticide is the common mode of attempt. More number of cases attempt during the months of August,
September and October. Majority of them have experienced more than 5 life events before the attempt. Therefore
we conclude that forenoon (8 a.m. to 11.59 a.m.) is the most vulnerable period for attempting suicide. Conclusion
The assessment of patients with history of suicide attempt in relation to the time of attempt is beneficial in
formulating suicide prevention strategies.
Keywords: Attempted suicide; Time of attempt, methods pesticides.
INTRODUCTION
There is an increase in the number of attempted
suicide worldwide. It is a matter of global concern. 1,2
A number of studies from India 3,4,5 focusing on
various factors related to attempted suicide also
report high prevalence rate of suicide attempts.
The studies pertaining to psychological, social and
demographic factors along with modes, causes and
time of attempt are helpful in formulating suicide
prevention strategies. Attempted suicide were less
during nights and early morning.6 Nearly half of the
successful suicides were committed during the night
when there were little interruption, and genuineness
of the day time attempts were doubtful.7
A Bangalore study shows a definite time preference

as noted in the sense that midnight has least preferred
and the early morning and proximity to noon were the
periods most preferred.8 In another study there was an
equal distribution for each of the four hour periods
from 8 a.m to 12 midnight, while the lowest figure is
evidenced for attempts that were made between 12
midnight and 8 a.m., while suicidal activity is higher
during the other periods and is evenly distributed.3
In a similar study 35.44% of patients attempted
suicide between 12 noon and 6 p.m. and another
34.6% attempted between 6.01 p.m. and 12 a.m.9
169
Srinivasagopalan et al.,
Similar findings have been reported by some of the

Indian studies.10,11
That day time attempts do not necessarily favour
survival may be seen from the observation that more
than half of the fatal ones succumbed to the attempts
made between 8 a.m. and 8 p.m. The objective of the
study is to investigate various factors associated with
the time of occurrence of suicide attempt in people
attending hospital following suicide attempt.
The study is a hospital based analysis of suicide
attempts. We recruited74 consecutive patients with
H/o. attempted suicide who were admitted in the
Emergency Medical Ward of Meenakshi Medical
College & Research Institute and subsequently
referred for evaluation in the Psychiatry OPD during
Oct. 2009 to Sep. 2010. The study was approved by
the local ethical committee. Informed consent was
obtained from all the patients. The time of suicide
attempt was recorded based on the Accident Register
copy (AR copy) and also the same was cross verified
with patients and their relatives. Exclusion criteria:
Patients with chronic medical illness like Diabetus
Mellitus / Hypertension and cardiac problems,
bronchial asthma, were excluded.
All relevant clinical and demographic data were
collected in a semi-structured proforma.
The
following instruments were used.
1. ICD 10 Criteria 12 used to ascertain the Psychiatri
Diagnosis.
2. Hamilton rating scale for Depression13 : The
Hamilton Rating scle for depression (HRSD) is
for assesing depression at the time of interview.
By using HRSD any room for bias in the subjects
presentation in his or her self report is eliminated.
3. Presumptive Stressful Life event Scale by
Gurmeet Singh et al.14 (PSLES): The PSLES is
formulated by Singh et al 1984 is to evaluate the
life events that occurred within 1 year prior to the
suicide attempt.
4. Becks Suicide Intent scale : 15 Becks Suicide
Intent scale is a 15 item questionnaire each item
score 0 to 2 giving a total score range of 030.
The questionnaire is divided into Circumstances
section and self report section.
Suicide attempt in the present study refers to A nonfatal act whether physical injury, drug over dose or
poisoning, carried out in the knowledge that was

potentially harmful.
Statistical analysis Software: Graph pad prism
version 5.
RESULTS
Table 1: Socio demographic and other data
Time item
00 to 07.59 AM
08.00 to 11.59
AM
12.00 to 3.59 PM
04.00 to 07.59 PM
08.00 to 11.59 PM
BELOW 20
20-29
30-39
40-49
50& above
Frequency
11
25
%
14.90%
33.87%
11
10
17
7
43
11
5
8
14.90%
13.50%
23.00%
9.5%
58.10%
14.90%
6.80%
10.7%
30
44
40.5%
59.5%
Sex
Female
Male
Rural, Urban
Rural
Urban
59
79.7%
15
20.3%
Marital Status
Divorced
1
1.40%
Married
43
58.10%
Separated
1
1.40%
Unmarried
28
37.70%
Widow
1
1.40%
Educational Status
College
16
21.60%
Hr. Sec.
8
10.80%
Illiterate
22
29.70%
School
28
37.80%
Occupational Group
Unskilled
13
17.60%
Skilled
13
17.60%
Student
12
16.20%
House wife
17
23.00%
Professional
2
2.70%
Business
4
5.40%
Unemployed
13
17.60%
Day of attempt: Test of Chisquare used to find out
the days of preference if any the 2 value arrived is
3.35 and P < 0.05, not significant when compared
with table value 12.59, The distribution of events
registered by different days can be concluded equal or
same. Hence there is no significant difference for the
days of the events.
170
Table 2: Month, Day and Place of suicide attempt

Months of Attempt
January
2
2.7%
February
7
9.5%
March
3
4.0%
April
1
1.4%
May
2
2.7%
June
8
10.8%
July
4
5.4%
August
10
13.5%
September
11
14.9%
October
13
17.6%
November
7
9.5%
December
6
8.9%
Day of Attempt
Mon
10
13.50%
Tues
15
20.30%
Wed
12
16.20%
Thurs
10
13.50%
Fri
11
14.90%
Saturday
8
10.80%
Sun
8
10.80%
Place of Attempt
College & Hostel
4
5.40%
Farmland
8
10.8%
Hospital
1
1.30%
House
50
67.60%
Not known
11
14.90%
During August, September and October the events
registered are more when compared to other months.
The data is converted to a moving average for 3
months to avoid of overlaps. It is seen that the
attempt registered are more in August, September and
October months. During the time period of 8.00 a.m.
to 11.59 a.m. 40% (10) of persons attempt during the
month of August, September and October which
found to be comparatively more.
Table 3: Time distribution
Time item
Frequency Expected d
d2
00 to 07.59 AM
11
24.6 13.6 185.0
8.00 to 11.59 AM
25
12.3 12.7 161.3
12.00 to 3.59 PM
11
12.3
1.3 1.69
04.00 to 07.59 PM
10
12.3
2.3 5.29
08.00 to 11.59 PM
17
12.3
4.7 22.14
Preferred time 8.00 to 11.59 A.M. their time at

attempt, now 2= d2
E
Table 4: Mode of attempt and diseases
Mode of Attempt %
Analgesics and Antipyretics
x60
5.4%
Sedatives, Hypnotics
x61
10
13.5%
x63
1.4%
x64
6.8%
Organic solvents
x66
1.4%
Pesticide
x68
29
39.2%
x69
6.8%
hanging, strangulation
x70
16
21.6%
Fire & Smoke
x76
1.4%
x84
2.7%
Drugs on Autonomic
System
Other unspecified drugs &
Biological substances
Other Unspecified
Chemicals
Unknown means
Diseases
Adjustment Disorder
5.4%
Alcohol Dependence
8.1%
Alcohal with Depression
5.4%
Depression
21
27.0%
No Diagnosis
36
48.6%
OCD
1.4%
Paranoid Schizophrenia
1.4%
Schizophrenia
1.4%
Shizoid Personillity
1.4%
The frequency of the events reported with time of

attempt was analysed 2 test applied to verify the
similarities. 2 = 40.6 and It is significant when
compared the 2 (0.05) = 9.49. Hence we conclude that
the preference of time of attempt by the cases are not
same. Further it is seen that attempts during 8 A.M. to
11.59 A.M. is higher and statistically significant
difference with other cases in different times.
171
Table 5: AGE, Sex, Place of living, Status of living, educational status, Occupation
TIME RANGE
Age Group
12.00 to 3.59
00 to 7.59am 8.00 to 11.59am
pm
<20
2
3
1
20-29
5
14
7
30-39
1
1
3
40-49
1
2
0
50 & above
2
5
0
Total
11
25
11
Sex
Female
4
9
6
Male
7
16
5
Place of living,
Rural
10
21
7
Urban
1
4
4
Status of living
Divorce
0
0
0
Married
4
14
7
Separated
1
0
0
Unmarried
6
10
4
Widow
0
1
0
Educational
College
2
3
5
Hr. Sec.
2
3
1
Illiterate
3
10
3
School
4
9
2
Occupation
Unskilled
1
4
0
Skilled
3
3
2
Student
2
5
3
House wife
3
5
4
Professional
0
0
1
Business
0
2
0
Unemployed
2
6
1
Place of attempt
College/
1
1
1
Hostel
Farm land
1
4
0
Hospital
0
0
1
House
7
17
7
Not Known
2
3
2
The distribution of cases by age and time of attempt
is given in table 5. in which it is seen that 58.1% (43).
were in the age group of 20-29. It is the largest group
32.5% (14) in this age group prefer their time of
attempt between 8 a.m. to 11.59 a.m. Out of 74
attempters, it was recorded as 40.5% were females
and 59.5% were males. There is no gender difference
TOTA
L
7
43
11
5
8
74
9.4
58.1
14.8
6.8
10.8
0
10
0
0
0
10
8.00 to
11.59pm
1
7
6
2
1
17
3
7
8
9
30
44
40.5
59.5
7
3
14
3
59
15
79.7
20.3
0
6
0
4
0
1
12
0
4
0
1
43
1
28
1
2
0
3
5
4
2
4
7
16
8
23
27
3
1
1
1
0
2
2
5
4
1
4
1
0
2
13
13
12
17
2
4
13
1
0
9
0
2
0
10
4
8
1
50
11
4:00 to 7:59pm
in the peak time (8 a.m. to 11.59 a.m.) cases.

(Statistically no evidence as P> 0.05 (P = 0.6)).
Living place: Out of 74 cases, 59 (79.7%) belonged
to rural and 15 (20.37%) belonged to Urban. The 2
= 0.47, & P > 0.47. Though the cases registered for
rural (21) is more when compared to for Urban (4), it
is not statistically significant (P > 0.05), but, Majority
of rural cases 35.6% (21) has been attempted during
172
8.00 a.m. 11.59 a.m. 58.1 % (43) of married people

and 37.8% (28) were unmarried. Among them 32.5%
(14) married and 35.7% (10) of unmarried preferred 8
a.m. to 11.59 a.m. as their time of attempt. It is not
statistically significant.
Educational:
The distribution of cases by
educational status is as follows: illiterate 29.7%,
School 37.8%, Hr. Sec. : 10.8%, College 21.6%. 2
test was conducted to see if any association between
education and time of attempt. As 2 value is 7.969
for 12 df, P = 0.788 and P > 0.05, there is no
association established between educational level and
time of preference for attempt and it is inferred that
except college going, all other lesser level of
Table 6: Time wise distribution of Mode of attempt
education preferred 8 a.m. to 11.59 a.m. out of which

illiterates are higher than the educated.
Occupation: [ df = 4, 2 = 9.49 at ( P = 0.05) ] The
distribution of cases by occupation is given in table :
5 The time of attempt and occupation have been
tested for its association through 2 test. It is found
that p = 0.587 and hence not significant.
Place of attempt: [Chi-squre = 9.49 at P = 0.05 with
4 df] Calculated Chi-square value 107.75 > 9.49
(table value). Hence the distribution of events
according to the place of attempt differs from each
other. Therefore we concluded that the attempts at
house are significantly higher than other places.
TIME RANGE
00 TO
07.59 AM
08.00 TO
11.59 AM
12.00 TO
3.59 PM
0.400 TO
07.59 PM
08.00 TO
11.59 PM
Total
10
Analgesics and
Antipyretics
Sedatives, Hypnotics
Drugs on Autonomic
System
Other Unspecified drugs
and biological substances
Organic solvents
x60
x66
Pesticide
Other Unspecified
Chemicals
hanging
x68
11
29
x70
16
Fire & Smoke
x76
x61
x63
x64
x69
x84
Unknown means
0
1
1
0
0
2
29/74 = 39.2%, Hanging = 16/74 = 21.6%, Sedative and other drugs = 10/74 = 13.5% During the peak time
37.9%(11), 37.5%(6) and 20%(2) of persons with mode of pesticides hanging and tablets respectively preferred
8 a.m. to 11.59 a.m.
Table 7a :Time range, Suicide Intent Score,
TIME RANGE
Suicide Intent
Score
0
1
4
5
6
7
8
9
10
00 TO 07.59
AM
0
0
0
3
1
3
1
0
0
08.00 TO
11.59 AM
2
0
0
2
1
3
2
2
0
12.00 TO
3.59 PM
0
0
2
1
0
0
1
0
1
0.400 TO
07.59 PM
0
0
1
0
0
1
5
1
0
08.00 TO
11.59 PM
1
1
1
2
2
1
0
3
1
Total
3
1
4
8
4
8
9
6
2
173
Table 7b: No. of Stressful Life Events

No. of Stressful Life Events
00 TO 07.59
08.00 TO
12.00 TO
0.400 TO
08.00 TO
Total
AM
11.59 AM
3.59 PM
07.59 PM
11.59 PM
1
0
1
1
0
1
3
2
1
1
0
1
1
4
3
2
2
0
2
0
6
4
0
3
2
1
2
8
5
2
2
1
3
2
10
6
1
2
1
0
2
6
7
1
0
0
0
2
3
8
1
0
0
0
1
2
9
0
0
0
1
0
1
10
0
0
0
0
1
1
13
0
1
0
0
0
1
The mean intent score was 6.29 as observed from 45
acts which can occur in the day time more often than
cases. The confidence interval is CI = (5.534 7.56).
in other times.
But score 5 falls outside this range, which implies
Epidemiological studies point out throughout the
that cases suffered with burden and stress. It is noted
world, percentage of cases attempting suicide under
that 26.6% of person preferred 8.00 a.m to 11.59 a.m.
the age of 30 years ranges from 30% to 70%.1 Most
and 8.00 p.m. to 11.59 p.m. equally.
of the Indian studies. 10,16,17 showed that the age group
The mode is 10 and the model event is 5. On an
most vulnerable to suicide attempt is between 16 to
average the cases had 5 events for leading to suicide
30 years.58% (43) of our sample who attempt were
attempt.
20 29 age group. It is the largest group of
ICD Psychiatric diagnosis: Only in 38 persons
attempters in our study. Among this group 32.56%
psychiatric diagnosis is made out. Among them
(14) attempt during the 8 a.m. to 11.59 a.m. time
33.8% (25) were depressives. Of all the categories.
period. When these time period and against all other
37.3% (9) of depressive patients attempt suicide
time periods were compared with age group there was
between 8 a.m. to 11.59 a.m. No psychaitric
no significance. In a different study in India peak age
diagnosis is made out for 48.6% (36) of persons.
is between 21 and 30 years.18 In a study done at
Himachal Pradesh it is between 15 and 24 years.19
DISCUSSION
More youngsters use attempt as a threat, to
manipulate, to change the situation, and to make
The time of attempt most preferred in our study is
others to comply with their demands may be the
between 8 a.m. to 11.59 a.m. (38.8% (25)). It is
reason for the day time attempts, and also
statistically significant. One who has seen a thousand
interpersonal conflicts and impulsive acts occur in the
cases of attempted suicide found that attempts were
6
day time more often than in other times. Our study
relatively rare in the early morning. The lowest
shows that 40.5% (30) of females and 59.5% (44) of
number of attempts in our study also between
males attempt suicide. Among them 64% (16) of
midnight to 8 a.m. period. In a study done at Madurai
males and 36%(9) of females were choosing 8 a.m. to
there is an equal distribution of number of attempts in
3
11.59 a.m. as their preferred time of attempt. It is not
the five times period. In our study except for the time
statistically significant. In other studies 20 also males
periods of 8 a.m. to 11.59 a.m. and 8 p.m. to 11.59
prefer day time attempts. Male preponderance is in
p.m. all other periods were almost equally distributed.
line with our Indian studies unlike in western studies
In Bangalore study like in our study a definite time
where female attempters more higher in numbers.21,22
preference was noted in the sense that midnight was
Culturally glorifying position of males in Indian
least preferred and the early morning and proximity
8
society puts them more stress and expectations.Males
to noon were the periods most preferred. In another
in Indian society faces responsibilities in regard to the
study 12 noon is the preferred time of attempt as in
9
economic, financial and the prestige aspects of the
our study. High prevalence in the day time attempts
family. 23 He is compelled to take a self destructive
may be due to interpersonal conflicts and impulsive
Score
174
decision. This view is close agreement with that of

Schneider.
In our sample 79.7% (59) belonged to rural area,
20.3% (15) from urban area. Among the rural cases
35.6%(21) and urban 26.7%(4) has been registered
during 8 a.m. and 11.59 a.m. period which is not
statistically significant and it also implies that both
locality have no influence in selecting specified time
of attempt. In the Himachal Pradesh study also rural
cases were high. 19
In our sample overall 58.1% (43) married people
and 37.8%(28) unmarried people attempt suicide.
Among them 32.5 %(14) of married and 35.7%(10)
of unmarried people prefer 8 a.m. to 11.59 a.m. as
their time of attempt. Married people face more
domestic and interpersonal conflicts and hence in
them impulsive acts occur more often in day time.
Similar results were shared by a multinational
study,24 in which subjects from Indian centre who
attempted suicide or Indulged in self harm were more
frequently married than single individuals. In India
marriage is a social obligation and is performed by
elders irrespective of the individuals preparedness
for it.25 Divorce being socially frowned upon.
There was no association established between
educational level and time of preference of attempt
and it was inferred that except college going all other
lesser level of education preferred 8 a.m. to 11.59
a.m. out of which illiterates were higher than the
educated. More housewives attempt suicide in the
time period of 8.00 a.m. to 11.59 a.m. Unemployed
people were also the highest number who attempt at
the above time period. The same findings were noted
in other studies also.19,22
In contrast to other studies where more no. of suicide
attempt had occurred in the month of Feb. 11.2%(90)
and March. 10.16%(83), in our study during Aug.
13.5%(10), Sep. 14.9%(11) & Oct. 17.6%(13) the
events registered were more.[9] In some other studies
suicidal activity 10-20 times more common in spring
(peak in may) than in winter or summer.26 There is a
small peak in October. Since it is the monsoon season
(August, September, October) and majority of
patients from rural background, hectic agricultural
activities and increase number of festivals were more
in these months may be the reason for high suicidal
activity due to interpersonal conflicts.
Tuesday 20.3%(15) and Wednesday 16.2%(12) were
the days preferred in our study. In a study of thousand
cases of suicide attempts it was found that attempts

were relatively rare in the middle of the week and
most frequent near the week end, especially on
Sundays and Mondays. We presume for adolescents
and young adults, week days are more stressful than
weekends. That may be the reason for the findings in
our study.
As far as the place of attempt 67.60% (50) prefer the
house as the place of attempt.
Among them 68
%(17) of people attempt in their house during the
time period of 8 a.m. to 11.59 a.m. and it is
significantly higher than all other places and it is also
statistically significant. In contrast to this, in
Ponnuduari27 et al (1997) study 33.71% of males and
3.64% of females of completed suicide patients
chosen the venues other than their houses and most of
them were suffering from mental illness. The
distribution of events according to the place of
attempt differs from each other. Therefore we
conclude that the attempts at home are significantly
higher than other places.
Pesticides (39.2% (29)) were found to be the
commonest mode of attempt which is in conformity
with the observations made by most of the authors
from India. 28,29,22,5 During 8 a.m. to 11.59 a.m. period
37.9% of persons took pesticides and 37.5% preferred
hanging as their mode of attempt. In another study
25% preferred hanging as their mode of attempt.22
An interesting observation in our study as in the study
of P.N.Sureshkumar30 (1998) was that among males
the common mode of attempt was insecticide poison
whereas in females it was drug overdose. In India
agricultural workers, as pointed out by the same
author30 were mainly males and have an easy
accessibility to these compounds. The incidence of
physical ailments in females which may lead to the
easy availability of prescription drugs.
When all the other time periods as a group compared
with 8 a.m. to 11.59 a.m. time period, it was not
statistically significant. Methods used in suicide
attempts were mostly non - violent. In a multi centre
study 64% of males and 80% of females used self
poisoning as their mode of attempt.2
Studies from India and abroad have consistently
reported a high incidence of Psychiatric illness in
suicide attempters. Several reports have indicated
depression as the most common diagnosis in 35% to
80% of the attempted suicide cases.[1,4] In Jain22 et al
(1999) study depression was 37.5%. 27% (21) of our
175
patients suffer from depressive illness. Alcohol

dependence is the next largest group. According to
Barraclough31 et al (1979), Gupta & Singh29 et al
(1981). With reasonable estimate depression
accounting for 75%, alcohol 15%, rest was other
miscellaneous psychiatric conditions. In a different
study 45% who attempt suicide, self-ham themselves
do not have a diagnosable psychiatric illnesses.[28] In
our study also 48.6% (36) persons have no
diagnosable psychiatric illness. In a study conducted
during 1994 over 26.82% of young suicide attempters
gave interpersonal conflicts as reasons for their
suicide attempts. 33 This means attempted suicide can
occur in normal persons as a coping mechanism
under stress, and to communicate their needs and
distress. 37.5 %(9) depressives attempt suicide
between 8 a.m. to 11.59 p.m. which is the highest
number but it is not statistically significant. When
combined the time period between 4 p.m. to 7.59 p.m.
and 8 p.m. to 11.59 p.m., about 49.9% depressives
attempt within this period.
Out of 74 cases only intent score obtained for 45
persons. Among them 26.6% prefer 8 a.m. to 11.59
a.m. and 8 p.m. to 11.59 p.m. equally. It is evident
that the individuals intent score falls between 5.534
to 7.046. The score 5 falls out of the interval. Hence it
can be conclusded that if the intent score is above 5,
then there is a chance for future attempt. Older adults
had higher suicidal intent than younger individuals,
the reason being older adults have more psychiatric
morbidity than younger ones.34 Since majority of
our sample are younger adults the intent scores are
uniformly low. Some studies showed that high
suicidal intent scores at the time of attempt were
associated with an elevated risk of eventual
suicide.35,36
Life events are rapid detectable changes in the
individuals environment which produces stress.
Especially negative events are likely led to depression
and eventually suicide attempt. Out of 74 cases life
events score obtained only for 45 cases. Among 8.00
a.m. to 11.59 a.m. category 5 (41%) people were
having more than 5 life events (highest no.) within
one year period. On an average the cases had 5 events
for leading to suicide attempt. Generally those who
attempt suicide experiences substantially more events
than the general population with the type of events
reported most often being interpersonal and relational
issues as in our study.
CONCLUSION
Our results showed 8 A.M. to 11.59 A.M. is the most
preferred time of attempt and it is statistically
significant. This is the time period were more young
(20-29) males, from rural background, married and
illiterates, unemployed (also housewives) and who
has a current psychaitic diagnosis of mostly
depression attempt suicide. House is significantly
associated with attempt. Insecticide poisoning was
the most preferred mode of attempt. Majority of them
have experienced more than 5 life events before the
attempt. Tuesdays & Wednesdays were their
preferred time of attempt. August, September and
October were the preferred months of attempt. Hence
forenoon is the most vulnerable period because as
pointed by other authors also majority of
interpersonal conflicts and relational issues occur in
the day time. This knowledge may be useful for the
effective planning of suicide prevention strategies.
Limitations: The absence of any association between
times of attempt with most of the variables may be
due to smaller sample size and different inclusion
criteria. It is pointed out that hospital based group is
somewhat selective and it is not entirely
representative of the whole class of patients who
attempt suicide especially because of the absence of
patients who used rapidly fatal means.
Future directions: Further in depth investigation into
the time of attempt of suicide could increase our
understanding of the reasons which will help the
ways for effective prevention of suicide. Crisis
management for primary care physicians problem
solving skills, social skill training, will be of help to
prevent day time attempt of suicide in youngsters
who are also more impulsive, less psychiatrically
inclined.
Acknowledgment: Acknowledgment of financial and
material support nil.
REFERENCES:
1. Weissman MM. The epidemiology of suicide
attempts (1960-1971) Archives of General
Psychiatry.1974; 30: 73746
2. WHO Suicide and the Young. World Health
Organization Chronicle. 1974; 29: 193-98.
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DOI: 10.5958/2319-5886.2015.00028.4

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Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
DOES BODY MASS INDEX INFLUENCE NASAL MUCOCILIARY CLEARANCE?

*Tamilselvan K, Latha R, Nirmala N, Susiganeshkumar E, Thananjayam A
Department of Physiology, Sri Venkateshwaraa Medical College, Hospital and Research Centre,
Ariyur,Puducherry, India
*Corresponding author email: ktamilselvan10@gmail.com
ABSTRACT
Background: The respiratory system is constantly exposed to particulate matter suspended in the inhaled air and
one among the efficient mechanisms to trap and expel the particulate substances is the nasal and bronchial
mucociliary clearance mechanism. This mucociliary clearance mechanism is influenced by both physiological and
pathological factors that alter the functioning of the respiratory cilia and the overlying mucosal layer that traps the
particulate agents. As Body mass index (BMI) determines the health of a person by influencing various
physiological parameters, this study has been planned to study the effect of normal and abnormal BMI
(overweight and obese range) on the nasal mucociliaryclearance (NMC). Aim: To evaluate the effect of BMI on
nasal mucociliary clearance (NMC). Materials &Methods: NMC was measured in 20 volunteers with normal
BMI (18.5-22.9 Kg/m2) and 20 volunteers with BMI in overweight and obese range (23 Kg/m2 and above). The
NMC time was recorded by the time the volunteers appreciated the sweet taste following the placement of of
saccharin tablet (1mm x 1mm) in the nostril referred as saccharin transit time(STT).Results: NMC was found to
be prolonged in overweight and obese population and BMI has positive correlation with NMC as calculated by
Pearson correlation with r value of 0.591 and p value 0.001 which is statistically significant. Conclusion:NMC
time is prolonged in abnormal BMI referring to the impairment in the mucociliary escalator mechanism thus
predisposing to disease states.
Keywords: Body mass index, Nasal mucociliary clearance
INTRODUCTION
The respiratory function of the lungs demands
perpetual exposure of the respiratory epithelium to
the inhaled air which is the source of oxygen as well
as the suspended particulate matter which includes
dust, allergen, toxins and pathogens. The suspended
particulates risk the infection and inflammation of the
respiratory apparatus and can finally lead to
functional impairment of the respiratory system as a
consequence of the systems pathologies.
The respiratory apparatus defence mechanisms:
As a measure of protection the respiratory system is
well equipped with an array of defence mechanisms
from the nostrils to the respiratory units, the alveoli.
The anatomical barriers constituted by the upper

airways and the major bronchi are associated with
defence mechanisms of coughreflex, mucociliary
escalator mechanism, secreted immunoglobulin A
(IgA)and the network of dentriticcells under the
superficial mucosal layer which scans for pathogenic
invasion and brings the victims of their surveillance
to the draining lymph nodes. Beyond the respiratory
bronchioles the protection is conferred by the local
macrophages, IgG, complement factors, surfactant
and fibronectin. Recriutment of neutrophils and
lymphocytes, in times of need further enhances local
defence in these regions 1.
178
Tamilselvan et al.,
Mucociliary Clearance Mechanism: Clearance of

the airborne particulates of the size 2-10 m is
effectively carried out by the mucociliary clearance
mechanism. This mucociliary escalator system is
constituted of the cilia of the respiratory epithelium
and the overlying mucus. The superficial mucus layer
constituting the gel layer is secreted by the mucus
glands of the bronchus and the goblet cells. The
underlying aqueous sol layer is secreted by Clara
cells. The cilia beat in a coordinated manner in the
aqueous sol layer moving the overlying gel layer
towards the oropharynx to be cleared to the exterior
or to be swallowed1. The direction of
ciliarymovement in nasal passage mirrors the
bronchial mucociliary clearance thus both attempting
to clear thetrappedparticulate matter towards the
pharynx 2. The mucociliary clearance is influenced by
physiological factors like age, gender, sleep, exercise
and posture thatalter the normal functioning of the
mucociliary escalator. Impairment of the mucociliary
clearance due to any cause that deranges either ciliary
movement or the hydration of the airway surface
leads to stasis of sinonasal and respiratory tract
secretions predisposing to infection, inflammation
and finally impairing the pulmonary functions leading
to pathological states3. Environmental pollutants and
local pathologies of the respiratory system like
immotile cilia syndrome, asthma, bronchiectasis,
cystic fibrosis and many pathologies have negative
influence on the clearance mechanism4. Recent
observations report that nasal mucociliary clearance
(NMC) is impaired in hypertension and diabetes
mellitus, the worlds leading causes of morbidity and
mortality5. Significant linear relation exists between
increased BMI and the above two disease states 6.
Overweight and obesity also foster the risk of other
cardiovascular disease conditions, cerebrovascular
accidents, certain types of cancer and arthritis 7.
Obesity is also implicated in the development of
several respiratory diseases like obstructive sleep
apnoea (OSA), obesity-hypoventilation syndrome
(OHS) and bronchial hyper-responsiveness associated
with asthma8. A Polish epidemiological study
revealed that children with BMI above 25 Kg/m2have
a greater risk of becoming susceptible to acute
respiratory infections than their normal counterparts 9.
Though extensive literature exists for the relevance of
BMI and various diseases,very minimal information
exists for the relation between BMI and nasal
Tamilselvan et al.,
mucociliary clearance .The pioneering study by

Valdez et al. carried out in 2009 on 30 subjects,
uncovered the fact that underweight and obese
individuals tend to have a prolonged mucus transit
time when compared to those with BMI in normal
range10. This observation makes us infer that
abnormal BMI impairs the NMC thus prolonging the
mucus transit time predisposing to disease states. As
the information about the influence of BMI on NMC
is scarce this study is designed to evaluate the relation
between body weight i.e. BMI and nasal mucociliary
clearance.
METHODS
This cross sectional study was conducted on 40
randomly selected volunteers (20 volunteers with
normal BMI for control group and 20 subjects in
overweight and obese range for cases) after obtaining
the Institutional ethical Clearance. Of the volunteers
recruited 10 were male and the other were10 female
in each group.Volunteers were between the age of 18
and 45years. The duration of the study was two
months. The study was carried out in the department
of Physiology, Sri Venkateshwaraa Medical College
Hospital and Research Centreand the study subjects
were students and staffs of the institution. The
volunteers were chosen after excluding the history of
nasal surgery, smoking, nasal abnormality (sinusitis,
allergic rhinitis, nasal polyps,deviated nasal
septum),asthma, topical nasal medication or systemic
anticholinergics use. Those with history of diabetes,
hypertension and those who were pregnant were also
excluded. The procedure was then explained to the
participants and an informed written consent was
obtained from them.
Calculation of BMI: Anthropometric measures of
height and weight were recorded to calculate the BMI
and the subjects were classified into case and control
groups based on the revised BMI classification
scoring for Asian population 11,12. BMI was calculated
using the formula (BMI) = weight in Kg/ height in
m2.The control group comprised of 20 volunteers
with normal BMI ( BMI 18.5 - 22.9 Kg/m2) and case
group with 20 volunteers with BMI in overweight and
obese range ( BMI 23 Kg/m2 and above) based on
the revised values by the Union Health Ministry of
India, 2008. According to the recent BMI
classification for Asian population as recommended
by WHO, the
normal BMI is 18.5 - 22.9
179
kg/m2,underweight <18.5 kg/m2, overweight 23.0 24.9 kg/m2 and 25 kg/m2 obesity11.
Measurement of Nasal mucociliary clearance:
NMC was measured by the saccharin transit time
(STT),i.e., the time taken for the saccharin molecule
placed in the nostril to reach the nasopharynx by
ciliary beat function. It was studied using the
saccharin method of Anderson et al.13. A 1 X 1 mm
particle of saccharin (quarter tablet of sweetex
(saccharin sodium)) was placed on the floor of the
nose, just behind the anterior end of the inferior
turbinate and the test was carried out in sitting
position with neck slightly flexed and the time
required by the subject to perceive the sweet taste
was noted in minutes. (As saccharin crystals were
unavailable quarter tablet of artificial sweetner
(Sweetex) was used similar to the method of
R.J.L.Valdez et al. who used Equal tablets.) The test
was carried out in both the nostrils with an interval of
half an hour. The time of mucociliary clearance ie the
saccharin transit time (STT) of each nostril was noted
separately. Nasal mucociliary clearance time is the
average time of the mucosal clearance of both the
nostrils. The subjects were advised to avoid nasal
manipulation, sniff, cough, inhale or exhale forcefully
during the test, and were told to report the perception
of any taste by raising their hand. Subjects were
blinded about the nature of particle. (The subjects
were informed that some harmless edible particle
would be placed in the nostril and they were not
informed about its taste nature.) A single examiner
performed the test in all subjects to avoid interobserver variability. The saccharin test is a simple
and inexpensive technique to screen abnormal
mucocilairy clearance, and its results are
comparablewith those obtained using a radioactively
labelled particle 14.
Statistics: The results were analysed using Statistical
Package for Social Sciences (SPSS) version 17 and
statistical evaluation was done using unpaired t-test
for comparison of STT between case and control
groups. To find the correlation between BMI and
STT Pearson correlation was used. P 0.05 was
considered statistically significant.
RESULTS
Age distribution: The mean age of the female
volunteers is 30.1 9.8 years and that of the male
volunteers is 29.4 9.7 years. There is no significant
difference in age between male and female

population as the p value is 0.821.
Comparison of BMI and NMC between case and
controls
Table 1: Comparison of BMI and Saccharin Transit
Time between the groups
Control
group
Case
group
t value
p
value
BMI
(Kg/m2)
20.581.36
28.32.47
12.28
0.0001
***
STT
(min)
5.742.35
9.773.02
4.72
0.0001
***
*** (P-Value < 0.001) Highly Significant,

STT: Saccharin Transit Time
From table 1 it could be inferred that the mean BMI
value and mean Nasal Mucociliary Clearance
(NMC)value measured by saccharin transit time
(STT) differed between the case and control groups.
The differences are statistically significant with p
value 0.0001.
Correlation between BMI and STT:
Fig 1:Correlation between BMI and STT

Fig 1shows a postitive correlation between BMI and
STT as calculated by Pearson corrrelation with r
value of 0.584 and p value 0.0001 which is
statistically significant.
DISCUSSION
Nasal mucociliary clearance is influenced by many
factors like age, sex, posture, sleep, exercise,
environmental factors etc, in both health as well as in
disease4. But the influence of BMI on NMC is not
well established as there is a paucity of literature on
this topic. In recent times the pioneering effort was
initiated by Valdezet al in 2009 who in their study
Nasal Mucociliary Clearance (Mucus transit time)
andAbnormal body Mass index (Underweight and
180
Tamilselvan et al.,
obese) in filipino Adult Volunteers observed that the

NMC is prolonged in people with abnormal BMI
(underweight and overweight and obese category
when compared to those with normal BMI). Similar
to their observation we found that STT is increased
with increase in BMI in our study. The difference is
statistically significant. Though the values of NMC
found in our study differed from the reference study
of Valdez et al. the difference could be attributed to
the influence of ethnicity. The correlation of BMI
with NMC was significant and therefore it could be
inferred that BMI has an influence on nasal
mucociliary clearance and the relation is linear when
the BMI is in overweight and obese range (as inferred
from our results and with that of the formers
observation) .Valdez et al. also observed that NMC is
prolonged in underweight subjects, inferring an
impairment in the mechanism. From the observations
made it is made clear that BMI influences respiratory
health with its deleterious effect in extreme
conditions of over-nourished and under-nourished
states by impairing the nasal mucociliary clearance,
an inherent defence mechanism of the respiratory
tract that prevents the accumulation of secretions.
Impairment of the clearance mechanism leads to
stasis of the respiratory secretions predisposing to
infection and inflammation and in turn it leads to
respiratory pathologies. Significant decline in the
lung functions associated with obesity was observed
by Bharat Thyagarajan et al. and Ling Yang et
al.made the observation that low BMI is an
unexplained correlate of COPD15,16. As no proper
mechanism is established to the cause of ciliary
dysfunction, it could be held with suspect that the
same mechanism of oxidative stress mediated
functional derangement in the obesity could be a
cause for ciliary action dysfunction in case of
overweight and obesity as studies proved a decline in
the antioxidant capacity in people with above
conditions for longerduration17. The derangement in
the lung functions in the case of obesity is also
attributed to an elevated level of cytokines and
decreased levels of adiponectin thereby leading to
functional impairment15. Further studies are needed to
establish the relation between the suspected causes
and the ciliary dysfunction.
CONCLUSION
It could be thus concluded from our observation that
BMI influences nasal mucociliary clearance with a
linear relation reflecting the slowing of the mucous
clearing function of the nasal cilia whereby the
mucous transit slows down leading to accumulation
of the secretions and its sequel of respiratory
infections.
Limitations of study: The study hypothesis could
have been better addressed had the study groups
involved a larger population and the assessment of
biomarkers of oxidative stress could have added a
better insight into systemic inflammation that is
implicated as a suspected cause of ciliary motility
impairment. But the assessment being an invasive
procedure of blood collection, just on evaluation basis
(not diagnostic) the feasibility of participant cooperation was less.
Acknowledgement: We thank the participants for
their cooperation and the ICMR for its funding and
motivation. We thank the management of our
Institution for the financial support and
encouragement.
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DOI: 10.5958/2319-5886.2015.00029.6

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Health Sciences
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Volume 4 Issue 1
nd
Received: 2 Dec 2014
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
COMPARATIVE STUDY OF ERYTHROCYTE FRAGILITY IN DIABETES MELLITUS AND NON

DIABETES MELLITUS
*Harika Priyadarshini K1, Asha Latha P2, Pradnya S3, Ayesha Juhi4, Samatha P5, Mani Ratnam.K6
1,2,3,5
Assistant Professor, Department of Physiology, Mallareddy Institute of Medical Sciences, Hyderabad,

Assistant Professor, Department of Physiology, Apollo Institute of Medical Sciences, Hyderabad,
6 nd
II year MBBS student, Mallareddy Institute of Medical Sciences, Hyderabad
4
*Corresponding author email:dr.harika03@gmail.com

ABSTRACT
Introduction: The present study has examined the effect of elevated glucose levels on osmotic fragility of
erythrocytes. Osmotic fragility determines the rate of hemolysis of erythrocytes. Blood glucose is the sole energy
source for erythrocytes. Diabetes mellitus (DM) is a metabolic disorder characterized by hyperglycemia and has
become a major public health problem globally. Diabeties is the risk factor for osmotic fragility. Aim: the aim of
the present study is to describe erythrocyte osmotic fragility changes from type II diabetes to non diabetes.
Materials and methods: The osmotic fragility test is a measure of the resistance of erythrocytes to hemolysis by
osmotic stress. The study was conducted on (n=60) aged between 50-55 years, case group will include 30 type II
diabetes who were randomly selected from outpatients of the Malla Reddy Hospital, Suraram. Control group
involves 30 non diabetic individuals. Parameters selected for study are initial hemolysis, complete hemolysis,
median corpuscular hemolysis, haemoglobin, haemoglobin A1c, Fasting blood sugar, post prandial blood sugar
and respective parameters were compared in both the groups. Results & discussion: In this study when type II
diabetics were compared with non diabetic individuals, there was a significant change in osmotic fragility of type
II diabetics when compare to non diabetic controls. Conclusion: Hyperglycemia causes structural changes in red
cell corpuscles which lead to osmotic stress. Hence, it is necessary to rule out investigations of pathogenic
mechanisms induced by red cell fragility to prevent complications of diabetes mellitus.
Keywords: Type II diabetes, Osmotic fragility, Heamoglobin A1c, Blood glucose levels
INTRODUCTION
The International Diabetes Federation (IDF)
estimated in 2011 that 366 million adults, aged 20 79 years, of the worlds 7 billion population have
Diabetes mellitus1. The association between
erythrocyte fragility and type II diabetes is well
documented. Patients with type 2 diabetes have a
significantly higher erythrocyte mechanical fragility
than matched nondiabetic subjects, and that fasting
plasma glucose is the strongest correlate of increased
Harika et al.,
mechanical fragility of erythrocytes in the patients

group2 anaemia is relatively common in patients with
Diabetes mellitus. Anaemia is defined by the World
Health Organization as a haemoglobin concentration
below the following threshold Women (>15 years)
<12.0 g/dl and Men (>15 years) <13 g/dl. Generally,
anaemia in chronic disease like Diabetes mellitus is
normocytic normochromatic type, although in a few
cases, microcytosis and hypochromia also occur3.
183
Osmotic fragility of erythrocyte was greater in type 2

diabetic subjects, which is positively correlated with
glycosylated haemoglobin. Diabetic patients had
significantly increased risk of cell hemolysis on start
of hemolysis 4. Type 2 diabetic patients have a
significantly higher erythrocyte mechanical fragility
than matched nondiabetic subjects, and that fasting
plasma glucose and anaemia are also strongest
correlate of increased mechanical fragility of
erythrocytes in patients group5.
The study was conducted on type II diabetic subjects
of both the sex groups (n=60) aged between 50-60
years. The criteria for selection of diabetics were 10
years exposure of diabetes. Cases are selected from
the outpatient ward of Malla Reddy Hospital,
Hyderabad. Age matched non diabetic subjects were
selected as controls for study from general population
of same region. The present study includes
erythrocyte fragility changes in diabetics and
nondiabetics. To compare the results of the above two
groups and study the effect of diabetes on
erythrocytes, the subjects detailed history was taken.
Each subject was medically examined and their past
medical history was carefully evaluated solely aimed
at excluding hypertension. Thus, unhealthy subjects
were excluded and the only suitable subjects were
accepted for this study prior to the study, each subject
was informed in detail of research protocol and
methods to be used. Their consent was obtained prior
to the study and Ethical committee clearance has
taken.
Experimental protocol: All the biochemical tests done
in the central lab of Malla Reddy Institute of Medical
Sciences, Hyderabad. Haemoglobin estimation
measured using symx Kx 21 fully automated
hematology analyser, Haemoglobin A1c % measured
using Nycocard Reader2, Fasting Blood Sugar, Post
Prandial Blood Sugar, were measured using
Chemwell Auto Analyser. The osmotic fragility test
is useful because it is inexpensive and causes
minimum discomfort to the subject.5ml blood sample
was collected under aseptic condition and the blood
sample was used for Initial heamolysis, Complete
hemolysis, Median heamolysis. The osmotic fragility
test was done by Dacies method on the subjects
within 30 minutes of collection of blood. The study
was conducted in accordance with the Declaration of
Harika et al.,
Helsinki and under the terms of local relevant local

legislations.
Statistical methods: Data was presented as mean and
standard deviation (mean SD). Means are compared
between two groups by unpaired student ttest . A p
value of < 0.05 was considered statistically
significant. Descriptive statistical analysis was carried
out in the present study by using SPSS, 17 version
software. Results on continuous measurement were
presented on mean SD. Studentt test was used to
find the difference of the present study parameters
between two groups.
RESULTS
Table: 1.Comparision of various parameters of
diabetes & erythrocyte fragility among test group
and control group
Variable
Type II
Non
P
diabetes
Diabetes values *
Heamoglobin (gm/dl) 9.330.7 11.51.2 <0.0001
Hb A1c(%)
6.750.8 5.220.08 <0.0001
FBS (mg/dl)
11230 89.865.3 <0.0001
PPBS (mg/dl)
15120
1143.9 <0.0001
Initial heamolysis
5.450.5 4.550.24 <0.0001
(Conc of NaCl)
Complete hemolysis 4.550.6 3.420.19 <0.0001
(Conc of NaCl)
Median heamolysis
6.380.4 4.440.29 <0.0001
(Conc of NaCl )
*P values comparison with diabetics vs. non diabetics
showing highly significance
DISCUSSION
Diabetes is a metabolic disorder characterized by
hyperglycemia, either due to insulin deficiency or
insulin resistance. Despite some progress in the
development of new anti-diabetic agents, the ability
to maintain tight glycemic control in order to prevent
complications of diabetes without adverse
complications still remains a challenge6. The osmotic
effects of hyperglycaemia and glycosylation of
haemoglobin and erythrocyte membrane proteins may
play important role in the deformability of RBC in
the diabetic state. These effects may be exaggerated
in poorly controlled diabetes. The study aimed to
determine the fasting blood sugar levels (FBS),
glycated haemoglobin (HbA1c) and osmotic fragility
of red cells (MCF) in diabetics and non-diabetics.
184
Hyperglycaemia alters the membrane properties of

the red cells leading to increased osmotic fragility of
the red cells7. Na+/ K+ ATPase levels are
significantly decreased, which may cause disturbance
of intracellular ion balance and thereby acceleration
of cellular ageing. This further leads to an increase in
cell size and osmotic fragility, which contribute to the
disturbances in microvascular circulation observed in
diabetes mellitus. Alterations in membrane lipidprotein The oxidative stress due to high glucose
concentrations causes damage to the erythrocyte
membrane proteins, even in a relatively short
exposure time8. Peroxidation of membrane lipids can
result in the inactivation of enzymes and cross linking
of membrane lipids and proteins will cause increased
membrane osmotic fragility and in cell death.
Glucose induced lipid peroxidative damage can cause
changes in the properties of the RBC membrane9.It is
well known that, RBCs have to be squeezed and
deformed to pass in blood capillary vessels of
diameter smaller than that of RBCs itself, the degree
of squeezing of RBCs depend mainly on their
membrane elasticity. Therefore, the decrease of the
RBCs membrane elasticity will lead to the increase of
the blood capillary resistance for RBCs passage to the
body cells for carrying normal metabolism and hence
it may lead to toxicity10.
3.
4.
5.
6.
7.
CONCLUSION
Our study demonstrated that osmotic fragility of
erythrocyte is greater in type 2 diabetic subjects
compared to nondiabetic controls and red blood cell
fragility was positively correlated with increased
duration of exposure of diabetes for 10 years.
Acknowledgement: The authors would like to thank
management, department of physiology, Mallareddy
institute of medical sciences & Hospital, Suraram,
Hyderabad, for their support throughout the study.
Conflict of Interest: Nill.
References
1. Wild S, Roglic G, Green A, Sicree R, King

H. Global prevalence of diabetes: Estimates
for the year 2000 and projections for 2030.
Diabetes Care 2004;27:1047-53
8.
9.
10.
patients with type 2 diabetes. Eur J Intern Med.

2012;23(2):150-3.
Alfred Friday Ehiaghe, Joy Imuetinyan Ehiaghe,
Ositadinma Martin Ifeanyichukwu, Ikusemoro
Augustina Isioma, Justus A. Ize-Iyamu, Lily O.
Ize-Iyamu.
Socio-Economic Status and
Hemoglobin Concentration of Type 2 Diabetes
Mellitus Patients Attending Diabetic Clinic in
Benin City, Nigeria Open Journal of
Pathology,2013;3,139-143
Kung CM, Tseng ZL, Wang HL. Erythrocyte
fragility increases with level of glycosylated
hemoglobin in type 2 diabetic patients. Clinical
hemorheology and microcirculation.2009; 43(4):
345-51
Giuseppe Lippi, Mariella Mercadanti, Rosalia
Aloe, Giovanni TargherErythrocyte mechanical
fragility is increased in patients with type 2
diabetes. European journal of internal medicine
Published Online: 2012;23(2):150-3
Abdulrahaman A Momin, Mangesh P Bankar,
Gouri M Bhoite, Glycosylated Hemoglobin
(HbA1C): Association with Dyslipidemia and
Predictor of Cardiovascular Diseases in Type 2
Diabetes Mellitus Patients, IJHSR. 2013; 3(8):
40-46
Ibanga IA, Usoro CA, Nsonwu AC. Glycaemic
control in type 2 diabetics and the mean
corpuscular
fragility.
Niger
J
Med.
2005;14(3):304-6.
Megha singh & Sehyun Shin. Changes in
erythrocyte aggregation and deformability in
diabetes mellitus. Indian journal of experimental
Biology. 2009;47: 7-15.
Sushi1 K. Jain Hyperglycemia Can Cause
Membrane Lipid Peroxidation and Osmotic
Fragility in Human Red Blood Cells, the
journalof biological chemistry, The American
Society for Biochemistry and Molecular Biology,
Inc. 1989;264(35):21340-45
Sherif A A. Moussa,Biophysical Changes in Red
Blood Cells and Hemoglobin Components of
Diabetic Patients,
Original Article jgeb.
2007;5(1):
2. Lippi G, Mercadanti M, Aloe R, Targher G.

Erythrocyte mechanical fragility is increased in
Harika et al.,
185
DOI: 10.5958/2319-5886.2015.00030.2

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Volume 4 Issue 1
th
Research article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
A COMPARATIVE EVALUATION OF SHEAR BOND STRENGTH OF PORCELAIN FUSED TO METAL

SUBSTRUCTURE FABRICATED USING CONVENTIONAL AND CONTEMPORARY TECHNIQUES: AN
IN VITRO STUDY
*Mhaske Prasad N1, Nadgere Jyoti B2, Ram Sabita M3

1
Lecturer, Department of Prosthodontics, Rural Dental College and Hospital, Loni, Ahmednagar, Maharashtra,
India
2
Professor, 3Dean, Professor and Head, Department of Prosthodontics MGM Dental College and Hospital,
Kamothe, Navi Mumbai, Maharashtra, India
*Corresponding author Email: drprasadmhaske@gmail.com
ABSTRACT
Base metal alloys due to their low cost, are being used more often as the substructure because of their good
mechanical properties, excellent metal ceramic bonding and biocompatibility. The bonding of porcelain to metal
is an important point to be considered for the success of the restoration. Aim: To compare and evaluate the shear
bond strength of porcelain fused to metal substructure fabricated using conventional and contemporary
techniques. Methods and Material: Thirty sample discs were fabricated 10 of cast nickel chromium alloy, 10
of cast cobalt chromium alloys and 10 of laser sintered cobalt chromium alloy. Conventionally used feldspathic
porcelain was used and fired over the metal discs. These samples were placed in a specially fabricated jig, which
was held in a universal testing machine. The samples were subjected to shear stress until they fractured and the
readings were noted. The fractured surface of the sample was then viewed under stereomicroscope. Results: The
mean shear bond strength was highest in group C (porcelain fused to laser sintered cobalt chromium), followed by
group A (porcelain fused to cast nickel chromium) and group B (porcelain fused to cast cobalt chromium) which
was the least. The level of significance was fixed at p < 0.05. After applying Students Unpaired t test there is no
significant difference in shear bond strength in group A compared with group B, highly significant in group A and
group C and very highly significant in group B and group C. Conclusions: All the three groups showed adequate,
but laser sintered cobalt chromium alloy had the highest shear bond strength to porcelain. Nickel chromium alloy
fabricated by conventional casting method showed lesser values of the shear bond strength, followed by cobalt
chromium alloy fabricated by conventional casting, which had the least shear bond strength.
Key words: Shear bond strength, porcelain fused to metal, laser sintered cobalt chromium, direct metal laser
sintering.
INTRODUCTION
Fixed restorations can be fabricated in various
materials such as, metals which include precious,
semi-precious and non precious alloys, porcelain
fused to metal restoration and full ceramic
restorations. Full ceramic restorations with enhanced
aesthetics have become very popular, but do have

their limitations. Full ceramic restorations with
enhanced aesthetics have become very popular, but
do have their limitations. The demands for full metal
restoration has decreased because of unpromising
186
Mhaske Prasad et al.,
aesthetics and are advocated in fewer situations,

whereas porcelain fused to metal restorations have
always remained as gold standard due to their high
strength and good aesthetics. For the restoration to
fulfil esthetic requirements, porcelains have been
fused to metal for fabrication of restorations.
Porcelain fused to precious metal restorations were in
demand in the late 20th century and the beginning of
the 21st century as it improved the esthetics of the
restoration and the yellow colour of gold resulted in a
more natural appearance for the restoration1. Base
metal alloys, due to their low cost, are being used
more often as the substructure because of their good
mechanical properties, excellent metal ceramic
bonding and biocompatibility. The bonding of
porcelain to metal is an important point to be
considered for the success of the restoration2. Failure
in the bonding between the porcelain and metal may
lead to debonding of porcelain from the metal
substructure and failure of the restoration. The metal
substructure can be fabricated by conventional
casting by lost wax technique or by contemporary
techniques such as CAD CAM processing and
Laser Sintering technique3. Nickel chromium alloy
has been a popular alloy for restoration as it has its
advantages, but many have reported its allergies and
hence attempts are made to fabricate the substructure
with an alternative alloy such as cobalt chromium.4
When CAD CAM was introduced into esthetic
dentistry scene few years ago, it got with it a wide
range of features such as, excellent marginal fit,
reduced adjustments, superior esthetics and
mechanical properties and controlled materials.
However the advances in rapid manufacturing
technology have brought CAD CAM benefits
within reach of mainstream dentistry.5 Traditional
metal castings require a sequence of steps to fabricate
a restoration. However, with introduction of Direct
Metal Laser Sintering (DMLS), the prostheses have
been simplified as low cost CAD CAM frameworks
can now be produced in pure, medical grade Cobalt Chromium. The Laser sintered porcelain fused to
metal restorations gives the laboratory a new
opportunity to stay ahead of the competition and
keeping down the cost. This study is to evaluate and
compare the shear bond strength of cast base metal

alloys i.e. Nickel Chromium, Cobalt Chromium
and Laser Sintered Cobalt Chromium alloy to
dental porcelain.
After the approval by the Institutional Ethics
Committee, the comparative study was done. In total
of 30 samples were fabricated to carry out the study,
which conducted 10 samples each of cast nickel
chromium alloy, cast cobalt chromium alloy and laser
sintered cobalt chromium alloy. A circular disc of self
cure clear acrylic resin (DPI RR Cold Cure, Dental
Products of India) was fabricated with dimensions 10
mm in diameter and 4 mm in thickness. A putty
(Express XT Putty Soft, 3M ESPE) impression of
this disc was made to prepare a mould for fabrication
of wax pattern (Crown Wax, BEGO) for preparation
of sample discs. Wax patterns in the form of disc
were prepared in the putty mould. 10 wax patterns
were fabricated for each of Nickel Chromium
(Cerabond, BEGO) and Cobalt Chromium (Wironit,
BEGO) castings and a single wax pattern was
prepared to scan three dimensionally for fabricating
laser sintered cobalt chromium discs. The discs to be
casted were then sprued using Sprue wax (Sprue
Wax, Sigmadent). Nickel chromium, cobalt
chromium alloy for conventional casting, and cobalt
chromium alloy for laser sintering was used.
Conventional feldspathic porcelain was also included
in this study. Other metal alloys such as gold, and
ceramics such as Zirconia and glass ceramics were
not used for this purpose.
The pattern, following the standard water powder
ratio, was then invested with a ring liner used on the
casting ring to allow the expansion of the final
outcome. Wax burnout was carried out in a burnout
furnace (Miditherm, BEGO, USA) at the temperature
of 980 o C and the mould was then subjected into an
induction casting machine ( Fornax, BEGO, USA)
in which the molten metal was flown into the mould
for fabrication of the discs. The procedure is same for
the casting of Nickel Chromium and Cobalt
Chromium alloys (Fig 1).
187
Fig 1: Steps in fabrication of samples

Whereas on the other hand the single wax pattern
prepared was scanned in a three dimensional scanner
(LAVA Scan, 3M ESPE) from all the aspects. This
pattern was then transferred to the machine computer
with all the details of its diameter and thickness.
Conventional casting method: Fresh pellets of metal
alloy were taken and casting for nickel chromiumm
and cobalt chromium alloy was carried out on an
induction casting machine. Once the molten metal
had flown into the mould completely, it was taken out
of the machine and allowed to cool gradually. The
investment material was removed in aluminium oxide
sand microblaster (Duostar, BEGO) and the casting
was retrieved. The sprues are then cut using
carborandum disc and the samples were finished
using metal finishing points (Metal finishing and
polishing kit Shofu Inc.). Both the Nickel
chromium and Cobalt chromium discs were finished
in the same way to achieve the desired dimensions.
Laser sintering method: On the other hand the data
of the scanned disc was transferred to the machine
computer. The software (EOSTAT 1.2) created a
CAD data and transferred it to the machine for
fabrication. The machine, EOS M 270 laser sintering
system has a radiation heater, a focussed laser beam
at the roof, a platform on the floor with metal powder
on both the sides of the platform, which is adjusted
by a movable piston at the level of the platform. The
metal powder is of very fine particles (20 microns), is
moved over the platform and spreads evenly so that
the laser beam on top melts the metal locally and the
powder gets fused. This procedure was repeated until
the samples were fabricated. The samples were then
retrieved and finished.
All the samples were microblasted for roughening the
surface. After microblasting they were subjected to
ceramic furnace (Vacumat 40 T, VITA Zahnfabrik,
Germany) for oxidation firing. After the oxide layer

was removed, the discs were cleaned in the ultrasonic
cleaner and using a steam cleaner. Now the discs
were ready for porcelain build up. Feldspathic
porcelains (VMK 95, VITA Zahnfabrik, Germany)
were used, layer of wash opaque, after mixing the
powder and liquid on a glass slab, was applied with a
brush over the discs and subjected to firing cycle as
per the manufacturers instructions. After that the
liquid and powder opaque was mixed to apply over
the disc and was fired. The dentin layer was applied
using a brush; excess liquid was withdrawn by
tapping with soaking paper. Both the 1st and the 2nd
dentin firing followed by enamel firing were carried
out according to manufacturers instructions. A
ceramic layer of thickness 2 mm and diameter 10 mm
was achieved and measured using metal gauge.
Anything in excess of these dimensions was trimmed
off and finished with porcelain finishing points
(Shofu Inc). The discs were once again cleaned in the
ultrasonic cleaner and allowed to dry for application
of glaze. Application of glaze (VITA AKZENT) was
followed by firing. Porcelain was fired on all the
samples together to standardize the procedure (fig 2).
Fig 2: Samples of Group A, B and C.

The shear bond strength was measured in a Universal
testing machine (Instron 3367). For this purpose a
special jig was required to hold the disc. A stainless
steel cylinder with a hole having internal diameter 10
mm and depth 4 mm was fabricated (Shakti
Engineering and Fabricators, Navi Mumbai). At the
base of the hole a screw nut assembly was attached
which would enable us to move the disc up and down
to get the correct interface of porcelain and metal. A
special jig assembly was also fabricated with two
plates. These plates had holes at both the ends, one to
engage the rods for the Universal Testing Machine
and another to hold the disc. The plates were
188
positioned one over the other which had the sliding

mechanism so that one plate would engage the metal
part of the disc and the other plate engages the
porcelain portion.
The disc was placed such that the metal porcelain
interface lied exactly in between the two plates and
the metal and the porcelain portion was engaged in
the holes of the plates, and this entire assembly was
placed in the Universal Testing Machine. The testing
was done and the discs were subjected to shear load
at the metal-porcelain interface with increasing load
and the crosshead speed of 5 mm / sec till the disc
debonded completely. The values obtained were in
the units of kilogram force (KgF) and were converted
into Megapascals (Mpa).
The debonded samples of cast nickel chromium, cast
cobalt chromium and laser sintered cobalt chromium
alloys were cleaned in an ultrasonic cleaner and were
kept
ready
for
observation
under
the
stereomicroscope. The fractured surface of the
debonded samples was observed for scoring the area
of the debonded surface and determining whether the
fracture was adhesive, cohesive or a mixed. The
Fractographic analysis is interpreted through the
Stereomicroscopic images.
This examination was done to check whether the
fracture occurred was in the porcelain layer or in the
interface of porcelain and metal. This determined
whether the fracture was cohesive or adhesive. The
fractured surface was evaluated using Adhesive
Remnant Index (ARI)4 (Fig 3,4, and 5 shows
fractured surface of sample of group A, B and C
respectively).
Fig 3: Stereomicroscopic image of Sample of

group A
Fig 4: Stereomicroscopic image of Sample of group B
Fig 5:Stereomicroscopic image of Sample of group C

Statistical analysis: Statistical significance was
determined using one - way analysis (ANOVA),
followed by POST HOC test. Level of significance
was p < 0.05. There is a highly significant difference
between average values of shear bond strength when
group A, B and C were compared together. After
applying Students Unpaired t test there is no
significant difference in shear bond strength in group
A compared with group B, highly significant in group
A and group C and very highly significant in group B
and group C.
RESULTS
The porcelain to metal shear bond strength of each
sample was calculated from the load applied on a
Universal testing Machine with a crosshead speed of
5 mm/ Sec. While the mean shear bond strength was
higher in laser sintered cobalt chromium samples, the
bond strength was significantly different (p < 0.05)
from that of cast nickel chromium and cast cobalt
chromium. The shear bond strength of cast nickel
chromium (23.88 Mpa) was less as compared to laser
sintered cobalt chromium (34.56 Mpa) and that of
cast cobalt chromium (23.70 Mpa) was the least.
189
Table 1: Shear bond strength of samples of Group A in Megapascals (Mpa)

Samples A1
A2
A3
A4
A5
A6
A7
19.64
17.84
29.83
18.62
35.99
18.78
24.35
Samples B1
B2
B3
B4
B5
B6
B7
13.80
30.12
26.67
16.74
26.19
29.69
18.65
Samples C1
C2
C3
C4
C5
C6
C7
47.83
48.62
28.97
30.43
25.86
37.83
34.67
Table 2: Comparison of shear bond strength
between the three groups with One- way ANOVA
Samples
shear bond Df F Value p value
strength
Group A
23.88 6.3
2.00 8.73
0.012*
Group B
23.70 5.49
Group C
34.56 7.93
Data presented as Mean SD, *p value < 0.05, F=
Degree of Freedom
Table 3: Comparison of shear bond strength
within three groups by POST HOC test
Samples
Students t test value and p
Value with significance
Group A vs Group B t = 0.03, p > 0.05@
Group A vs Group C t = 3.35, p < 0.01*, highly
significant
Group B vs Group C
t = 4.32, p < 0.001**
@
not significant, *highly significant, ** extreme highly
significant
DISCUSSION
Many methods have been proposed to quantify such
as adhesion, but none is completely exempt from
errors, due to the complexity of the porcelain - metal
bonding5, 6,7. Metal- porcelain restorations for clinical
use contain thermal stresses upon which the load
stresses are superimposed. For the majority of bond
experiments described in the literature, stress
concentration is present at the site near the load
application shear tests8.
This study was carried out first to evaluate the
porcelain fused to metal bond strength of
conventionally used feldspathic porcelain to cast
Nickel Chromium alloy, cast Cobalt Chromium alloy
and newly introduced direct metal laser sintered
Chrome cobalt alloy and then to compare them.
Conventionally used Ni-Cr alloy was used along with
Co-Cr alloy for fabrication of the substructures. The
Ni-Cr alloy is known to cause allergy and
hypersensitivity reactions as found out in earlier
studies. Co-Cr alloy has less bonding with the
A8
26.21
A9
29.34
A10
18.22
B8
26.05
C8
32.14
B9
24.59
C9
28.53
B10
24.56
C10
30.67
porcelain as suggested by Joias et al9. These alloys

were fabricated using traditional lost wax casting
procedure. The alloy used in the third group was laser
Sintered Co-Cr alloy, which known to be medical
grade alloy produced from fine metal powder of
approx 20 m in size and thereby promising 99 %
density of the resultant product. Conventional used
feldspathic porcelains- VITA VMK 95 was selected
for layering as it is the most widely used veneering
porcelain in combination with metals. Porcelain build
up over these samples of the group A and B was done
in a conventional method, except for group C where,
wash opaque of Cerambond was used as it bonds the
porcelain well with laser sintered Co-Cr alloys. A
pull type of test was carried out to fracture these
samples and readings were noted.
The test carried out in this study showed a significant
difference in the shear bond strengths in between the
three groups. The highest load required to fracture the
samples was for group C, i.e., laser sintered Co-Cr,
followed by cast Ni-Cr group A and cast Co-Cr
group B. Akova10 and associates carried out a similar
study, but found out no significant difference in the
bond strength of cast Ni-Cr, cast Co-Cr and laser
sintered Co-Cr. They found out that all metal ceramic
specimens of cast Ni-Cr and cast Co-Cr alloys
exhibited a mixed mode of cohesive and adhesive
failure, whereas five samples of laser sintered Co-Cr
alloy exhibited a mixed failure and five samples
exhibited adhesive failure in the porcelain. Cohesive
failure within the porcelain is the most desirable bond
failure mode5, indicating a strong bond between the
oxide layer and both the metal and ceramic. This
study shows that laser-sintering the CoCr alloy
powder to form the substructure for a metalceramic
restoration, rather than using conventional dental
laboratory casting, does not significantly degrade the
metalceramic bond strength. One limitation of this
study may be the sample size of ten for the specimen
190
groups, and only one base metal alloy was compared

with casting and laser sintering.
OBrien11 in 1977 classified porcelain-metal bond
failures according to various interfaces and concluded
that the cohesive failure within the porcelain
represented a proper porcelain to metal bond. Sced
and McLean12 considered the possibility that the
oxide layer formed at the interface between the
materials may impair adhesion because it decreases
the coefficient of thermal contraction of the porcelain.
Mackert et al13 found a positive correlation between
the thickness of the oxide layer formed and the
adhesion of the porcelain to the metal.
Hegedus et al14 performed a detailed microstructural
investigation to compare the reaction layer developed
among 3 different brands of dental porcelains and a
Ni-Cr alloy (Wiron) under different firing conditions.
Evaluations of the fit of crowns made with this
technique are essential before being recommended for
porcelain fused to metal restorations. It should be
noted that preparation of laser-sintered idealized
restorations from Ti-6Al-4V have also been reported.
This group noted that improvements in the processing
parameters are needed to yield clinically acceptable
fit of restorations prepared from the laser-sintered
titanium alloy.
CONCLUSION
A total of thirty porcelain fused to metal discs were
fabricated for testing the shear bond strength at the
metal ceramic interface. Within the limitations of the
study the following conclusions were drawn:
Porcelain fused to laser sintered cobalt chromium
alloy had the highest shear bond strength.
The shear bond strength of porcelain fused to
nickel chromium alloy was better than that of
cobalt chromium alloy fabricated by conventional
method but was less than that with laser sintered
cobalt chromium alloy.
The shear bond strength of porcelain fused to
cobalt chromium fabricated by conventional
casting showed the least among the three groups.
Limitations of the study: This study limits the
evaluation of some other properties such as
compressive strength and colour stability. The sample
size is small and so a larger sample size can be taken
into consideration for more significant results. There
are several other studies are that are required for
assessment of properties such as marginal fit and

adaptation.
Acknowledgements: My sincere thanks to Dr.
Dinesh Jain, Neerav Jain and team of Dental
Ceramists (I) Pvt Ltd. for extending the laboratory
support. I am very thankful to Mr. Hemant Pawar, for
helping me with the statistical analysis.
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DOI: 10.5958/2319-5886.2015.00031.4

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Health Sciences
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Volume 4 Issue 1
Coden: IJMRHS
th
Research article
Copyright @2014
ISSN: 2319-5886
PERIODONTAL DISEASES & TREATMENT FROM PERSPECTIVE OF MEDICAL PROFESSIONALS: A

SURVEY STUDY
Mundhe Priti G1, Neelima Rajhans S2, Nilofer Sheikh.S3, Nikesh Moolya N4, Nilkanth Mhaske4, Nikhil Gutte D5
1,3
Post Graduate Student, 2 Professor & Head, 4Reader, Department Of Periodontics, Y.C.M.M. & R.D.Fs Dental
College Ahmednagar, Maharashtra, India.
5
Consultant, Pediatrician Siddhivinayak Pediatrics Hospital, Ahmednagar, Maharashtra, India
*Corresponding author email: pritim222@gmail.com
ABSTRACT
Background: Periodontics is fast evolving dental specialty. But periodontics is still seen to be nascent &
perception of it is variable among different health professionals. Aim: To assess the awareness of periodontal
diseases, its causes & treatment modalities available among medical professionals. Materials & methods: Two
hundred & five medical professionals working in Ahmednagar were interviewed through questionnaire. The
questionnaire was consist of different terminologies, periodontal diseases their cause, its systemic effects,
different treatment techniques used and newer treatment modalities. Results: positive attitude towards periodontal
diseases were observed. The level of awareness was marginally higher with consultants. The difference was
statistically significant among three groups. Conclusion: Awareness about periodontal diseases, its aetiology
and association between systemic diseases was observed. But awareness about periodontal therapy & newer
treatment modalities was poor.
Key words: Periodontal awareness, attitude, treatment modalities
INTRODUCTION
The term "periodontal diseases" is a nonspecific term
that refers to any disease or disease process that
affects the periodontium.1 while Preventive
periodontics is preventing the initiation and
recurrence of periodontal disease & discussing on
minimizing or eliminating the etiological factors that
are currently believed to contribute to it. The main
aim of preventive periodontics is to promote
optimum health of the periodontium.
The surgeon generals report 2 recognizes the mouth
as a mirror of health or disease, as a guard or ward of
warning, and as a potential source of pathogens
affecting other systems. thus Medical practitioners
must play an active role in periodontal health
promotion.
Though periodontics is rapid developing dental

specialty, but it is still seen to be budding &
perception of it is erratic among different health
professionals. Many studies are carried out to
evaluate the awareness of patients attending the
hospitals and dental clinics.3,4 There are few studies
addressing periodontal awareness in various
healthcare professionals.5,6,7 Hence present study was
conducted to assess the awareness of periodontal
diseases, its causes & availability of treatment
modalities among medical professionals in
Ahmednagar.
Aim: To assess the awareness of periodontal
diseases, its causes & availability of treatment
modalities among medical professionals.
193
Priti et al.,
MATERIALS & METHODS:

The present study was done after approval from the
ethical committee of our college, and the
participations were informed about survey study and
consent forms were taken before interview.
Inclusion criteria: Medical interns, Postgraduate
students, and consultants present in Ahmednagar, as
well as rurally based medical institutes in
Ahmednagar which were randomly selected for the
present study.
A total two hundred five [132-males & 73-females]
medical professionals (i.e., M.B.B.S. & further
specialist of clinical branches) were interviewed. All
medical professionals were interviewed through
questionnaire.7 They were interviewed at their place
of work 30 minutes were given to fill the
questionnaire.
The questionnaire is based on information about
different terminologies, periodontal diseases their
cause, its systemic effects, different treatment
techniques used and newer treatment modalities7. The
questionnaire consists of 24 questions which are
divided under headings such as: 1] knowledge about
periodontal diseases, 2] awareness about treatment
availability and 3] awareness about newer treatment
modalities. Eight questions under each heading.
Statistical analysis was done by descriptive analysis
as percentage/proportions. Chi-Square test was
applied to test the association between medical
professionals and their awareness, cause and
treatment modalities of periodontal diseases.
Probability level p<0.05 was considered as
significant.
RESULTS
Results of the present study showed that affirmative
attitude was observed among medical professionals.
The knowledge about the periodontal diseases its
causes and association with systemic conditions.
Awareness about availability of treatment options
such as T/t of pigmented gums, gummy smile were
good, but the awareness about newer treatment
modalities used in periodontal treatment such as local
drug delivery systems, LASER, alloderm, bone
substitutes, and platelet-rich plasma is slightly poorer.
100%
Interns
Post graduate
students
Consultants
80%
60%
62%
74%
45%
40%
20%
0%
Knowledge about periodontal diseases

Fig 1: knowledge about periodontal diseases:
100%
80%
60%
40%
Interns
Post graduate
students
consultants
78%
55%
42%
20%
0%
Awareness about treatment availability
Fig 2: awareness about treatment availability
100.%
90.%
80.%
70.%
60.%
50.%
40.%
30.%
20.%
10.%
0.%
Interns
Post graduate students
Consultants
66.10%
51%
22.50%
Awareness about newer treatment

modalities
Fig 3: Awareness about newer treatment
modalities
The level of awareness was higher with consultants
than interns and post graduatestudents. The difference
was statistically significant among groups.
194
Priti et al.,
DISCUSSION
Medical professionals need to have a basic

periodontal knowledge as they were the first
person to encounter oral problems in patients
while practicing such as swelling in the oral
cavity, bleeding gums, if they examine the oral
cavity regularly these conditions can be
identified in the initial stages. Another important
fact to consider is that some periodontal
infections may not always be easily identified.
The symptoms are vague. And if left untreated,
will destroy both periodontal tissue and the
underlying bone.
The present study reveals, positive attitude towards
periodontal diseases. The knowledge about the
periodontal diseases its causes and association with
systemic conditions such as halitosis, association with
diabetes mellitus cardiovascular diseases was
significant.
Recent studies reveal the association between
periodontal diseases and many serious and lifethreatening systemic diseases, such as, coronary heart
disease8, 9,10; contribute to low pre-term birth
weights11; increase the severity of diabetes12; play a
role in osteoporosis; rigorously hassle the immune
system; lower resistance to other infections; and
reduces life expectancy13.
Awareness about drugs as a cause of gingival
enlargement is higher with Ca. channel blockers then
phenytoin sodium then cyclosporin and other drugs.
Percentage of awareness is again higher among
consultants compared to other groups.
The awareness about newer treatment modalities such
as, local drug delivery systems, LASER, alloderm,
bone substitutes and platelet-rich plasma is slightly
poorer. Questions regarding local drug delivery
systems, use of LASER or platelet rich plasma should
have evoked a higher affirmative response than
obtained i.e. 22%66% because these are the
modalities which are frequently used in different
medical practices.
A similar study was done by Swati pralhad et al.
(2011) which has a similar type of questions. The
result of study shows that a positive attitude towards
dental and periodontal check up and treatment needs
was observed.7
The drawback of the present study was it contained

close ended questions, so the assessment of
knowledge may be affected.
CONCLUSION
A positive attitude towards periodontal diseases, its
aetiology and association between systemic diseases
was observed. But awareness about periodontal
therapy & newer treatment modalities was poor
among those questioned. However, inputs from such
surveys can be used in preventive periodontal
programs. Periodontal health programs and joint
ventures can be planned in future. So physicians can
provide oral health counselling and helps to install a
positive dental attitude. They can also help to
intercept soft and hard tissue lesions in order to
restore health and prevent further damage.
REFERENCES
1. The American Academy of Periodontology.
Glossaryof Periodontal Terms. Chicago: The
American Academy of Periodontology; 1992:37.
2. US Department of Health and Human Services.
Oral health in America: a report of the surgeon
generaldexecutive summary. Rockville (MD): US
Department of Health and Human Services,
NIDCR, NIH; 2000. p. 113.
3. Subhashraj K, Subramaniam B. Awareness of the
specialty of oral and maxillofacial surgery among
health care professionals in pondicherry. Indian J
Oral Maxillofac Surg 2008;66:2330-34
4. Rastogi S, Dhawan V, Modi M. Awareness of
oral and maxillofacial surgery among health care
professionals a cross sectional study. J Clin
Diagn Res 2008;2:1191-5
5. Joshipura KJ, Pitiphat W, Douglass CW.
Validation of self-reported periodontal measures
among health professionals. J Public Health Dent
2002;62:2
6. Mali A, Mali R, Mehta H. Perception of general
dental practitioners toward periodontal treatment:
A survey. J Indian Soc Periodontol 2008;12:1
7. Pralhad S, Thomas B. Periodontal awareness in
different
healthcare
professionals:
A
questionnaire survey. J Educ Ethics Dent
2011;1:64-7
195
Priti et al.,
8. Syrjanen J, Peltola J, Valtonen V, Iivanainen M.

Dental infections in association with cerebral
infarction in young andmiddle-aged men. Journal
of Internal Medicine1989: 225, 17984
9. Umino M, Nagao M. Systemic diseases in elderly
dental
patients.
International
Dental
Journal1993;43:21318
10. Madianos PN, Bobetsis GA, Kinane DF. Is
periodontitis associated with an increased risk
factor of coronary heart disease and preterm
and/or low birth weight births? Journal of
Clinical Periodontology. 2002;29:2236.
11. Moreu G T, ellez L, Gonzalez-Jaranay M.
Relationship between maternal periodontal
disease and low-birth-weight pre-term infants. J
Clin Periodontol 2005; 32: 62227
12. Loe H. periodontal disease: the sixth
complication of diabetes mellitus. Diabetes Care
1993:16 (suppl1): 329.
13. Piia Hama la inen , Jukka H. Meurman,
Markku Kauppinen , Marja Keskinen; Oral
infections
as
predictors
of
mortality:
Gerodontology 2005, 22; 151-57
196
Priti et al.,
DOI: 10.5958/2319-5886.2015.00032.6

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
Coden: IJMRHS
st
Review article
Copyright @2014
ISSN: 2319-5886
DIFFERENT FACES OF HUMAN PAPILLOMA VIRAL INFECTIONS IN A TROPICAL RURAL

PRACTICE IN NIGERIA
*Salami T.A.T1, Momoh M2, Irekpita E3, Obasikene G4
Departments of Medicine1, Obstetrics and Gyneacology2, Urology3 and OrthoRhinoLaryngology4 (ORL)
Departments, Irrua Specialist Teaching Hospital Irrua and Ambrose Alli University Ekpoma Edo State Nigeria.
*Corresponding author email: tatsalami@gmail.com
ABSTRACT
Introduction: The human papilloma virus (HPV) is a ubiquitous virus that manifest in different parts of the body
in various ways. It particularly has a unique ability to affect the skin and mucous membranes. It can present
benignly or in an aggressive malignant manner depending on the part of the body involved. Methods: This
review describes several different ways in which it presents in our tropical rural practice in Nigeria. This ranges
from sexually transmitted infections of the skin and mucous membranes of the genitalia to non-sexual
transmissions of the skin and mucous membrane of other parts of the body apart from the genitalia. It also
describes the benign and the malignant manifestations of this infection. The peculiarities of the various types are
discussed. Conclusion: The human papilloma virus has evolved a unique ability to attack various parts of the
human body where keratinocytes are present ranging from benign lesions to malignant ones. The infections are
becoming commoner with various conditions that compromise the body`s cell mediated immunity particularly
infections like HIV. The recognition of these lesions may aid in the prompt commencement of the appropriate
therapy for this group of patients and may help to reduce morbidity and sometimes mortality of malignant ones.
Keywords: Human papilloma virus, Tropical, Rural practice
INTRODUCTION
The human papilloma virus (HPV) is a ubiquitous
DNA virus that is capable of infecting the human
keratinocytes on the skin and mucous membranes.
The papilloma virus genus is a member of the
Papovaviridae family. They are small, non-enveloped
viruses measuring about 55 nm in diameter1. It establishes
productive infections only in the keratinocytes of the
skin or mucous membranes.
It is transmitted in various ways, such as sexually
(genital, anal and oral) and it is the most frequent
sexually transmitted infection in the world2, 3. It is
also transmitted perinatally from mother to child4 and
non -sexually by contact of infected hands to another
part of the body5 as well as via sharing of
contaminated objects. It has also been postulated that

it can be transmitted via blood transfusion6. HPV is
restricted to the basal layer of the stratified epithelium
where they replicate via proliferation of infected
basal keratinocytes7. Infection occurs via traumas and
mild bruises that expose segments of the basement
membrane. The infectious process takes 1224 hours
for initiation of replication. Once an HPV virion
invades a cell, an active infection occurs, and the
virus can be transmitted. The lesion that such an
infection causes depends on the part of the affected
and this review describes 5 different ways it presents
in our tropical rural practice in Nigeria.
197
Salami et al.,
Fig 1: Genital warts.

Condyloma acuminatum or genital warts are benign
growths occurring in the skin and mucous membranes
of the genital areas and anus due to infection with the
human papillomavirus. This is the commonest way
for it to manifest (as seen in figure 1 above). Genitals
(condylomata acuminata or venereal warts) are the
most easily recognized.
Typical lesions are found on the penile shaft of males
as raised circular plaque like lesions clustered in
groups. They are usually painless and it is only the
appearance and gritty feeling by the patients that
makes them seek attention. Ninety percent of cases
occurring around the genitalia are caused by types 6
and 11 and are acquired through micro lacerations of
the skin8. Auto inoculation of virus onto nearby
adjacent skin is common. This type of infection
usually spreads through the skin and not through the
blood. Cell mediated immunity (CMI) appears to play
a significant role in its regression making patients
with CMI deficiency such as those with HIV
infection to be particularly susceptible to the infection
and notoriously difficult to treat9. The highest
incidence of genital warts is found in young adults
aged years with a female-to-male ratio reported to be
1.4:1 in some series10.
Warts on other parts of the body, such as on the hands
and inner thighs are caused by other types of HPV
different from that infects the genitalia. Barrier
protection with condoms (particularly in males) does
not completely protect from the infection since they
do not cover exposed areas such as the inner thighs
that may still be smeared with infected
secretions11.Most infections are however mild and can
resolve on its own without any treatment.
Fig 2: Anal warts.

These are similar to the above in appearance, but are
located around the anal orifice as seen in figure 2
above. Anal sex is the usual predisposition. Infections
in this area are transmitted primarily via sexual
activity11.The importance of this relatively benign
infection is that it is associated with an increased risk
of secondary malignancy. This is particularly
common with types 16,18,31,33 and 45. It occurs in
up to 75% of sexual contacts12.
Fig 3: Verrucous carcinoma of genitalia (giant

Condyloma of Buschke-Lwenstein)
This is a low-grade, locally invasive, squamous cell
carcinoma that is associated with HPV types 6 and
11. This giant genital mass (figure 3 above) was seen
in an HIV positive woman.
Patients with genital warts have an increased risk of
anogenital malignancy13. Of the 120 known human
papillomavirus, 51 species and three subtypes infect
the genital mucosa. Of these, 31 are considered to
present a low risk of carcinogenesis; 17 are
considered to be high risk and 6 are of intermediate
risk. Infection with HPV is the primary cause of
cervical malignancy, although most patients with
HPV-infected cervices have a benign outcome. Up to
198
Salami et al.,
90% of cervical cancers are caused by HPV infection

of the cervix. Strong epidemiologic evidence suggests
that 10% of patients who had a high-grade squamous
intraepithelial lesion (HGSIL, which includes socalled moderate-to-severe dysplasia, carcinoma in
situ, and cervical intraepithelial neoplasia II and III)
would have persisted of lesions that eventually would
progress to invasive cancer without treatment.
Patients with perianal warts, patients who are HIV
positive, and those with a history of receptive anal
intercourse are at increased risk for anal HGSIL. No
direct evidence suggests that this would progress to
invasive anal cancer, as lesions of the cervix are
capable of doing. Nonetheless, penile, vulvar,
vaginal, ovarian, and anal carcinomas have been
linked to HPV infection. Female patients with genital
warts should therefore be advised to have an annual
screening examination and Papanicolaou test even
after receiving a preventive vaccination. Cervical
cancer screening recommendations have not changed
for females who receive HPV vaccine14.Without
continued screening; the number of cervical cancers
preventable by vaccination alone is less than the
number of cervical cancers prevented by regular
screening alone15.
Fig 4: Focal epithelial hyperplasia

Focal epithelial hyperplasia or Hecks disease is a
rare viral infection of the oral mucosa caused by
human papillomavirus. It was first described in
Native Americans in 1965 by Archard et al16but since
then several cases have been reported from other
parts of the world including Nigeria17, 18. It is a rare
benign lesion of the oral mucosa produced by the
subtypes 13 or 32 of human papillomavirus (HPV) 19.
It primarily occurs in children (as seen in figure 4
above in this 7 years old girl) with no gender
predilection. The subtype 32 of HPV tends to cause
the disease in the older age groups while the subtype
Salami et al.,
13 of HPV seems to be equally involved in the

development of the disease in both young and old
patients. This condition is characterized by the
occurrence of multiple or unique whitish or normal in
color small papules or nodules in oral cavity,
especially on labial and buccal mucosa, lower lip and
tongue, and less often on the upper lip, gingiva and
palate20.The frequency of this disease varies widely
from one geographic region to another21. A sitespecific predilection for keratinized and nonkeratinized surfaces has been observed in these HPV
infections22.
Fig 5: Epidermodysplasia verruciformis.
Epidermodysplasiaverruciformis (EV) is a rare
cutaneous disorder characterized by persistent
widespread, generalized human papillomavirus
(HPV) infection23. HPV causes epidermo dysplasia
verruciformis in immuno compromised individuals as
demonstrated by some of the patients seen in figures
5 above. This viral infection manifests by excessive
keratin production as a result of inefficient immune
containment or regulation leading to typical lesions of
plain warts24.Epidermodysplasia verruciformis (EV)
in the classical form without HIV infection results
from a genetically determined defect in cutaneous
immunity that leaves afflicted individuals susceptible
to persistent HPV infection and later development of
squamous cell carcinoma of the skin. Many of the
HPV types found in EV lesions are non-pathogenic to
the general population25. Its occurrence in patients
with HIV infection has been reported severally in the
Nigerian literature due to the high prevalence of HIV
infection26-28. EV is a rare disorder of cutaneous
immunity characterized by an inherited susceptibility
to infection with specific HPV. It was first described
by Lewandowsky andLutz29 in 1922. There does not
appear to be any racial or geographic predilection,
although there have been few reports of EV in
199
individuals of African descent30. The initial cutaneous

changes seen with EV often occur at a young age31
EV typically presents with two main types of
cutaneous lesions. Flat wart like lesions that present
as scaly hyper- or hypopigmented confluent patches
and linear streaks are widely distributed on the hands,
arms, and face such those seen in the patients in
figure 5 above (there are prominent Koebnerization
visible in all the patients due to the following lines of
scratching. HIV infection is the common denominator
in all the patients). In addition, verrucous or
seborrheic keratosis-like lesions are commonly seen.
Skin cancers commonly occur in these patients,
especially in sun-exposed areas32There is increasing
evidence that the major predisposing factor to the
development of EV is a dysfunction in cell-mediated
immunity; however, the specific immune defect has
not been fully elucidated33.The underlying
abnormality involves the inability to recognize EVassociated HPVs, which is marked by the inhibition
of natural killer cells and cytotoxic lymphocytes34.Its
association with HIV infection has been reported by
several authors35-37. HIV infection as a potent
suppressor of all forms of immunity predisposes
patients to all forms of infection including viral
infections with HPV. These will develop as the
immune status of the patient continues to decline.
Other opportunistic infections may occur before or
after the development of EV. Steger et al38 suggested
that up to 20% of the population may sub clinically
harbour certain EV-associated HPVs. Progression of
HIV infection may therefore convert this subclinical
infection to a full blown disease. The disease
manifests as a congenital form in infancy (about
7.5%). During childhood (61.5%: in years), or at
puberty (22.5%). Epidermo dysplasiaverruciformis in
association with HIV infection may be a pointer to
underlying HIV infection and early commencement
of antiretroviral therapy in such patients might
sometimes lead to the resolution of the disease. The
above presentations are a few ways in which different
strains of human papilloma virus present clinically to
our tropical rural dermatology practice. The
occurrence of HIV infection increases the frequency
of occurrence of some while in others, it occurs rarely
with few reported associations with or without HIV
infection. Recognizing these different types helps the
managing clinician to approach its care in a logical
scientific manner as demonstrated by several studies
where human papilloma virus and HIV infection coexists and may even lead to reversal of clinical
features in some cases39.
CONCLUSION
In conclusion, though human papilloma viral
infection is restricted to the keratinocytes in the skin
and mucous membranes, it can still be a significant
cause of morbidity and mortality particularly in
tropical Africa.
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dysplasiaverruciformis in two half brothers with HIV
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36. Davison SC, Francis N, McLean K, Bunker CB.
Epidermodvsplasiaverruciformis-like
eruption
associated with HIV infection. Clin ExpDermatol.
2004 ;29(3):311-12
37. Barzeaar C, Paul C, Saiaa P, Cassenot P, Bachelez
H, Autran B, Gorochov G, Petit A, Dubertret L.
Epidermodysplasiaverruciformis-like
eruption
complicating human immunodeficiency virus
infection. Br J Dermatol. 1998; 139(1): 122-27.
38. Steger G, Olsewskv M, Stockfleth R, Pfister H.
Prevalence of antibodies to human papilloma virus
type in the human sera. .1 Virol 1990; 64: 4399-06.
39. Haas N, Fuchs PG, Hermes B, Henz BM.
Remission of epidermo dysplasia verruciformis like
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DOI: 10.5958/2319-5886.2015.00033.8

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Health Sciences
www.ijmrhs.com
Volume 4 Issue 1 Coden: IJMRHS
Copyright @2014
nd
th
Review article
ISSN: 2319-5886
A COMPARATIVE OVERVIEW OF POISONING IN MULTIDIMENTIONAL PERSPECTIVE

*Ghaffar UB1, Naser Ashraf Tadvi2, Sajid Hussain2
1
Assistant Professor, Department of Pathology, 2Assistant Professor, Department of Basic Medical Sciences,
College Of Medicine, Majmaah University, Al-Majmaah, Kingdom of Saudi Arabia
*Corresponding author email: ubghaffar@gmail.com
ABSTRACT
Background: Poisoning cases occur universally and have plagued mankind since antiquity. Keeping this in view,
this study was contemplated to find the comparative overview of poisoning in India and Saudi Arabia to knows
how the racial and cultural factors influence the pattern of poisoning. Material and Methods: A systematic web
based search was conducted and original studies on poisoning published in India and Saudi Arabia were analyzed
with respect to age, gender, category of poison, and overall distribution of toxic agents. Results: The study
concluded that the male to female ratio in India was 1.53:1 while in Saudi Arabia it was 1.2:1.In India, the highest
frequency of poisoning occurred with agrichemicals while in Saudi Arabia it was mainly due to pharmaceutical
drugs. In India the most common mode of poisoning is intentional (70.6%) and it is commoner in the age group
21-30 years (31.1%). This is in contrast with Saudi Arabia, which showed that most of the cases of poisoning is
accidental (54.1%) and occurred in children <10 years. Conclusion: The study suggested various similarities and
variations in the pattern of poisoning in the two countries with regards to distribution of poisoning among female
and young adult victims based on contextual factors like circumstances of poisoning and differential access to the
toxic agents. Careful and well planned strategies may reduce the incidence of poisoning in these countries
Key words: Poisoning, Age group, Agrichemical, Pharmaceutical drug, Intentional, Accidental
INTRODUCTION
Poison is any substance taken internally or applied
externally that causes injury or damage that causes
injury or damage to the body due to its exposure.
1
Poisoning cases are increasing day by day due to
changes in the lifestyle and social behaviour.
Advances in technology and social development have
resulted in the availability of most drugs and
chemical substances in the community.2The trend of
poisoning associated morbidity and mortality differs
from country to country and it varies with the span of
time. According to World Health Organization
(WHO), globally more than three million of acute
poisoning cases with 2,20,000 deaths occur
annually.3The present study was undertaken to
determine the trend of poisoning in the countries
where the original studies were conducted namely

India and Saudi Arabia. The study revealed that the
paradigm of poisoning illustrates some resemblance
and variation based on the socio-demographic figure
of the cases, the toxic agents involved and
circumstances surrounding the incidents.
MATERIAL AND METHOD
This study, conducted with the purpose of examining
similarities and disparities in the patterns of
poisoning across the two countries namely India and
Saudi Arabia. The comparison was based on the data
from the original paper published and collected
randomly from four different regions of India and
Saudi Arabia respectively. The papers which reported
203
Ghaffar et al.,
the age and gender distribution, distribution of toxic

agents and circumstances of poisoning were included.
In total, the four papers in India reported data on
1486 poisoning cases and in Saudi Arabia 1757 cases.
All papers described the data collection tools as a pretested data collection. The demographic and clinical
variables collected from the paper included the age,
and sex of the victims of poisoning; the names and
types of poisoning agent, the circumstances of

poisoning, whether accidental or deliberate. In line
with the objectives of the study, a re-analysis of data
was undertaken in order to make comparisons based
on pre-defined groups. On the basis of observation
and analysis, results were discussed and compared
with other relevant literatures.
RESULT AND DISCUSSION

Table1: Poisoning per age category and gender
Age categoryn(%)
Country
<10% 11-20% 21-30% 31-40%
41-50%
>50%
Total
India
n=1486
209
(14.1)
300
(20.2)
515
(34.7)
195
(13.1)
149
(10.0)
118
(7.9)
1486
Saudi Arabia
n=1757
715
(40.7)
290
(16.5)
466
(26.5)
167
(9.5)
86
(4.9)
33
(1.9)
1757
Table2: Overall distribution of toxic agents

Country
Toxic agentsn(%)
Pharmaceuticals Household Agrichemicals Animal and
products
insect bites
India n=1486 167(11.2)
259(17.4)
616(41.5)
187(12.6)
Saudi Arabia 839(47.8)
371(21.1)
134(7.6)
231(13.2)
n=1757
Table3: Circumstances of poisoning per age category
Country Circumstances Age categoryn(%)
<10yrs
11-20
21-30
31-40
41-50
India
n=1486
Gender
Male
Female
900
(60.6)
971
(55.3)
586(39.4)
786(44.7)
Food
Others
poisoning
12(0.8)
245(16.5)
99(5.6)
83(4.7)
>50
Total
Intentional
none
268(18.0)
461(31.1)
158(10.6)
102(6.9)
60(4.0)
1049(70.6)
Accidental
197(13.3)
32(2.2)
none
none
26(1.7)
49(3.3)
304 (20.5)
others
12(0.8)
None
54(3.6)
32(2.5)
21(1.4)
9(0.6)
133 (8.9)
209(14.1)
300(20.2)
515(34.7)
195(13.1)
149(10.0)
118(7.9)
1486
Total
Saudi
Intentional
none
192(10.9)
385(21.9)
139(7.9)
56(3.2)
10(0.6)
782(44.5)
Arabia
Accidental
715(40.7)
98(5.6)
68(3.9)
21(1.2)
28(1.6)
21(1.2)
951(54.1)
N=1757
others
None
None
13(0.7)
7(0.4)
2(0.1)
2(0.1)
24(1.4)
715(40.7)
290(16.5)
466(26.5)
167(9.5)
86(4.9)
33(1.9)
1757
Total
The increase in poisoning cases represents a major

health problem worldwide with high mortality and
morbidity. Incidence of poisoning varies from one
community to another and is influenced by age, sex,
economic status, local customs, social and
environmental circumstances. In both India and Saudi
Arabia males outnumbered females. The ratio being
1.53:1 in India, which is comparable to the studiesby

Dash S K et. al, (2005), Escoffery C T et.al, (2004).4,5
While in Saudi Arabiamales: females ratio was
1.2:1,which is comparable to other studies of
Ghaznawi HI et. al (1998).6This could be due to the
fact that males are more exposed to stress and strain
associated to family responsibilities in their day to
204
Ghaffar et al.,
day life. At the same time males are more susceptible

for taking risks as compared to females. 6
The age group with a maximum incidence of
poisoning in India was 21-30years(34.7%). It is
obviously due to the fact that this age group is the
determining factor of the life with high levels of
stress in terms of education, job issues, marriage and
other factors. Therefore, they are subjected to
substantial amount of mental strain during this
period.4,7While in Saudi Arabia the maximum
incidence of poisoning was in children under 10 years
of age(40.7%). This pattern came also in accordance
with other studies in Saudi Arabia that showed the
highest incidence of poisoning in children, Moazzam
M, etal (2009),8 Al-Barraq A(2011)9.This may be
because children have tendencies to explore the
surroundings and put everything in their mouths
without the knowledge to discriminate between the
safety of products.9 Irresponsibility on the part of the
parents could also not be ignored. Also the increased
number of boys in poisoned pediatric group could be
attributed to more mobility and exploratory behavior
in male children than female.10In the present study,
the lowest incidence of poisoning was in people over
50 years (1.9%). The incidence of poisoning in this
age group is very low as Islam condemns and strictly
proscribes intentional self-destruction (suicide).
The present study showed that in India the highest
frequency of poisoning occurred with Agrichemicals
(41.5%) followed by household products(17.4%).
Because, India is predominantly an agrarian country
about 60 to 80% of rural population depend on
agriculture and the poisoning with such products are
more
common.11Agrichemicals
particularly
organophosphates and aluminum phosphide were the
most commonly used poison. The high incidence is
because of unsafe practices, illiteracy, ignorance, lack
of protective clothing and easy available over the
counter for agriculture purposes.12,13
On the contrary, in Saudi Arabia most commonly
encountered group of poison was pharmaceutical
drugs (47.8%) both in adults and children followed
by house hold product(21.1%). The most frequently
ingested drugs among adults and children were
acetaminophen and other NSAID's. This pattern has
been reported in many western countries, some
eastern mediterranean and Asian countries. Similar
results as our findings were observed with the study
of Moazzam et al., in the Qassim Region of Saudi
Ghaffar et al.,
Arabia. They found that paracetamol and other

analgesics (NSAIDs) were frequently reported among
both adults and paediatric cases. 8 Drugs were a major
problem in several reports from Kingdom of Saudi
Arabia.8, 14 Some of the reasons include the lack of
dispensing drugs in child-resistant containers, an easy
access to medications without prescriptions and
careless storage of drugs inside homes.15 This
observation points out the urgency of implementing
the nationwide use of child-proof drug prescription
bottles, in order to eliminate or reduce childhood drug
poisoning in Saudi Arabia.16
In
India
among
pharmaceutical
agents,
Benzodiazepine group drugs (Diazepam, Alprazolam,
Nitrazepam etc.) were most commonly abused agents.
The second common cause of poisoning in both the
countries was by household products. Household
cleaning products like phenol, bleaches, and their
derivatives are stored in most houses and easy
availability of such products makes them responsible
for the higher incidence of poisoning. Parjapati et
al.17 also reported household chemicals as the second
most common toxic agents.
Animal stings and Scorpion bites are also on rise in
Saudi Arabia. The high rate of Animal stings and
bites in young adult victims may be explained on the
basis that this age category is associated with most
outdoor activities like moving out to the surrounding
mountains for recreation.18
In India the most common mode of poisoning was
intentional (70.6%) and it was commonest in the age
group 21-30 years (31.1%). It is comparable to other
studies18 and suggests that poisoning by intention has
increased because of their easy availability in the
market and also there is a general belief that poison
terminates life with minimal suffering.19,20Poverty,
inadequate income to run the family, monsoon failure
was responsible for higher incidence of poisoning
among laborers and farmers.21Failure in the exams or
inability to cope up the high expectation from parents
and teachers has increased the incidence of poisoning
among students.
This is in contrast with Saudi Arabia which showed
that most of the cases of poisoning is accidental
(54.1%) and occurred in children <10 years(40.7%).
This came in accordance with Izuora and
Adeoye(2001), who in their study in,Saudi Arabia
also found that there were no cases of intentional
poisoning in these age groups which may be due to
205
the rarity of this behavioral pattern in this area of the

world.22
This also could be explained by the different styles of
living between countries regarding the degree of
adherence of this age group to their families which
provide some protection against intentional
poisoning. Moreover, parents should be advised to
keep drugs in child secure lockers, cupboards with
secure locks in bathrooms can reduce accidental
poisoning by household insecticides.
In India accidental poisoning was observed in 13.3%
cases among children. In some of the cases poisonous
substances like house-hold products e.g. acid, caustic
soda etc were mistakenly given to the children by
their mothers. Studied showed that kerosene is the
commonest agent involved because it is still used as a
cooking fuel by the low socio-economic class.23
While in Saudi Arabia the second group comprises of
intentional poisoning cases(44.5%) that was highest
among young adults in the age 21-30years(21.9%),
with females significantly outnumbering males.
Females were mostly Saudis who had an intentional
intake of poison whereas males were predominantly
expatriate farm workers. Some of the reasons for the
lower percentage of intentional intake in Saudi
Arabia than India is because the level of stress (in this
age group)is low, level of education is better than
India, employment level is better, most important of
all is that as Islam condemns and strictly proscribes
intentional self-destruction (suicide) which plays a
major contributory factor for lower level.24
Unfairness towards females with high incidence of
family quarrels, domestic troubles, mal-adjustments
in married life which constitute some of the important
factors contributing towards the preponderance of
females.25
CONCLUSION
The present study findings suggest various
similarities and variations in the pattern of poisoning
in the two countries with regards to distribution of
poisoning among female and young adult victims,
based on contextual factors like circumstances of
poisoning and differential access to the toxic agents.
Careful and well planned strategies may reduce the
incidence of poisoning in these countries. Following
are the recommendations for prevention and limiting
the exposure of poisons and reducing the mortality

associated with it.
Recommendations
1. Foster the establishment of toxic exposure
surveillance system (TESS) which is used to
identify hazards early, focus on prevention
education, guide clinical research and direct
training.
2. That policies addressing the overall strategies
regarding the issues of illicit drug abuse as well
as pharmaceutical and pesticide misuse should be
designed and implemented in order to address
acute poisoning and related mortality.
3. Development of high quality poison information
and poison control services at national or regional
poison level to improve the evidence based
guidelines to aid management.
4. That restrictive legislation and regulations on
toxic agents particularly agrichemicals should be
enacted and enforced through a concerted effort
between the legislative and judiciary arms of
government with the active participation of civil
society.
5. Legalizations should be implemented to ban over
the counter selling of medications and to sell
potentially dangerous chemicals in childproof
containers.
6. Public education with appropriate messages and
exposure of children to toxic agents requires
more attention especially among families to
improve
their
awareness
about
safety
requirements inside homes and to provide
training programs especially for recently married
couples.
7. That prospective cohort studies, both facilitybased and population-based, should be conducted
so that data on a comprehensive range of
variables can be collected, and used in building
predictive models of acute poisoning patterns and
guide the design of interventions.
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DOI: 10.5958/2319-5886.2015.00034.X

&
Health Sciences
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Volume 4 Issue 1
th
Review article
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
MEDICAL UNCERTAINTY: ARE WE BETTER OFF IN ERA OF EVIDENCE BASED MEDICINE?

*Arun Tyagi1, Sharad Garudkar2, Gagare AG2, Amit Thopte3
1
Professor, 2Assistant Professor, 3Resident, Department of Medicine, Padmashree Dr. Vithalrao Vikhe Patil
Foundations Medical College and Hospital, Ahmednagar, Maharashtra, India
*Corresponding author email: aruntyagidr@gmail.com
ABSTRACT
Uncertainty is inherent to the medical profession. Medical profession incorporates science and the scientific
method with the art of being a physician. Every decision a clinician makes has some degree of uncertainty in it.
There are several factors which result in medical uncertainty during clinical practice, and this could arise from
physicians as well as patient factors, from test and treatment characteristics and practice environment. The
inability to come at a conclusion, despite a thorough and reasonable evaluation generates anxiety amongst patients
and physicians and the relationship between them may become strained and unproductive. Personal tolerance to
ambiguity and uncertainty also plays a significant role in medical students when it comes to career choice.
Medical Uncertainty may be technical, personal or conceptual. In the era of information overload and evidence
based medicine where guidelines, protocols and algorithms are available for every symptom complex and
disease, one would expect medical uncertainty to be less if not totally eliminated but that is actually not the case.
In fact, the protocols also threaten to depersonalize the relationship between the doctor and the patient. This
article reviews the underlying mechanisms, causes and effects of medical uncertainty and also some methods to
reduce uncertainty in todays clinical practice.
Keywords: Medical uncertainty, Evidence based medicine
INTRODUCTION
People prefer certainty in their lives and like to avoid
risk and uncertainty. Everyone expects that
professional people, including doctors, will give clear
and unequivocal advice. However, medical science is
far from exact. Virtually every decision a clinician
makes has some degree of uncertainty in it. It is this
uncertainty that makes the medicine a science and an
art1. Medicine is a profession that incorporates
science and the scientific method with the art of being
a physician2. The medical schools and colleges teach
the science of medicine, but what the clinician
practices is the art of medicine. Hippocrates3
commented, Life is short, The Art long....experience
fallacious and judgment difficult. The only certainty
in medicine is uncertainty and the appropriate

response to uncertainty is Hippocratic humility.
The medical education traditionally revolves around
the art of meticulous history taking, critically
analyzing the signs and symptoms and organizing the
patients problems in a known category of disease.
Clinicianstry to come to a perfect diagnosis and are
disappointed when their approach fails to provide a
clear diagnosis despite availability of latest
investigations and evidence based medicine. All
clinicians soon come to realize that uncertainty
surrounds every aspect of medicine, from history
taking, interpreting the physical signs, selecting an
investigative procedure, sorting out the probabilities
208
Tyagi et al.,
in the differential diagnosis and assessing the

outcome of a disorder.
In a study, it was observed that physicians used
expressions of uncertainty in 71% of the time6.
However; they may be oblivious of their uncertainty.
Different terms like intolerance to ambiguity, risk
averse and vagueness have been used in literature to
describe uncertainty in medical professionals7.
Budner8 introduced the term, intolerance of
ambiguity, as the tendency to perceive ambiguous
situation as sources of threat. Personal tolerance to
ambiguity and uncertainty also plays a significant
role in medical students when it comes to career
choice. Amongst medical students there is a higher
intolerance of uncertainty in students who ultimately
choose Anesthesia, Surgery, and Radiology as future
residency options as compared to medical students
who choose to go to Internal Medicine and
Psychiatry9.
Types of medical uncertainty:
Three kinds of uncertainties have been identified10:
1) Technical uncertainty which occurs from
inadequate scientific data,
2) Personal uncertainty which arises from being
unaware of the patients wishes; the patient and
physicians personal preference and bias and
3) Conceptual uncertainty which arises from an
inability of applying abstract criteria to concrete
situations. While one could address the issue of
technical and personal uncertainty with more
experience and effort, the problem of conceptual
uncertainty is likely to continue, since this
indecisiveness or uncertainty is almost part of the
doctors personality.
Medical uncertainty in clinical practice: Human
illnesses usually involve an abnormality of a complex
biological system. The clinical expression of an
illness involves the multi dimension interactions of
the abnormalities of various self-regulated
physiological mechanisms with the patients
environment. This is further complicated by the
patients and physicians variability in expression and
understanding of the problem. Variation in physician
practice styles and organization characteristics(sites
of medical care)are also linked to uncertainty11.
Uncertainty arises when the physician must weigh
probabilities. Patients' low tolerance for uncertainty
presents an additional burden and a challenge for the
clinician12, 13. Most clinicians respond to resolving

uncertainty by action, and studies have revealed that
this behavior could lead to increased hospital
admissions and investigations14, 15.Itis therefore
important to learn to manage uncertainty. All
physicians experience uncertainty. What changes
with increased clinical experience is the tolerance of
uncertainty.
The patient and physician encounter has been
described as the chain of uncertainty that involves
several links16. The several links in the chain include
factors like biological variability of the case,
uncertainty of the physician, the motives of the
consultation, the prejudice and preference of the
patient and the physician, medical errors, variability
in medical opinions, and the differing beliefs of the
patients and physicians. Uncertainty among medical
student stems from personal ignorance, limits of
available medical knowledge and an inability in
distinguishing between thetwo17. One could therefore
infer that in this era of information overload and
evidence based medicine medical uncertainty
should be less if not totally eliminated. Is that really
the case?
Information overload: All health care professionals
will acknowledge that there has been an information
explosion in the health services over the past few
decades. The huge amount of information is being
gathered in pursuit of knowledge and in the name of
the audit. The former provides the backbone of
evidence based medicine and the later facilitates
clinical governance18,19. Hardly anyone would
question the rationale behind the evidence based
medicine movement. Reliable information is
essential to both scientific advancement and process
management. This need for information has led to
such large quantities of evidence that clinicians need
assistance in choosing which evidence should
influence their practice. Properly collected and
handled research and audit information should
improve health service delivery20but there are limits
to the information, both in its comprehensiveness and
in its usefulness. In this era where everyone is busy
publishing papers (it is a mandatory requirement of
certain universities for passing exams and for
promotions) there are also questions concerning the
quality of information.
209
Tyagi et al.,
Clinical dilemma: The existence of an information

mountain provides a myth of certainty for the patient,
the public and for health care policy-makers. But
certainty is an illusion. However, much information
or evidence there is to hand, a decision still has to
be made and, at the point of making each decision,
there will always be some uncertainty. The guidelines
still leave the clinician the onus of making a decision.
The main advantage of following evidence based
medicine is that the clinician can pass the
responsibility of the management outcome to
protocols and guidelines. Protocols absolve the
clinician who follows the protocols, but the clinician
who does not follow protocols and algorithms may
become an easy target for criticism. The protocols
also threaten to depersonalize the relationship
between the doctor and the patient.
The placebo effect: A crucial function of the
clinician-patient relationship is that of containing the
patient's anxiety, much of which arises out of
uncertainties
of
various
kinds.
This
depersonalisation of doctor-patient relationship
threatens to destroy the placebo effect in the process
of healing. The literature acknowledges that the
placebo effect can be considered a boon to therapy21.
Causes of medical uncertainty: The causes of
uncertainty are many, but the feeling of stress or
discomfort, it creates is a familiar constant, though it
may vary in intensity. Medical uncertainty is similar
to the experience of irresolution or indecision in
everyday life, but with additional responsibility for
the patient.
Uncertainty in Diagnosis and Treatment: Three
closely related problems make it difficult to
determine whether or not a patient actually has a
disease that needs to be diagnosed and treated.
The first problem is that the dividing line between
normal and abnormal is not as clear and as sharp
as the reading of medical textbooks suggests to a
medical student. The clues on which the diagnosis of
many diseases is based can be very difficult to see,
with errors in both directions (missing a disease and
finding a non-disease).
The second problem is that many diseases do not by
themselves cause pain, suffering, disability or threat
to life. They are considered diseases only because
they increase the chance of a disease developing in
the future (the risk factors). Obesity, prehypertension,
prediabetes and hyperuricemia and dozens of such

conditions fall in this category. This creates
uncertainty in the physicians and the patients mind
alike to treat or not to treat.
Thirdly, the criteria for management of diseases are
being continuously redefined in this era of evidence
based medicine. Dyslipidemia and hypertension are
classic examples. For management of hypertension,
the target blood pressure that was 120/80 mmHg as
per JNC 7 guidelines was revised to 140/90 mmHg
by JNC 8 in 2013.
Diagnosis: Physicians vary widely in their
application of clinical criteria, in their ability to elicit
history, observe signs, interpret test results and record
the observations. For example, only 53% of the
physicians were definite in diagnosing cyanosis in
patients with extremely low oxygen content. On the
other hand, 26% of physicians said cyanosis existed
in subjects with normal oxygen content22.
The errors occur even when physicians study hard
evidence like x-rays and electrocardiograms. A set of
1807 x-ray films, containing 30 positive and 1760
negative films were read independently by ten
physicians. As many as 32% of the positive films
were reported as normal, while 2% of negative films
were incorrectly reported as positive. When
individual readers read the same films on two
separate occasions, they disagreed with themselves
about 20% of the time23.
In another study, a test series of 100 tracings was
selected: half had been reported routinely to show
myocardial infarction, a quarter to be normal, and a
quarter to show various abnormalities other than
infarction. Nine experienced readers reported their
opinions of these electrocardiograms on two separate
occasions. They were allowed the choice of one of
three reports-normal, abnormal, or infarction.
Complete agreement was reached in only one-third of
the 100 tracings, majority agreement in half, but there
was considerable dispute about one tracing in five.
After the second reading, it was found that on
average, the readers disagreed with one in eight of
their original reports24.
Investigations & Procedures: For any patient
condition, there are dozens of procedures that can be
ordered, in any combination, at any time. The list of
procedures that can be included in a workup of chest
pain or hypertension span from simple history taking,
210
Tyagi et al.,
blood tests, ECGs, X-rays, echocardiography, stress

test to thallium scan and coronary angiography. For
detection of colorectal cancer, a physician can choose
any combination of fecal occult blood tests, digital
examination, sigmoidoscopy, barium enema, and
colonoscopy or CECT abdomen. These are the
procedures for well-defined diseases. The problem is
augmented manifold if the clinician needs to select
the investigations to evaluate vague symptoms like
fatigue, body ache or headache.
Secondly, adding to the uncertainty of choosing a
procedure is the fact that the value of any procedure
depends on who performs it, on whom it is performed
and circumstances of its performances.
Outcomes: One of the important causes of medical
uncertainty is measuring the outcomes of medical
procedures conducted on the patients. The main
problem is the natural variation in the way people
respond to a medical procedure. If same operative
procedure was to be conducted on two identical
people who were identical in all respects, one may die
on the table and other may not. Therefore, because of
this natural variation we can only talk about
probabilities of various outcomes. Be its sensitivity or
specificity of a diagnostic test or outcome of a certain
treatment.
Determining the management plan: Almost all
medical procedures have multiple outcomes- some
good and some bad. The expected reduction in
anginal chest pain and effort intolerance after a
coronary artery bypass surgery is accompanied by, in
fact preceded by, hospitalization, cutting open of
chest, pain, anxiety, financial expense and of course a
chance of operative or post-operative mortality. Even
the best doctor cannot guaranty a positive only
outcome. Since outcomes are multiple and risks are
involved, risks and benefits of a procedure have to be
weighed carefully regarding different modalities of
management of any medical condition. Uncertainty is
further added because the decisions about medical
procedures are typically made by the physicians on
behalf of their patients. And to do this the
communication skills of the physicians are of utmost
importance.
Communication Skills: The patients must be able
clearly understand the need, the risks, the benefits and
various outcomes of all the options available to them.
Inadequate communication skills could often result in
Tyagi et al.,
an inability to comprehend the patients concerns.

The common communication deficiencies have been
listed in Table 1.
Table 125: Common patient-physician communication
deficiencies
Not allowing patient to narrate the problem in his
own words and interrupting the patient early.
Inability to bring out all of the patients
apprehensions
Inability to appreciate patients anxieties and
worries
Not assuring the patient that all his problems will be
addressed.
Undermining the patients role in the decisionsmaking process.
Not ensuring that the patient has understood the
decision taken by the clinician on his/her behalf.
Factors affecting medical uncertainty-Numerous
patient andphysician factors could affect the clinical
decisions and resultin medical uncertainty (Table 2).
Table 225: Patient and physician factors causing
medicaluncertainty
Patient Factors
Physician Factors
1. Vagueness in history
1. Poor communication
2. Wrong prioritizingof
skills
history
2. Incorrect appraisal of
3. Patients subconscious
probability
avoidance of risk
3. Physicians tolerance
associated with disease.
to uncertainty
4. Variabilityin
4. Inappropriate test
investigations results
interpretation
5. Inconstant response to 5. Failure to apply
treatment
evidence-based
6. Availability to various
treatment
sources of information
6.
Inability to assess the
on same topic
best evidence
7. Impact of society and
7.
Effect of medical
culture
organization and local
practice environment
8. Fear of litigation
Coping with uncertainty: Physicists have long
recognized the uncertainty principle26. Uncertainty,
like anxiety, cannot be killed. It can only be lived
with, controlled, or uncontrolled. The doctors need to
be educated into maturity and wisdom that they
require to be able to accompany people in times of
need, contain their own and their patients' anxieties
and facilitate healing and recovery in an uncertain
world27.The different techniques of dealing with
uncertainty include quantitative methods and
qualitative methods. Evidence-based medicine
211
(EBM) has been described as a technique to combine

physicians clinical expertise with the use of the best
available evidence and incorporating the patients
personal values in coming to a management plan28.
Hewson and colleagues29 identified nine strategies
that they felt were effective in managing uncertainty
in primary care. The best techniques for minimizing
uncertainty include a combination of qualitative and
quantitative approach and the use of tacit reasoning30.
These include steps that incorporate the principles of
medical decision-making, risk assessment and
communication of uncertainty. Using this framework
and incorporating the strategies when discussing with
a patient with an uncertain diagnosis could improve
the quality of patient-physician communication and
reduce uncertainty to a large degree. These strategies
can be summarized as below:
1. Clinicianss hould make it clear to the patient that
they are willing to answer any questions about
their health.
2. Clinicians should acknowledge that there is a
tremendous information explosion and should
suggest valid sources of information including
valid web-sites.
3. Clinicians should be open-minded and admit
ignorance if they are unable to answer a question
but volunteer to find the answer.
4. They should listen sympathetically and explore
the apprehensions of the patients.
5. They should concede their own preference and
explain that to the patients.
6. They should nurture a sense of collaboration and
involve the patient equally in the decisionmaking process.
7. Clinicians should use a language which is easily
understood by the patient and also explain the
results using a method which is most meaningful
to the patient.
8. If there are more than one option on the medical
treatment, that should be explicitly informed to
the patient.
CONCLUSION
There are several factors which result in medical
uncertainty during clinical practice, and this could
arise from physicians as well as patient factors, from
test and treatment characteristics and practice
environment. By understanding the tenets of medical
uncertainty and practicing the well-established

techniques that have been outlined, physicians could
probably decrease their as well as patients stress and
anxiety especially while dealing with patients with
vague and/or serious illness. Finally, the modern day
doctor should also remember and apply the age old
doctrines of clinical medicine(1) Trust between the
doctor and the patient, (2) Honesty: the doctor should
be open about the limits of his/her own knowledge
and capabilities. Such openness is only possible when
the doctor trusts the patient, (3) Awareness: of the
complex processes behind medical uncertainty and
that the failure of some degree will remain the
doctors unavoidable companion throughout their
career and finally (4) Kindness and caring are the
prerequisites of clinical medicine.
ACKNOWLEDGEMENT: The Secretary General
and Deputy Director, PDVVPFs Medical College,
Ahmednagar
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as an art and as a science. Med Humanities 2000;
26:18-22
2. Lee Goldman, Andrew I. Schafer, Approach to
Medicine. Cecil Medicine. 2012; 24 Ed:30
3. Hippocrates. Aphorisms. In: Adam F. The
genuine works of Hippocrates. London: The
Syndenham Society; Vol. II: Aphorisms iii-12
and iii-31,1869: 697.
4. Johnson CG, Levenkron JC, Suchman AL,
Manchester R. Does physician uncertainty affect
patient satisfaction? J Gen Intern Med
1988;3:144-149.
5. Katz J. Why doctors dont disclose uncertainty.
Hastings Cent Rep 1984;14:35-44.
6. Gordon GH, Joos SK, Byrne J. Physician
expressions of uncertainty during patient
encounters. Patient Education & Counseling.
2000;40:59-65.
7. Beresford EB. Uncertainty and the shaping of
medical decisions. Hastings Center Report 1991;
21: 6-11.
8. Budner S. tolerance to ambiguity as a personality
variable. J Per, 1962;30:29-50.
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9. Gerrity MS, White KP, DeVellis RE, Dittus RS.

Physicians reactions to uncertainty: Refining the
constructs and scales. Motivation and Emotion,
1995;19:175-91.
10. Norton RW. Measurement of ambiguity
tolerance. J Pers Assess, 1975;45:607.
11. Eddy DM, Billings J. The quality of medical
evidence: implication for quality of care. Health
Aff.1988;7:19-32
12. Politi MC, Clark MA, Ombao H, Dizon D, Elwyn
G. Communicating uncertainty can lead to less
decision satisfaction: a necessary cost of
involving
patients
in
shared
decision
making? Health Expect. 2011;14(1):8491.
13. Blanch DC, Hall JA, Roter DL, Frankel RM. Is it
good to express uncertainty to a patient?
Correlates and consequences for medical students
in
a
standardized patient
visit. Patient
EducCouns. 2009;76(3):300306.
14. Dawson NV. Physician judgment in clinical
settings: methodological influences and cognitive
performance. ClinChem, 1993;39:1468-80
15. Zaat JM, Eijk JT. General practitioners
uncertainty, risk preference, and use of laboratory
tests. Med Care, 1992;30:846-54.
16. Eddy DM. Variations in physician practice: the
role of uncertainty. Health Affairs 1984;3:74-89.
17. Fox RC. The evolution of medical uncertainty.
Milbank Memorial Fund Quarterly. Health and
Society, 1980;58:1-49.
18. Sackett DL, Haynes RB, Guyatt GH.Clinical
epidemiology: a basic science forclinical
medicine. 2nd Ed. Boston: Little, Brown and
company, 1991:53-57.
19. McLachlan G, ed. A question of quality. London:
Oxford University Press, 1976.
20. West RR. Evidence based medicine, overviews,
bulletins, guidelines and the newconsensus.
Postgrad Med J, 2000;76:3839.
21. Andrews G. Placebo response in depression: bane
of research, boon to therapy. Br JPsychiatry,
2001;178:1924.
22. Comroe JH, Botelho S. The Unreliability of
Cyanosis
in
the
Recognition
of
ArterialAnoxemia. TheAmerican Journal of
Medical Sciences,1947; 214:1-6.
23. Yerushalmy J. Reliability of Chest Radiography

in the Diagnosis of Pulmonary Lesions,
American Journal of Surger1955; 89:231-240.
24. Davies LG. Observer Variation in Reports on
Electrocardiograms. British Heart Journal,1958;
20:153
25. Ghosh A K, Understanding Medical Uncertainty:
A Primer for Physicians, JAPI, 2004, Vol 52:
739-42.
26. Heisenberg, W. ber den anschaulichenInhalt der
quantentheoretischenKinematik und Mechanik,
ZeitschriftfrPhysik (About the descriptive
content of quantum theoretical kinematics and
mechanics, Journal of Physics), 1927; 43 (34):
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27. West AF, West RR. EditorialClinical decisionmaking: coping with uncertainty, Postgrad Med J,
2002;78:319-21
28. Sackett DL. Strauss SE, Richardson WS, et. Al,
eds. Evidence based medicine: How to practice
and teach EBM. 2nd Ed. New York: Churchill
Livingstone; 2000:1-261
29. Hewson MG, Kindy PJ, Van Kirk J, Gennis VA,
Day RP. Strategiesfor managing uncertainty and
complexity. J Gen Intern Med, 1996;11:481-5
30. Ghosh AK. Understanding uncertainty.Minn
Med. 2003; 86:5- 6.
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DOI: 10.5958/2319-5886.2015.00035.1

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Volume 4 Issue 1
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Case report
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
A SINGLE VISIT IMMEDIATE TEMPORIZATION WITH NATURAL TOOTH PONTIC FOR

PERIODONTALLY INVOLVED ANTERIOR TEETH: AN ESTHETIC AND INNOVATIVE APPROACH
Nilofer Sultan Sheikh1, Neelima S. Rajhans2, Preeti Mundhe3, Gabriela Jude Fernandez4, Nilkanth Mhaske5,
Nikesh Moolya6, Sudeep HM7
1,3,
Postgraduate student, 2Professor & Head, 5,6Reader, 7Senior Lecturer, Department of Periodontics, YCMM &
RDFS Dental College, Ahmednagar, Maharashtra
4
Resident Doctor, Buffalo University, New York
*Corresponding author email: dr.nilu18sheikh@gmail.com
ABSTRACT
Aim and Objectives: Sudden loss of anterior tooth is a dreadful situation. It can be as a result of trauma,
endodontic failure or periodontal disease which is a true aesthetic emergency for a patient. Along with the patient,
the dentist also emphasizes on saving an anterior tooth for the primary reason of aesthetics. If the tooth crown is
intact, is not grossly decayed, broken down or discoloured, it can be used as a natural tooth pontic in designing an
interim prosthesis. Case: A chair side technique for replacing the missing tooth using the patients own natural
tooth as a pontic in the three dimensional original position using a fibre reinforced composite resin splint thus
restoring the aesthetics and relieving the apprehension of the patient, as described in this case report.
Conclusion: The concept of Natural tooth pontic placement is a simple, economical, minimal intervention, viable
and an easy to handle treatment option and promises an excellent transient aesthetic solution for a lost tooth as
well as require minimal or no tooth preparation, thus is a reversible technique and avoids the laboratory cost.
Keywords: Tooth loss, Natural tooth pontic, Immediate replacement, Splinting, Interim prosthesis, Interlig.
INTRODUCTION
For people with healthy, attractive smiles, a sudden
loss of an anterior tooth or teeth as a result of trauma,
periodontal disease or endodontic failure, is a true
aesthetic emergency and can be traumatizing to the
patient 1. The missing anterior tooth has implications
in how one presents themselves to others and the
psychological effects of how we feel about ourselves.
The most important concerns involve aesthetics,
phonetics and functional disability to some extent.2
Despite a varied range of treatment modalities that
can be applied in order to conserve the tooth after a
traumatic episode, there are situations where the
concerned traumatized tooth cannot be saved. The
treatment options involve the fabrication of an
immediate removable partial denture, placement of an

immediate implant etc. Another viable treatment
option is the placement of a periodontal splint
utilising the crown of the extracted tooth as a natural
pontic. The materials that are available for this
purpose include multiflex orthodontic wires, steel
meshes, glass or fibre splints etc 3.
Using the natural tooth as a pontic offers the benefits
of it being the right size, shape and colour. It also
adds up to the psychological status of the patient by
using his or her own natural tooth as a pontic 4,5.
214
Nilofer et al.,
CASE REPORT
A 34 year old male patient with a chief complaint of
pain in upper front region of jaw was referred to the
department of Periodontology, YCMM and RDFs
Dental College and Hospital, Ahmednagar. After
periodontal examination, there was grade III mobility
with 21, [Fig 1] periodontal pocket of 9mm on the
mid-facial aspect. [Fig 2]
the patient and the study approved by ethics

committee of YCMM & RDFs dental college
Ahmednagar. The duration of follow up of the case
was 1 year. The decision to extract the upper left
maxillary central incisor was undertaken. The tooth
which was to be extracted was used for the
restoration of its own extracted region. The patient
was appointed on the next day for splinting.
Preoperative analysis: - A study model was
prepared and the length of the natural tooth pontic
was determined on a study cast by measuring from
incisal edge of adjacent central incisor to the location
of gingival margin as a reference point. This length
was measured. [Fig 4]
Fig 1: Preoperative view
Fig 2: Preoperative probing depth measurement
Fig 3: Radiographic interpretation showing

extruded 21 with poor bone support.
Intra oral Periapical radiograph of 21, 22, 11, 12
region showed approximately 50% bone present with
21 and nearly 60% bone present with 22, 11, 12 [Fig
3]. Thus, a written informed consent was taken from
Fig 4 : Preoperative study model

Treatment plan: It was decided to extract the central
incisor and replace it immediately as a natural tooth
pontic using an Interlig fibre splint as a retainer. The
patient was informed about the procedure and the
patient readily agreed for the same. Inter occlusal
space was assessed and the occlusion was
determined. Pre extraction impression was made
and the study model was prepared. Measurement of
length of the crown was done with a periodontal
probe clinically and markings were transferred on the
study model. Atraumatic extraction of 21 was done
under local anaesthesia [1:100 epinephrine] lidocaine
and haemostasis was achieved. [Fig 5a & 5b]
Pontic preparation phase: - The extracted tooth was
sectioned at a predetermined length measured from
the study model and edges were rounded, allowing
for post extraction resorption and tissue shrinkage.
Try in of the newly prepared pontic was done to
ensure that the patient was satisfied with the
appearance. Access opening was done palatally.
215
Nilofer et al.,
Fig 5a: Atraumatic extraction with 21

5b: Extracted 21
The pulpal remnants were extirpated and the pulp
chamber was thoroughly cleaned and dried. The pulp
chamber was then acid etched and dentin bonding
agent was applied, the resulting cavity was filled with
composite resin. [Fig6 a &b]
Fig 7: Photograph showing acid ecthing done with

pontic and adjacent teeth
Fig 8: Interlig fibre placed facially for stabilization
Fig 6a: Pontic prepared 7b: Access opening done

palatally
Cementing the pontic: The abutment teeth were
isolated with a rubber dam, cleaned with pumice,
washed and dried. The pontic was also cleaned with
pumice, washed and dried and then placed in the
mouth to the required position. Acid etching was
done on facial aspect from 13 to 23 with 40%
phosphoric acid for 30 seconds washed and dried.
Predetermined length of Interlig [fibre reinforced
with composite] was carefully placed. [Fig7,8,9].
After initial stabilization facially with Interlig fibre,
palatally composite resin with orthodontic wire was
used for placing pontic in proper position, and
Interlig fibre was then removed [Fig 9,10]. While
placing a layer of composite care was taken to avoid
rough surface, excess composite was removed
completely to give a smooth feel and cured. After
smoothening of surfaces, occlusion was checked in
protrusion and lateral excursions. The patient was
happy and satisfied with end result [Fig 11].
Fig 9: Photograph showing placement of interlig

fibre facially.
Fig 10: Photograph showing postoperative view.

216
Nilofer et al.,
A 1- year evaluation showed good aesthetic results

with no problems and bridge was intact, [Fig 11]. The
patient will be kept under yearly evaluation.
Fig 11: After 12 months of follow up.

DISCUSSION
This case report describes a simple, minimal
intervention, economical and rapid method to replace
a single tooth. It requires minimal or no tooth
preparation thus, it is a reversible technique and
avoids laboratory costs 6. Replacement of a lost
anterior tooth, immediately definitely lessens the
trauma and psychological impact of tooth loss on the
patient 7. One or two anterior teeth can be replaced
using the natural teeth as a pontic 8. Conventional
methods employ the use of the fabrication of bridges,
removable appliances and implants for the
replacement of a lost tooth. However, the above
described method may prove to be more
advantageous in terms of the cost and time9.Besides,
it helps avoid the inconvenience associated with the
use of a removable prosthesis, as well as, the
irritation of the palate and ill-fitting problems that are
consistent with it. At times, the natural tooth can act
as a temporary splint while the final prosthesis is
being fabricated, in order to save time. It also helps to
maintain the gingival architecture as well as present
the drifting of the adjacent tooth into the vacant space
10
.
Placement of a fixed prosthesis on periodontal
compromised teeth is highly contraindicated. In such
circumstances, where the replacement of a missing
tooth is inevitable, this method may prove to be a
viable option 11. Besides being an economical method,
long term results have well demonstrated great
success while employing this technique 12. The use of
a fibre reinforced splint is also aesthetically pleasing,
considering the lighter shade which is closely
associated with the colour of the tooth and can be

easily employed to splint teeth, even with minimal
diastema or interproximal spaces anteriorly, since it
can be easily covered with flow able composite 13.
Quirynen et al assessed the longevity of composite
bonded resin or natural teeth as replacements for
periodontally lost lower incisors and reported a
survival rate of 80% after 5 years of function14. This
design allows for exact repositioning of the coronal
part of the extracted tooth in its original intraoral
three dimensional position. Fibre reinforced splints
have also demonstrated long term durability and
higher bonding strength as compared to stainless steel
wire splints, which causes a fracture at the composite
interface in wire splints15.Additionally, fibre splints
do not produce corrosiveness unlike their stainless
steel counterparts and are also translucent, which
bestow an aesthetic and pleasing smile.
CONCLUSION
Natural teeth serve as an excellent transient treatment
option for immediate replacement of a missing tooth
following extraction in the anterior aesthetic zone.
The patient satisfaction of continuing to have their
natural tooth in the post-extraction period, taking care
of his aesthetic needs and simultaneously providing
him with time to choose from the various final
treatment options available is immense. However,
appropriate patient selection, their motivation levels,
plaque control and precision during placement should
be kept in mind to achieve the desired objective.
Limitations of the study: As Natural tooth pontic is
a temporary treatment option, further studies are
needed with a larger sample size in order to confirm
the efficacy. It cannot be suggested for patients with
traumatic bite.
It is advised for an anterior tooth region where less
masticatory force is applied.
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RM, Floyd PD. Periodontology: a
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Purra AR, Mushtaq M. Aesthetic replacement of
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Khetarpal AS, Talwar, Verma M. Creating a
Single-Visit, Fibre-Reinforced, Composite Resin
Bridge by Using a Natural Tooth Pontic: A
Viable Alternative to a PFM Bridge. J Clin Diagn
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Belli S, Ozer F. A simple method for single
anterior tooth replacement. J Adhes Dent.
2000;2(1): 67-70.
Auplish G, Darbar UR. Immediate anterior tooth
replacement using fibre-reinforced composite.
Dent Update; 2000. 27(6): 267-70.
Bhandari S, ChaturvediR. Immediate natural
tooth pontic: a viable yet temporary prosthetic
solution: a patient reported outcome. Indian J
Dent Res, 2012;23(1): 59-63.
Parolia A. Use of a natural tooth crown as a
pontic following cervical root fracture: a case
report. Aust Endod J, 2010;36(1): 35-8.
Walsh LJ, Liew VP. The natural tooth pontic--a
compromise treatment for periodontally involved
anterior teeth. Aust Dent J, 1990;35(5): 405-8.
Dimaczek B, KernM. Long-term provisional
rehabilitation of function and esthetics using an
extracted tooth with the immediate bonding
technique. Quintessence Int, 2008;39(4): 283-8.
Strassler HE, Serio CL. Esthetic considerations
when splinting with fiber-reinforced composites.
Dent Clin North Am, 2007;51(2): 507-24
Quirynen M. A long-term evaluation of
composite-bonded
natural/resin
teeth
as
replacement of lower incisors with terminal
periodontitis. J Periodontol, 1999;70(2): 205-12.
Chaudhary V. Multifunctional Ribbond--a
versatile tool. J Clin Pediatr Dent. 2012;36(4): p.
325-8.
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DOI: 10.5958/2319-5886.2015.00036.3

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Volume 4 Issue 1
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Case report
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
Accepted: 3rd Nov 2014
ANCIENT SCHWANNOMA OF THE CERVICAL VAGUS NERVE: A RARE BENIGN NEUROGENIC

TUMOR
*Basavaraj1, Rajendrakumar NL2, Hemanth PN3 , Umamaheshwari KB3, Nishanth RK4
1
Postgraduate student, 2Associate professor, 3Assistant professor, 4Senior Resident, Department of RadioDiagnosis, Mysore Medical College And Research Institute, Mysore Karnataka, India
*Corresponding author email: pavanb16@gmail.com
ABSTRACT
Schwannomas are benign, slow-growing encapsulated tumors that originate from Schwann cells of the nerve
sheaths. Schwannoma originating from the cervical vagus nerve is an extremely rare neoplasm that usually occurs
in men between the 3rd and 6th decades of life. Ancient schwannoma is a rare variant that was first described by
Ackerman and Taylor in 1951 as a long standing degenerative schwannoma that presented with wide areas of
hyalinized matrix. A case of ancient Schwannoma of the cervical vagus nerve in a 56-year-old male who
presented to our department with history of a firm and painless mass lesion on right side of the neck is being
reported here.
Keywords: Ancient schwannoma, Vagus nerve, Computed tomography, Head and neck.
INTRODUCTION
Schwannomas are neurogenic tumors arising from
schwann cells of neural sheath. Schwannomas are the
most common types of neurogenic tumors found in
the head and neck. Common sites for schwannomas
in the neck are the vagus nerve, less commonly the
glossopharyngeal nerve, the ventral and dorsal
cervical nerve roots, the cervical sympathetic chain,
and the brachial plexus1. Radiological Imaging plays
a significant role when evaluating a parapharyngeal
space mass2. Ancient schwannoma is a uncommon
variant that was first described by Ackerman and
Taylor in 19513, which is an encapsulated tumor
with benign nature. It is characterized by
degeneration and diffuses hypocellular areas. These
changes are believed to occur because it takes a long
time for schwannomas to develop4. It is characterized
by degenerative changes typified by perivascular
hyalinization, calcification, cystic necrosis, relative
loss of Antoni type A tissue, and degenerative nuclei
Basavaraj et al.,
that may be misinterpreted as sarcomatous

pleomorphisms5. However, the absence of mitosis
and the presence of cystic necrosis and a well-defined
capsule without surrounding invasion helps to
differentiate these lesions from high-grade lesions6.
The cause of schwannomas is not clear, although it
appears genetics play a role. Most schwannomas are
sporadic, but about 10% are associated with familial
neurofibromatosis type 2. The goal of treatment is
complete excision with possible preservation of the
involved nerve7.
CASE REPORT
A 56 Yr old male patient presented with history of
painless swelling in right side of neck since 3 years.
Department of Radiodiagnosis, Mysore Medical
College and Research Institute, Mysore.
219
Color Doppler ultrasound of the neck [figure1]

revealed a 6cm x 4.5cm x 3.3cm heterogeneous mass
with no evidence of internal vascularity. The internal
Jugular vein was compressed and the carotid artery
was significantly displaced by the mass lesion.
Computed tomography scan [figures 2-5] revealed a
well defined heterogeneously enhancing mass lesion
with few non enhancing cystic areas within, on right
side of the neck extending from the level of the C2
vertebra to the level of the D2 vertebra, measuring
6.5cm 5.5cm 4.2cm, displacing the carotid artery
anteriorly and compressing the right internal jugular
vein.
Histopathology showed spindle cells in clusters.
These cells showed moderate degree of nuclear
pleomorphism with bland chromatin. Fibrillary
intercellular stroma was noted. No necrosis or mitosis
was seen. Correlating with the long standing nature of
the lesion and radiological evidence of well defined
borders favoured a benign neck mass, and hence a
diagnosis of ancient schwannoma was made.
Fig 2A
Figure 2: (A, B) Axial unenhanced CT scan shows
a heterogeneous, predominantly hypodense mass
lesion in the post styloid compartment(black
arrow) of right parapharayngeal space
Fig 3 A
Fig 1: Ultrasonography of the neck on right side

showing an heterogeneous mass lesion displacing
and compressing internal jugular vein and
common carotid artery.
Fig 3 B
Figure 3 (A, B) Axial contrast enhanced images
show a heterogeneously enhancing mass lesion
(arrow) with few non enhancing areas displacing
the right internal carotid artery anteriorly (black
arrowhead).
Fig 2 B
Basavaraj et al.,
220
Fig 4 A
Fig 4 B
Fig 4: (a) Coronal reformatted image, (b) sagittal
reformatted image shows a heterogeneously
enhancing mass lesion in right side of the
neck(arrow).
DISCUSSION
A schwannoma is a benign nerve sheath tumor
composed of schwann cells, which normally produce
the insulating myelin sheath covering the peripheral
nerves. In the parapharyngeal space of neck,
schwannomas may arise from the last four cranial
nerves or the autonomic nerves, the vagus being the
more common site. The differential diagnosis of a
parapharyngeal space mass is based on the division of
the space into prestyloid and post-styloid
compartments. The prestyloid compartment contains
the parotid gland, fatty tissue, and lymph nodes. The
post-styloid compartment contains the carotid sheath
with the sympathetic chain and cranial nerves IX
through XII. Thus, masses arising in the post-styloid
compartment include carotid artery lesions,
paragangliomas arising from the vagus nerve or the
carotid body, neurogenic tumors involving cranial
nerves IX to XII, or sympathetic chain neurogenic
lesions1. Most schwannomas are fairly homogeneous
soft tissue masses and appear hypodense or isodense
Basavaraj et al.,
to skeletal muscle on noncontrast CT and tend to be

hypointense or isointense to skeletal muscle on T1weighted MR images and variably hyperintense on
T2-weighted images. Despite their hypovascularity,
they enhance significantly on both CT and MR
images and can mimic a paraganglioma. The
enhancement of the schwannomas is seen at least 2
minutes after the contrast injection and depicts the
equilibrium phase of the contrast agent and the poor
venous drainage of the tumor. Dynamic scans can
reveal the true nature of the lesion and differentiate it
from hypervascular lesions. The enhancement pattern
of neural tumors can vary; it may be an
inhomogeneous enhancement (owing to necrosis and
hemorrhage) or even lack of enhancement 1.
When evaluating a parapharyngeal space mass which
helps in guiding surgical approach for the mass lesion
, the most important landmarks to note in terms of
imaging are (a) the deep portion of the parotid gland
and the stylomandibular tunnel region; (b) the ICA,
its size, shape, and the direction of any displacement;
(c) the direction of any displacement of the fat of the
prestyloid compartment; (d) the effect of a mass on
the surrounding structures, including the pharynx,
masticator space, mandible, and skull base; and (e)
the size of the mass2.
Ancient schwannoma, a degenerative neurilemmoma,
a rare variant of schwannoma first described by
Ackermanand Taylor in 19513, is a schwannoma
subtype characterized by degeneration and diffuse
hypocellular areas. These changes are believed to
occur because it takes a long time for schwannomas
to develop4.The radiologic findings for ancient
schwannoma are similar to those for schwannoma,
which on contrast-enhanced computed tomography
shows enhancement in capsules or pericystic areas
5
.It is characterized by degenerative changes typified
by perivascular hyalinization, calcification,cystic
necrosis, relative loss of Antoni type A tissue, and
degenerative nuclei that may be misinterpreted as
sarcomatous pleomorphisms. However, the absence
of mitosis and the presence of cystic necrosis and a
well-defined capsule without surrounding invasion
helps to differentiate these lesions from high-grade
lesions5,6.
Ancient schwannomas are benign tumors and the goal
of treatment is complete excision with possible
preservation of the involved nerve as complete
resection is usually curative with a good prognosis7.
221
CONCLUSION
Ancient schwannomas are rare benign tumors,
radiological and histological findings in correlation
with long standing nature of the lesion will aid in the
pre operative diagnosis and proper management. The
goal of treatment is complete excision with possible
preservation of the involved nerve.
ACKNOWLEDGEMENT
We are thankful to Dr.C.P.Nanjaraj, Professor &
Head, Department of Radiodiagnosis, Mysore
Medical College & Research Institute, Mysore.
Authors also acknowledge the immense help received
from the scholars whose articles are cited and
included in references of this manuscript.
REFERENCES
1. Thomas Vogl,
Sotirios Bisdas.
Cervical
Adenopathy and Neck Masses in J.R. Haaga,
V.S. Dogra, M. Forsting, R.C. Gilkeson, H.K.
Ha, and M. Sundaram.(eds.), CT and MRI of the
whole body. 5th ed. philadelphia: Mosby
Elsevier, 2009. 664-65.
2. Peter M. Som, Hugh D. Curtin. Parapharyngeal
and Masticator Space Lesions in Peter M. Som,
Hugh D. Curtin (eds) Head and Neck Imaging.
5th ed. St. Louis: Mosby Elsevier,2011. 2390.
3. Ackerman LV, Taylor FH. Neurogenous tumors
within the thorax: a clinicopathological
evaluation of forty-eight cases. Cancer 1951;4:
66991.
4. Dahl I. Ancient neurilemmoma (schwannoma).
Acta Pathol Microbial Scand 977;85: 81218 .
5. Isobe K, Shimizu T, Akahane T, Kato H. Imaging
of ancient schwannoma. Am J Roentgenol 2004;
183(2):331-36.
6. Kagaya H, Abe E, Sato K, Shimada Y, Kimura
A. Giant cauda equina schwannoma: a case
report. Spine 2000; 15: 26872.
7. Ugokwe K, Nathoo N, Prayson R, Barnett GH.
Trigeminal nerve schwannoma with ancient
change.Case report and review of the literature. J
Neurosurg 2005; 102(6):1163-5.
Basavaraj et al.,
222
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ANTERIOR DISLOCATION OF SHOULDER DUE TO ENTANGLEMENT OF ROPE AND PULL BY

CATTLE IN AN OCTOGENARIAN
*Ganesh Singh Dhramshaktu, Irfan Khan
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
*Corresponding author email: drganeshortho@gmail.com
ABSTRACT
The shoulder joint is a common site of dislocation owing to its inherent anatomical characteristics. It is common
in young individuals and is frequently related to sports and other activities. Mostly they are managed successfully
with urgent reduction and rehabilitation in uncomplicated scenario. However, risk of recurrence calls for periodic
review and future assessment. The occurrence in older patients is uncommon. Our case depicts an unusual mode
of this injury in an octogenarian lady who sustained injury due to entanglement of rope while pulled by a cow and
its satisfactory management.
Keywords: Shoulder Dislocation, Injury, Trauma.
INTRODUCTION
The shoulder joint is commonest site of all major
joint dislocations.1 In most instances, it follows a
traumatic event in 96% of all cases.2 Abduction,
external rotation and extension while forceful loading
of the arm is a common mechanism of injury. Most of
the dislocations are anterior with subcoracoid,
subglenoid or intra-thoracic patterns. Most of these
injuries are managed well with closed reduction by
various methods described in literature.3 Presented
case is a rare example of the violent sudden pull by a
cattle and forceful shoulder injury resulting in
dislocation and its appropriate management.
CASE REPORT
The patient, an eighty one year old active lady
presented to us with a history of injury to her right
shoulder region a day back while she was grazing her
cow in a field. She was holding the rope attached to
the cows neck. All of a sudden the cow took a turn
and started running to the opposite side and she was

pulled along with it due to entangled rope. She was
pulled to a distance of twenty meters before the cow
stopped and she could untangle the rope and call for
help. She was unable to use her right extremity since
then and the injury was painful and discomforting.
There were some abrasions over the back and neck
region, but fortunately no other injury was noted. She
was taken to a primary centre for first aid before
referred to us. She was evaluated for other associated
or remote injuries. There were no other injury and no
associated neurovascular deficit present clinically.
There was a loss of contour of shoulder with sulcus
defect and she was not able to cross the affected
elbow to midline and beyond. The probable diagnosis
of uncomplicated anterior dislocation was made. The
radiograph of the patient confirmed the diagnosis.
The poor socioeconomic status of patient precluded
use of advance imaging to check associated capsulolabral injuries.
223
Ganesh et al.,
Fig 1: Radiograph of
dislocation.
the
injury showing
immobilizer was applied as per the standard practice

in our department. There was dramatic relief of pain
and disability post- reduction. The immobilizer care
and instructions were explained and demonstrated.
The immobilizer was maintained for three weeks to
allow soft tissue healing and decrease risk of
recurrence. The appropriate exercises in rehabilitative
phase assured early functional recovery. The clinical
evaluation of rotator cuff pathology was negative.
The follow up at three, six, twelve weeks and finally
at three and six months showed good functional
outcome and a stable shoulder with no history of
recurrence.
DISCUSSION
Fig 2: Schematic diagram depicting mode of

injury - The case with cattle and then forcefully
pulled through entangled rope.
The elderly patients are affected in one fifth of all

shoulder dislocations.4 Shin SJ et al studied 61 cases
of shoulder dislocation in patients over sixty years of
age and found half of the cases with no associated
defect and other half with associated rotator cuff
injury. They also reported effectiveness of
conservative management in most cases.5 However
the patients can be reviewed for associated capsulolabral tear and recurrence is not dependent on
increased age.5 The Milch method is a useful method
of reduction with fewer reported complications as it is
base on position rather than distraction.6 The
recurrence rate is limited in elderly age group as
posterior supports are affected more in contrast to
anterior support in young patients.7 Persistent pain
and disability calls for ruling out rotator cuff
pathology and its due management. Associated
neurovascular injuries may be evaluated for
documentation
and
further
appropriate
management.4,7
CONCLUSION
Fig 3: Post reduction radiograph showing a

successful reduction.
RESULT
The patient was prepared for urgent closed reduction
under appropriate anaesthesia after proper informed
consent. The shoulder was reduced uneventfully with
Milch method as described. The reduction was
confirmed clinically and by imaging and a shoulder
The presented report underlines an uncommon mode

of a common trauma in the setting of farm side
injuries related to cattle and livestock that are an
inherent part of a large percentage of the population
living in our country. However the treatment involves
sticking to basic principles of care and follow up. An
anticipation of such injuries may help prevent it with
appropriate caution.
ACKNOWLEDGMENT - None
Conflict of interest Nil
224
Ganesh et al.,
REFERENCES
1. Nordqvist A, Petersson CJ. Incidence and causes
of shoulder girdle injuries in an urban population.
J Shoulder Elbow Surg 1995;4(2):107-112.
2. Rowe C. Prognosis in dislocations of the
shoulder. J Bone Joint Surg 1956;38(5): 957-977.
3. Wirth M, Rockwood C. Subluxations and
dislocations about the glenohumeral joint.
Rockwood and Green's Fractures in Adults. Vol
2, 5th Edition. Edited by Bucholz RW, Heckman
JD. Philadelphia: Lippincott Williams & Wilkins;
2001:1109-1207.
4. Murthi AM, Ramirez MA. Shoulder dislocation
in the older patient. J Am Acad Orthop
Surg. 2012;20(10):615-22.
5. Shin SJ, Yun YH, Kim DJ, Yoo JD. Treatment of
traumatic anterior shoulder dislocation in patients
older than 60 years. Am J Sports
Med. 2012;40(4):822-7.
6. Jose M. Rapariz, Silvia Martin-Martin, Antonio
Pareja-Bezares, and Jose Ortega-Klein. Shoulder
dislocation in patients older than 60 years of age.
Int J Shoulder Surg. 2010 ; 4(4): 8892.
7. Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ.
Anterior dislocation of the shoulder in the older
patient. Clin Orthop Relat Res. 1986;(206):192-5.
225
Ganesh et al.,
DOI: 10.5958/2319-5886.2015.00038.7

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Accepted: 1stDec 2014
BILATERAL STEROID INDUCED GLAUCOMA IN VERNAL KERATOCONJUNCTIVITIS

Bangal Surekha V1, *Bankar Mahima S2, Bhandari Akshay J3, Kalkote Prasad R2
1
Professor, 2Post Graduate Student, 3Assistant Professor, Department of Ophthalmology, Rural Medical College,
Institute of Medical Sciences, Loni, Rahata, Ahmednagar, Maharashtra, India
*Corresponding author email: mahi.dreamz@gmail.com
ABSTRACT
VKC is a bilateral recurrent allergic interstitial conjunctival inflammation with a periodic seasonal incidence and
of self limiting nature, mainly affecting the younger population. Patients of VKC on steroid therapy are at higher
risk of developing steroid induced glaucoma. Raised intraocular pressure due to steroids typically occurs within
few weeks of starting steroid therapy and comes back to normal on immediate stoppage of steroids. A case of
steroid induced glaucoma in a 30 years old female with vernal keratoconjunctivitis. She was on topical steroids
for 3-4 years. She was incompliant with the instructions to stop steroids. She eventually developed steroid
induced glaucoma and glaucomatous optic neuropathy with tunnel vision.
Keywords: Vernal keratoconjunctivitis, Steroids, Secondary glaucoma
INTRODUCTION
Vernal keratoconjunctivitis (VKC) is a bilateral
recurrent
allergic
interstitial conjunctival
inflammation having a periodic seasonal incidence
and of self limiting nature, mainly seen in young
population. It is type 1 IgE mediated hypersensitivity
reaction.
It is characterized by redness of eyes, itching
sensation ropy discharge and presence of conjunctival
papillae. Incidence of glaucoma in VKC patients
receiving corticosteroid therapy is 2-7%1. Sometimes
these patients develop complications in the form of
keratitis, keratoconus, refractive errors, steroid
induced glaucoma, rarely chronic anterior uveitis2, 3,4.
Topical steroids and antihistamines are the mainstay
of treatment of vernal keratoconjunctivitis5.These
medications are required to be given for long duration
considering the chronic nature of the disease.
Patients of VKC on steroid therapy are at higher risk
of developing steroid induced glaucoma. Raised
intraocular pressure due to steroids typically occurs
within few weeks of starting steroid therapy, which

comes back to normal on immediate stoppage of
steroids6.
CASE REPORT
A 30 years old female presented with recent onset
headache. She gave a history of itching, redness,
photophobia in both eyes since 6 years. Symptoms
used to get aggravated in early summer and to
continue throughout the season. Self medication in
the form of steroid eye drops was tried by the patient
since last 3-4 years.
On presentation, Snellen visual acuity was 6/9 in both
eyes. Anterior segment examination showed mild lid
oedema, ropy discharge and conjunctival congestion
with papillary hypertrophy (cobblestone appearance).
Bulbar conjunctiva and cornea were normal. IOP
recorded by Goldmannaplanation tonometer was
raised up to 34 mm of Hg and 31 mm of Hg in right
and left eye respectively.
Ophthalmoscopic examination of both eyes showed
226
Mahima et al.,
pale optic disc with well defined margins, thin

neuroretinal rim, nasal shifting of blood vessels with
bayoneting sign. The cup disc ratio in the right eye
was 0.8 and in the left eye was 0.6. Her visual field
examination on standard automated Humphrey
perimeter showed an extensive visual field loss,
impinging on central vision.
Fig 1: Cobblestone appearance of papillary

hypertrophy
Fig 2: Glaucomatous disc in Left eye
timolol eye drop bd. Patient followed up after 20

days. Her IOP recorded in both eyes were 24 mm of
Hg and 21 mm of Hg.
Although she maintained low IOP and good visual
acuity of 6/9 in both eyes, she had developed severe
visual field defects.
DISCUSSION
Vernal Keratoconjunctivitis is a bilateral chronic
allergic inflammation of the conjunctiva, which
mostly affects young adults in tropical climate. It is
characterized by marked burning and itching
sensation which is usually not tolerable and
aggravated during the summer. Type I and IV
hypersensitivity contribute to symptomatology and
pathogenesis of VKC. Stimulation of T cellsreleases
cytokines which activates eosinophils and mast cells,
responsible for its pathogenesis6. These patients may
be at high risk of permanent visual impairment due to
complications like refractive errors, keratoconus,
corneal scarring, corticosteroid induced glaucoma and
cataract formation. Up to 85% of patients with VKC
require corticosteroid therapy at sometime during
their course of illness6. As a result of this regular
monitoring of IOP should be done of these patients.
Corticosteroid induced IOP elevation is an iatrogenic
condition caused by decreased trabecular outflow6.
Changes in trabecular mesh-work cells have been
identified, including increased deposition of several
components of the extracellular matrix and
rearrangement of the trabecular mesh-work
cytoskeleton with cross linking of actin of
microfilaments7.Generally the corticosteroid induced
ocular hypertension is reversible on discontinuation
of steroid therapy but if unrecognized, this may lead
to secondary open angle glaucoma and ultimately
glaucomatous optic neuropathy which is irreversible.
In our case the patient was from a rural area, where
health facilities are not easily accessible. Lack of
health awareness, illiteracy about the disease
condition, side effects of drugs and regular and
frequent follow up leads to irreversible glaucomatous
damaged to optic disc leading to visual field defects
in the patient.
Fig 3:Visual field defects on perimetry
CONCLUSION
To suppress the symptoms of VKC and to control the

IOP, patient was started on topical cyclosporine eye
drop tds, loteprednol eye drop qid, olopatadin and
Bilateral steroid induced glaucoma is an important

complication seen in patients of VKC due to prolong
use of topical steroids. It can be prevented by proper
227
Mahima et al.,
counseling for regular follow up and monitoring the

IOP along with visual field testing.
REFERENCES
1. Leonardi A, Busca F, Motterle L et al. Case
series of 406 vernal keratoconjunctivitis patients:
a demographic and epidemiological study. Acta
Ophthalmol Scand 2006; 84(3): 406-10.
2. M Daud Khan, NiamatullahKundi, Nasir Saeed,
ArifaGulab, andAnoisa F Nazeer. Incidence of
keratoconusin spring catarrh. www.ncbi.nlm.
nih.gov/.../
3. Andrea Taddiol, Rolando Cimaz, Roberto
Caputo, Cinzia de Libero, Laura Di Grande,
Gabriele Simonini, et al., Childhood chronic
anterior uveitis associated with vernal
keratoconjunctivitis. PediatrRheumetol Online J
2011; 9: 34.
4. Marcus Ang, Seng-EiTi, Raymond Loh,
SonalFarzavandi, Rongli Zhang, Donald Tan, etal
Steroid induced ocular hypertension in Asian
children
with
severe
vernal
catarrh.
Clinophthalmol 2012;6:1253-8.
5. SaadiaFrooq, Aslam Malik. Evaluation and
Management of Steroid Induced Glaucoma in
Vernal Keratoconjunctivitis Patients. Pak J
Ophthalmol 2007;23: 1
6. Mithal S, Soodv AK, Manini AK, Management
of vernal keratoconjunctivitis with steroid
induced glaucoma-a comparative study. Indian J
Ophthalmol. 1987; 35(6):298-01.
7. Sihota R, Konkal VL, Dada T, Agarwal HC,
Singh R. Prospective long-term evaluation of
steroid-induced glaucoma. Eye (Lond).2008;
22(1):26-30
228
Mahima et al.,
DOI: 10.5958/2319-5886.2015.00039.9

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DEEP AGGRESSIVE ANGIOMYXOMA IN THE PELVIC REGION: A CASE REPORT

*Sangeeta Singh1, Ravindra R. Karle2, Pandure MM3, Minal Desale1, Tanwi Singh1, Harsh Shah1
1
Resident, 2Prof. of Pathology, 3Asso. Prof. of Pathology, Department Of Pathology, Rural Medical College,
Pravara Institute of Medical Sciences (DU), Loni, Ahmednagar, Maharashtra, India
*Corresponding author email: drs_sangnit25@rocketmail.com
ABSTRACT
Introduction: Aggressive angiomyxoma is a rare soft tissue neoplasm that usually arises within perineum of
woman of reproductive age. A mass in vulva, which clinically can be diagnosed as a Bertholin gland cyst, should
have aggressive angiomyxoma in differential diagnosis. Rarely, cases reported in males and children. Case
report: A case of 40yrs female, presented with complaints of pain in abdomen and distension of abdomen since
20 days, is being reported. On abdominal palpation: Tender, abdominal mass felt corresponding to 24-26 weeks.
Per speculum examination revealed that cervix taken up. Ultrasound abdomen suggestive of 36x23x15cms
neoplastic abdomino-pelvic mass, heterogenous, hypoechoic & solid. Uterus bulky with loss of endometrialmyometrial complex. Total abdominal hysterectomy with bilateral salpingoopherectomy done. Grossly, a huge
32x20x14cms tumor, weighing 2500gm, was received; whose histological diagnosis was deep aggressive
angiomyxoma. Conclusion: Aggressive angiomyxoma is a rare, mesenchymal neoplasm, which infiltrates
surrounding tissue. It is more common in women.
Keyword: Aggressive angiomyxoma, Soft tissue neoplasm.
INTRODUCTION
Aggressive angiomyxoma is a rare mesenchymal soft
tissue neoplasm which has a high predilection to
vulva, vagina and perineum of women. In 1983,
Steeper and Rosai presented a case series of 9 female
patients1. At that time, tumor was first reported in
literature. In that case series, they found the most
common age group of presentation of the tumor was
21-38 years (young adult women) and size of the
tumor was large (up to 60 X 20 cm), and seen
infiltrating into the surrounding tissue and found to
recur at the same site. For this reason, they labeled
the tumor as aggressive1. It occurs predominantly in
woman of reproductive age in the second or third
decade of life, but cases have been reported in
children2. Rarely this tumor has been described in
Sangeeta et al.,
scrotal and inguinal region in males3,4. The female to

male ratio was found to be 6.6:1 in the literature5.
When a patient presents to a clinician, a clinician may
think of other superficial lesions of vulva, vagina and
perinium such as vaginal or labial cysts and lipomas.
On clinical examination, the size of tumor cannot be
assessed properly, as the depth can only be seen by
radiological examination. It is difficult to remove it
completely by surgery because it infiltrate the
surrounding tissue. Because of this reason, in
ischiorectal and retroperitoneal spaces tumor
recurrence occurs commonly2. Distant metastasis is
seen in 2 cases. Both were of lung metastasis6,7.
229
CASE REPORT
We are presenting a case of 40 yrs female presented
with complain of pain in abdomen, difficulty in
passing stools and urine and feeling of abdominal
mass since 2 months. There was no history of fever,
nausea, vomiting, and bleeding per-vaginal, apparent
weight loss.
Menstrual history was regular with cycle and flow
and there were no clots and no dysmenorrhea. Last
menstrual period was 10 days back. Obstetric history:
Patient was Para 2 Live 2. Both were full term normal
deliveries & history of tubal ligation done 15yrs back.
On general examination, vitals were stable. No
peripheral lymphadenopathy and other signs of
malignancy found.
Per abdomen: Tender, abdominal mass felt
corresponding to 24-26 weeks; oval, on Rt. side of
lumbar spine, arising from pelvis, slightly mobile,
firm in consistency, around 20x15cm. Rt. iliac fossa
completely obliterated.
Per vaginal examination: Uterus normal size, firm,
mobile, separately felt from the mass which was felt
in Rt. Adnexa. Rt. Adnexa was fixed; bogginess felt
in Rt. fornix, Lt. Fornix was relatively free.
Per Rectal examination: large firm mass felt
anteriorly free from rectal mucosa, POD was
obliterated & mass compressing rectal lumen.
All hematological investigations were done and the
investigation reports were within normal limits.
Ultrasound abdomen suggestive of 36x23x15cms
neoplastic abdomino-pelvic mass, heterogenous,
hypoechoic & solid. Bulky uterus with loss of
endometrial-myometrial complex. Ovaries seen
separately from tumor on Transvaginal sonography
examination.
Exploratory laprotomy under General anaesthesia
performed. Large whitish shiny tumor drawn out of
peritoneal cavity which was arising from Rt. Adnexa
of the uterus and its extension as peduncle in POD
and also in the ischiorectal fossa noted. Total
abdominal
hysterectomy
with
bilateral
salpingoopherectomy done.
Gross examination (Figure1): Weight: 2500gm,
32x20x14 cms in dimension. External surface: Shiny,
gray white in colour and rubbery in consistency. Cut
surface: Smooth, gelatinous, and gray-white . Areas
of haemorrhage seen.
Sangeeta et al.,
Fig 1: Gross examination and cut surface.

Microscopic
examination
(Figure2&3):
A
hypocellular myxoid stroma with numerous small to
large blood vessels. At places, perivascular rings of
condensed collagen are noted. The tumor cells are
oval, spindle shaped, and stellate in appearance. The
cells are bland and benign in appearance with illdefined cytoplasmic borders.
Fig 2: Microscopic examination showed hypocellular

myxoid stroma with numerous small to large blood
vessels; x200 (H& E Stain).
Fig 3: Microscopic examination show cytologically

bland, spindled, ovoid and stellate shaped cells.
Perivascular rings of condensed collagen are noted;
x400 (H& E Stain).
230
DISCUSSION
Aggressive angiomyxomas are locally invasive
connective tissue tumors presenting in about 90% of
cases in women of reproductive age group with a
peak incidence in the fourth decade of life8. Locally
infiltrative, may present as a vulval mass, vaginal
polyp, bartholin or a vaginal cyst, ovarian cyst, etc.
Cases presented as retroperitoneal mass9 and gluteal
mass10 have been reported. These lesions are
characterized as soft, non-encapsulated tumors with
finger-like projections infiltrating the surrounding
soft tissues. These tumors are mostly benign, as we
have seen histologically, composed of benign and
bland cells. Their growth is slow, and generally do
not metastasize. However, it usually tends to recur
locally. The rarity of this condition makes the
preoperative diagnosis fairly difficult. It has also been
also related to hormonal activity which explains
female dominance.
Immunohistochemistry: The stromal cells can show
immunoreactivity to different combinations of
vimentin, desmin, smooth muscle actin, muscle
specific actin, CD 34, estrogen and progesterone
receptors11.
Angiomyxoma genetics: Chromosomal abnormality
involving chromosome 12, associated with
rearrangement of HMGIC gene, has been reported in
cases of aggressive angiomyxoma12. HMGIC
expression seen in the spindled stromal cells in high
proportion but in blood vessels not as high and
consistent. This fact indicates that these stromal cells
are neoplastic in nature rather than vascular
component. Probably, after stromal cell proliferation,
blood vessels genesis occurs.
By immunohistochemistry, neoplastic stromal cells
show HMGIC expression. As, this is specific to
neoplastic cells, the margins can be assessed, which is
difficult on clinical ground and also histologically.
Differential diagnosis: Myxolipoma, myxoid variant
of liposarcoma, myxoid neurofibroma, myxoid
leiomyoma, leiomyosarcoma, and myxofibrosarcoma,
fibroepithelial stromal polyp,
angiomyofibroblastoma, cellular angiofibroma,
massive vulvar edema, fibrous histiocytoma and
botryoid rhabdomyosarcoma.
The blood vessels (small and large) and perivascular
rings of condensed collagen are helpful in
Sangeeta et al.,
distinguishing aggressive angiomyxoma from other

neoplastic lesions.
Treatment: As, we have discussed that this tumor
has high tendency for recurrence at the site of origin,
wide local excision is considered the treatment of
choice. The margins should be tumor free, otherwise,
reexcisions will be the next step during follow up of
patient. Sometimes, marked operative morbidity has
been reported because of Involvement of surrounding
organs, as bladder, large intestine, uterus, cervix and
bone. So tumor free margins are necessary, and this
can be confirmed by immunohistochemical
examination.
As, stromal cells show immunoreactivity to estrogen
and progesterone receptors, so hormonal therapy can
influence the proliferation of tumor cells. GnRH
analogues have been used in a few instances in
premenopausal
women
with
aggressive
angiomyxoma13,14.
Radiotherapy or chemotherapy are not as good
treatment options, because tumor proliferation rate is
slow and mitotic activity is low.
CONCLUSION
Aggressive angiomyxomas are rare, locally
aggressive tumors, arising mainly in the female pelvis
with a high likelihood of recurrence even after
complete surgical excision. Preoperative diagnosis is
difficult due to its rarity and lack of characteristic
features. Few management options are available and
multimodal therapy may be a good option.
ACKNOWLEDGMENT
We would like to acknowledge the technical
assistance given by Mrs. Lata D. Aher, Mr. Ugale M.
Laxman, Mrs. Swati P. Chavan, technicians in
Department of Pathology, Rural Medical College.
Conflict of interest: Authors declare that they have
no conflict of interests.
REFERENCES
1. Steeper TA, Rosai J. Aggressive angiomyxoma
of the pelvis and perineum: report of nine cases
of a distinctive type of gynaecologic soft tissue
neoplasm. Am J Surg Pathol 1983;7:463-475.
231
2. Fetsch JF, Laskin WB, Lefkowitz M, Kindblom

LG,
Aggressive
angiomyxoma:
a
clinicopathologic study of 29 female patients.
Cancer 1996; 78:7990
3. Iezzoni JC, Fetchner RE, Wong LS, Rosai J.
Aggressive angiomyxoma in males. A report of
four cases. Am J Clin Pathol 1995, 104: 391-96.
4. Takeshi Kondo. Aggressive angiomyxoma in the
inguinal region: A case report. Journal of medical
case reports. 2010;4:396.
5. Sutton
BJ,
Laudadio
J.
Aggressive
angiomyxoma. Arch Pathol Lab Med. 2012;
136:217-221.
6. Siassi RM, Papadopoulos T. Metastasizing
aggressive angiomyxoma. The NEJM. 1992 Dec;
341: 1772.
7. Blandamura S, Cruz J aggressive angiomyxoma:
a second case of metastasis with patients death.
Human Pathol. 2003 Oct; 34: 1072.
8. Chan YM, Hon E, Ngai SW, Ng TY, Wong LC.
Aggressive angiomyxoma in females: is radical
resection the only option? Acta Obstet Gynecol
Scand. 2000;79(3): 216-20.
9. Col S Rudra, Lt Col RN Banerji, Col NS Mani.
Aggressive angiomyxoma. MJAFI. 2007; 63:386387.
10. Kumar S, Agarwal N, Khanna R, Khanna AK.
Aggressive angiomyxoma presenting with huge
abdominal lump: A case report. Cases journal.
2008;
1:131.
Retrived
from:
http://www.casesjournal.com/content/1/1/131.
11. Amezcua
Ca,
Begley
SJ.
Aggressive
angiomyxoma of the female tract: A clinicpathologic and immunohistochemical study of 12
cases. Int J Gynecol Cancer 2005; 15: 140-145.
12. Nucci MR, Weremowicz S. Chromosomal
translocation t(8:12) induces aberrant HMGIC
expression in angiomyxoma of vulva. Genes,
Chromosomes & Cancer 2001; 32:176.
13. McCluggagu WG, Jamieson T. Aggressive
angiomyxoma of vulva: dramatic response to
gonadotropin-releasing hormone agonist therapy.
Gynecol Oncol. 2006 Mar; 100(3): 623-5.
14. Poirier M, Fraser R, Meterissian S. Aggressive
angiomyxoma of the pelvis: Response to
luteinizing hormone releasing hormone agonist.
Journal of clinical pathology. 2003; 2(18):35353541.
Sangeeta et al.,
232
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NEOVASCULAR GLAUCOMA SECONDARY TO CAROTID ARTERY ATHEROSCLEROSIS

Bangal Surekha1, *Patil Bhushan2, Padghan Dipti3, Bhandari Akshay4
1
Professor,
India
2,3
Resident, 4Assistant Professor, Department of Ophthalmology, Rural Medical College, PIMS,Loni,
*Corresponding author email: meettobhushan@gmail.com

ABSTRACT
A 65 year old male patient presented with pain, redness and loss of vision in right eye. Slit lamp examination
revealed mid dilated, fixed pupil with rubeosisiridis. Intraocular pressure was raised in right eye. Fluroscein
examination showed dye leaking in right eye anterior chamber due to iris neovascularisation. Carotid Doppler and
CT carotid angiography study showed right common carotid artery atherosclerotic plaque and reduced blood flow
in right central retinal artery. Proper ophthalmological evaluation of patient having carotid artery disease is
essential for prevention of intractable neovascular glaucoma and permanent blindness.
Keywords: Neovascular glaucoma, Carotid occlusive disease, chronic ocular ischemia
INTRODUCTION
Chronic ocular ischemia occurs due to carotid artery
stenosis which can lead to neovascular glaucoma.1It
is a potentially blinding condition. Neovascular
glaucoma term is coined by Weiss et al in 1963. It
was also known as haemolytic glaucoma and
Rubeotic glaucoma, first described by Coats in 1906.
It can be the result of carotid artery occlusion.1 In one
series, carotid occlusive disease was the fourth most
common cause and accounted for 8 % of the cases of
rubeosis iridis.2 It eventually leads to zipping up of
the angle resulting in the classical endpointneovascular glaucoma with high pressure, pain and
corneal oedema.2
right eye and visual acuity in left eye was 6/6.

Intraocular pressure was 29 mm Hg in the right
eye and 17mm of Hg in the left eye. Slit lamp
biomicroscopic examination of the right eye
revealed circumcorneal congestion of the
conjunctiva with diffuse corneal edema.
Anterior chamber depth was normal. Iris
neovascularisation was noted along the pupillary
margin with absence of hyphema (Fig.1).
CASE REPORT
A 65 year old male presented with intermittent

pain, loss of vision and redness since one year in
the right eye. Patient was not a known case of
hypertension or diabetes mellitus. There is no
history suggestive of cerebrovascular accident in
past.There was absence of light perception in
Surekha et al.,
Fig1: Slit-lamp examination of Right eye showing

Rubeosisiridis
233
Direct and consensual light reflexes were absent in

the right eye. Ophthalmoloscopic examination
revealed presence of pale optic disc. However rests of
the details were not appreciated due to lenticular
opacity. Anterior and posterior segment examination
of the left eye was unremarkable. Blood pressure was
110/70 mm Hg in right arm supine position. Random
blood sugar was 120 mg/dl and lipid profile was
within normal limits except triglyceride level which
was 154 mg/dl.
On Fundus Fluroscein angiography, leakage of
fluroscein dye was noted in the anterior chamber of
the right eye (Fig.2).
Fig 2: Leakage of flurosceinedye in aqueous on

Cobalt blue filter.
Carotid Doppler study showed patterns suggestive of
atherosclerotic changes in right and the left common
carotid artery. Presence of an ulcerated, irregular
plaque measuring 8.83.1 mm was noted at the
bifurcation of the right common carotid artery which
was confirmed on CT carotid angiography (Fig.3).
The blood flow velocity in the right and left central

retinal artery was 4.5 cm/sec and 8.8 cm/sec
respectively.
DISCUSSION
In 1956, Wise proposed that production of diffusible
angiogenic factors from ischemic retina was
sufficient to induce neovascularisation of the iris,
optic nerve and retina3.With the advent of Fluroscein
angiography it was demonstrated that the risk of
neovascularisation was directly correlated to the
extent and severity of the retinal ischemia4.Retinal
blood flow is autoregulated by balancing metabolic
and myogenic factors. Numerous factors influence
the vascular resistance. In ocular manifestations due
to the carotid disease, most common cause is carotid
artery atherosclerosis. Atherosclerosis of common or
internal carotid artery usually affects the ipsilateral
eye.
Presence of signs such as conjunctival congestion,
presence of iris neovascularisation, fixed semi dilated
pupil is suggestive of anterior segment ischemia.
Fundus Fluroscein angiography of other eye was
normal, but fluroscein dye is noted in the diseased
eye which is due to the leaking neovascularisation of
iris (Fig.2)
Fundus examination revealed pale optic disc but
details could not be appreciated due to cataractous
changes. Raised intraocular pressure in the affected
eye is suggestive of development of neovascular
glaucoma. One of the most striking features is the
narrowed lumen and reduced blood flow in the right
central retinal artery on carotid Doppler study. There
is an absence of systemic diseases like Diabetes
Mellitus, Hypertension etc which is an important
finding because presence of these conditions have
been found to be present in more than half of the
patients of this condition.5, 6 In 10-15 % of patients of
ocular ischemic syndrome due to carotid
insufficiency, there is history of an episode of
transient visual loss.6,7 But there is no such history of
an episode of transient visual loss in this patient.
CONCLUSION
Fig 3: CT carotid angiography showing

obstruction at the bifurcation of the right common
carotid artery
Lumen of the right central retinal artery was 1.2sq.cm
and that of left central retinal artery was 1.7 sq.cm
Surekha et al.,
Chronic ocular ischemia resulting from the

extracranial carotid artery occlusion leads to the
neovascularisation in the eye and progressive loss of
vision.
Therefore,
careful
ophthalmological
234
evaluation of patient having carotid artery disease is

essential for prevention of intractable neovascular
glaucoma and permanent blindness.
REFERENCES
1. Huchman MS, Haas J. Reversed flow through the
ophthalmic artery as a cause of rubiosisiridis. Am
J Ophthalmol 1972; 74: 1094-1099.
2. Hoskins HD. Neovascular glaucoma. Current
concepts. Trans Am AcadOphthalmolOtolaryngol
1974; 78: 330-333.
3. Albert, Jakobiec. In: Principles And Practice Of
Ophthalmology. 2ndEdn. 1900-1936, 3rd 1799.
4. Wise GN: Retinal neovascularisation, Trans Am
Ophthalmolsoc.1956:54:729-826.
5. Sivalingam A, Brown GC, Magargal LE,
Menduke H. The ocularischemic syndrome II
Mortality and systemic morbidity. IntOphthalmol
1989;13:187-91.
6. Mizener JB, Podhajsky P, Hayreh SS. Ocular
ischemic syndrome.Ophthalmology 1997;104:
859-64
7. Brown GC, Magargal LE. The ocular ischemic
syndrome clinical,fluorescein angiographic and
carotid angiographic features. IntOphthalmol
1988; 11:23
Surekha et al.,
235
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rd
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RETAINED STONE PIECE IN ANTERIOR CHAMBER: A CASE REPORT

BangalSurekha1, *Siddiqui Fuzail2, Kalkote Prasad3, Bhandari Akshay4
1
Professor, 2,3Resident, 4Assistant Professor, Department of Ophthalmology Rural Medical College, Pravara
Institute of Medical Sciences (DU), Loni, Maharashtra, India
*Corresponding author email:dr.fuzail18@gmail.com
ABSTRACT
Background: Anterior segment foreign bodies are un-common, making up only about 32% of all intraocular
foreign bodies. The present case report aims to study the effects of foreign bodies in the anterior chamber. Case
Report: Sixty year old female presented with a gradual diminution of vision in left eye since one year with a
history of trauma twenty years back. Examination revealed presence of stone piece in the anterior chamber
coincident with cataract. No signs of any damage due to retained foreign body were observed. Conclusion:
Although prompt removal of certain intraocular foreign bodies is warranted to avoid untoward ocular effects in
the present case, the piece of stone has remained silent without causing any ocular morbidity.
Keywords: Retained stone piece, Anterior chamber, Ocular trauma.
INTRODUCTION
Anterior segment foreign bodies are un-common,
making up only about 32% of all intraocular foreign
bodies.1 Ocular trauma is more common among the
rural population of India. In cases of penetrating ocular
trauma, Intraocular foreign bodies are potentially
vision threatening. Intraocular foreign bodies account
for almost 40% of all cases with penetrating ocular
trauma.2The extent of injury often depends on four
factors: the size and composition of the foreign body,
the force at which the foreign body enters the eye, the
location of the entrance wound and the final resting
place of the foreign body.3 Retained intraocular
foreign bodies most commonly results from
occupational activities and predominantly involving
males in their 3rd to 4th decades4.The velocity and
point of entry determines the site at which a foreign
body comes to rest . Non metallic foreign bodies
usually have a lower velocity than the metallic ones,
therefore once they penetrate the cornea, they tend to
remain in the anterior chamber5. The resulting reaction
in the anterior chamber depends on its composition,
shape and size together with the presence or absence

of irritation of the adjacent structures, corneal
endothelium, iris and lens. Ocular trauma is common
among the rural population of India as people are
exposed to work related conditions like agriculture
injuries, thorn pricking injuries, construction work
related injury.
Siddiqui Fuzail et al.,
CASE REPORT
A 60 year old female, presented to the
Ophthalmology department of a tertiary care
hospital, based in a rural area with complaints of
gradual, progressive, diminution of vision in her left
eye for the past year. The patient gave a history of
trauma to left eye while working 20 years back for
which she received no treatment at the time of
injury. The patient was, however asymptomatic for
the last 19 years.
On examination best corrected visual acuity in her
right eye was 6/12 and her left eye was 6/36. On
236
anterior segment examination with slit lamp biomicroscope her right eye was within normal limits
except for the presence of immature senile cataract.
Left eye examination showed a linear leucomatous
corneal opacity 4mm in length located in the inferotemporal quadrant at 4 o clock meridian 2mm inside
the limbus extending into the visual axis. The
anterior chamber depth was normal and a triangular
piece of stone measuring approximately 4x4x1 was
noted in the anterior chamber in the infero-nasal
quadrant at 6 to 8 oclock position without any signs
of active inflammation (Fig.1)
Computed tomography of Left orbit was done to locate

and measure the dimensions of foreign body and to
know if there is any extra-ocular foreign body present.
It showed a well-marginated oval hyper dense area
with C.T. attenuation 305-380 HU measuring about
4.64.8mm seen embedded in infero-medial aspect of
the anterior chamber. In our case no active
interventions were done at present.
Fig.3 CT orbit showing foreign body in left eye

DISCUSSION
Fig.2: B-scan showing foreign body embedded in

the anterior chamber
The rural population of India is highly exposed to

various types of occupational injuries. Ocular
injuries can present as an isolated problem or as a
part of poly-trauma.5 They are workers and are
involved in laborious outdoor field work such as
farming, road construction.
The majority of them are from poor socioeconomic
class and are illiterate. They are not aware of the
complications of ocular injuries and therefore land
up with higher ocular morbidity and mortality. Use
of protective devices at work is not a routine
practice. The index, patient in this case report was
injured from a piece of stone while she was working
at the road construction site. Under such
circumstances the possibility of a piece of stone
carrying micro-organisms and resulting into
fulminant infections is usually high. Primary repair
with removal of foreign body should be the plan of
treatment in such cases. Surprisingly, this was not
attempted in our case as the patient was poor and
being a daily wedges worker could not afford time
away from work. So the foreign body remained
embedded in the anterior chamber for twenty years
causing no direct or indirect harm to the surrounding
structures. No active interventions were warranted as
the foreign body was silent and did not disturb the
Fig1: Stone piece in anterior Chamber with sealed

corneal tear
The foreign body appeared between cornea and iris
and was immobile with fibrosis around it, was
suggestive of previous inflammation. The lens showed
early cataractous changes. Bscan Ultrasonography
was done to rule out any posterior segment pathology
associated with ocular trauma and localise and
posterior segment foreign body if present. It showed a
hyper-reflective, ill-defined area measuring 4.74 mm
present without posterior acoustic shadowing in the
anterior chamber while the posterior chamber was
normal (Fig.2).
237
visual acuity of the individual. A study of 70

military soldiers who sustained IOFB injuries
concluded that Delayed IOFB removal with a
combination of systemic and topical antibiotic
coverage can result in better visual outcome without
an apparent increased risk of endophthalmitis or
other deleterious side effects.6 In our case no active
interventions were done at present, however routine
cataract surgery can be planned in future without
disturbing the foreign body.
CONCLUSION
From our case, we conclude that in selected cases of
anterior segment foreign body Prompt removal of
foreign body is not warranted if it appears to be inert
or encapsulated and may be left alone.
ACKNOWLEDGEMENT: Nil
REFERENCES
1. Sanduja N, Aurora A, Luthra G. Retained IOFB.
In: Jaypee Brothers Medical Publishers. Clinical
diagnosis and management of ocular trauma;
2009.
2. Iqbal M. Retained Intraocular Foreign Body. Pak
J Ophthalmology. 2010;26(3):158-61.
3. Greven, CM, Engelbrecht, NE, Slusher MM, et
al. Intraocular foreign bodies : Management ,
prognostic factors , and visual outcomes.
Ophthalmology 2000 March ; 107 ( 3) : 608 612.
4. Dhir SP, Mohan K, Munjal VP, et al. Perforating
ocular injuries with retained intra-ocular foreign
bodies. Indian J Ophthalmol.1984; 32:289-9.
5. D B Archer, M S Davies & J Jkanski : NonMetallic foreign bodies in the anterior chamber
BJO 1969 : 53,453-456.
6. Marcus H. Colyer, Eric D. Weber, Eric D.
Weichel, John S.B. Dick, Kraig S. Bower,
Thomas P. Ward, Julia A. Haller: Delayed
Intraocular Foreign Body Removal without
Endophthalmitis during Operations Iraqi
Freedom
and
Enduring
Freedom
Ophthalmology, August 2007 114, (8): 14391447.
238
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th
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SUBCUTANEOUS PHYCOMYCOSIS: A CASE REPORT

*Thilak Sundararaj1, Meera Govindaraju2, Brindha Thangaraj3
1
Associate Professor, 2Assistant Professor, 3PostGraduate Student, Department of Dermatology, Venereology and
Leprosy, Meenakshi Medical College & Research Institute, Enathur, Kanchipuram,Tamilnadu
*Corresponding author email: drthilakderm@gmail.com
ABSTRACT
Subcutaneous Phycomycosis is a rare tropical Mycoses characterized by the development of a chronic, firm
swelling of the subcutaneous tissue. Infection caused by Basidiobolus species commonly affects young children.
In this article we present a case of Subcutaneous Phycomycosis which presented as a diffuse swelling in the
posterior aspect of the knee. Early diagnosis and treatment with Itraconazole caused complete clearance of the
lesion. We highlight the merits of accurate diagnosis and early therapeutic intervention in this rare case.
Keywords: Phycomycosis, Basidiobolus, Conidiobolus, Subcutaneous, Aseptate hyphae
INTRODUCTION
Subcutaneous Phycomycosis is also called
Basidiobolomycosis, Subcutaneous Zygomycosis,
Conidiobolomycosis, Rhinoentomophthromycosis. It
is a rare tropical subcutaneous mycosis1. It is caused
by Basidiobolus ranarum and Conidiobolus
coronatus2. The lesion usually starts as a small
subcutaneous nodule that slowly increases in size
over a period of months. Lesions are usually painless
and ulceration over skin is uncommon. Commonly
involved areas are trunk, limb and buttocks3.
CASE REPORT
A 8 year old girl presented to Dermatology OPD with
swelling over the back of Right leg for the past 2
years (Figure 1). It started as a small swelling and
progressed to the present size. The swelling was not
itchy and was painless. There was no history of fever
or other constitutional symptoms. There was no
history of difficulty in walking.
Examination: On examination, there was a firm, non
tender, annular diffuse swelling of size 10 x 7 cm on
the posterior aspect of right knee joint. The borders
were raised and nodular (Figure 1). Regional lymph
nodes were not palpable. The finger insinuation test

was positive. Her general, physical and systemic
examination was normal. Routine lab investigations
were also normal. Biopsy was done from the swelling
and sent for histopathological examination and fungal
culture.
On
Histopathological
examination,
multiple
eosinophilic, broad, aseptate fungal hyphae were seen
in the dermis (Figure 3). Fungal culture was done
with Cycloheximide free Saborauds Dextrose agar at
30 degrees Celsius. It showed waxy yellow colonies
with radial folds classical of Basidiobolus.
Treatment: As soon as the diagnosis was confirmed,
the patient was started on Capsule Itraconazole
100mg once a day. Lesions started regressing from
day 10. There was complete resolution of the lesions
after 30 days of Itraconazole. (Figure2). Post
inflammatory Hyperpigmentation was present. The
child tolerated Itraconazole very well and there were
no adverse effects. The child was followed up for 6
months after the treatment with no relapse of the
disease.
239
Thilak et al.,
Fig 1: Diffuse swelling over the posterior aspect of

the knee
may grow to a huge size to involve the whole limb6.

The skin may be atrophic and discoloured or
hyperpigmented but does not ulcerate. Vessel
involvement and thromboses does not occur.
Definitive diagnosis is made by histopathological
study and fungal culture. HPE shows multiple
eosinophilic, broad, aseptate fungal hyphae in the
dermis7. Culture is done with Cycloheximide free
Saborauds Dextrose agar at 30 degrees Celsius. A
waxy yellow colony with radial folds in fungal
culture is conclusive of Basidiobolus ranaraum
infection. Itraconazole8 is the drug of choice.
Potassium Iodide9can also be given. It carries a good
prognosis if diagnosed early and treated properly10.
CONCLUSION
As it is said, Subcutaneous Phycomycosis is very rare
in India. Biopsy and fungal culture can establish an
accurate diagnosis. Timely management with
systemic therapy is required for curing this disease.
ACKNOWLEGEMENT
Fig 2: Complete resolution with treatment
We would like to thank our Department of

Dermatology for helping us with this article and our
families for their constant support.
Fig 3: HPE Eosinophilic, broad, aseptate fungal

hyphae
DISCUSSION
Subcutaneous Phycomycosis is a rare subcutaneous
fungal infectio..Two organisms which are usually
responsible for causing this infection are
Basidiobolus ranarum and Conidiobolus coronatus4.
The Basidiobolus infection is seen in Paediatric age
group, whereas Conidiobolus is seen in adults.
Basidiobolus infection commonly affects limb and
limb girdle areas5. Route of entry is not known. The
swelling is firm, painless and well circumscribed and
REFERENCES
1. Antonelli M, Vignetti P, Dahir M et al
Entomophthromycosis due to Basidiobolus in
Somalia, Trans R Soc Trop Med Hyg 1987; 81:
186-7
2. Sivaraman,
Thappa
DM,
Karthikeyan,
Hemanthkumar Subcutaneous Phycomycosis
mimicking Synovial Sarcoma. International
Journal of Dermatology. 1999;38(12):920923.
3. Sujatha S, Sheeladevi C, Khyriem AB, Parija
SC,Thappa DM. Subcutaneous zygomycosis
caused by Basidiobolus ranarum- a case report.
Indian Journal of Medical Microbiology 2003;
21(3):205-6
4. Scholtens RE,Harrison SM, Subcutaneous
Phycomycosis. Trop Geogr Med 1994; 46:371-73
5. Burkitt DP, Wilson AMM, Jelliffe DB.
Subcutaneous Phycomycosis; A review of 31
cases seen in Uganda. Br Med J 1969; 1: 166972.
240
Thilak et al.,
6. Prabhu RM, Patel R. Mucormycosis and

Entomophthoramycosis: A review of the clinical
manifestations, diagnosis and treatment. Clin
Microbial Infect 2004; 10 (1):31-47.
7. Lal
S,
Baruah
MC,Padiyar
NV
Clinicopathological study of Subcutaneous
Phycomycosis. Indian J Dermatol Venereal
Leprol 1984:50;245-8
8. Gugnani HC. A review of Zygomycosis due to
Basidiobolus ranarum. Eur J Epidemol 1999; 15:
923-9
9. Naniwadekar MR, Jagtap SV, Nikam BP,
Sanghavi KD. Subcutaneous Phycomycosis in a
Child. Online J Health Allied Scs 2009; 8(3): 14.
10. Chandrasekhar HR, Shashikala P, Haravi R,
Kada. Subcutaneous Phycomycosis. Indian J
Dermatol Venereal Leprol 1998;64: 89-90
241
Thilak et al.,
DOI: 10.5958/2319-5886.2015.00043.0

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Revised: 7thDec2014
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BILATERAL OVARIAN CARINOSARCOMA-A RARE ENTITY

*Sinkar Prachi1, Pande Pankaj2,Yelikar BR.3
1
Post Graduate Student, 2Associate Professor,3Professor& Head of Department, Department of Pathology, Shri
B.M. Patil Medical College, Hospital &Research Centre, BLDE University, Vijayapur, Karnataka, India
*Corresponding author email: doc.prachi@gmail.com / prachi.doc@gmail.com
ABSTRACT
Malignant mixed Mullerian tumor (carcinosarcoma) of the ovary is rare neoplastic condition with an incidence of
less than 1% of all ovarian neoplasms. Histologically, carcinosarcomas comprise of epithelial as well as
mesenchymal components, which are either homologous (normally found in ovary) or heterologous (not normally
seen in ovary). Here, we report a case of a 50 year old female patient who presented with abdominal distension
and was diagnosed as malignant mixed mullerian tumor of bilateral ovaries histopathologically. Carcinosarcomas
of the ovary are extremely rare and aggressive. We wanted to draw the attentionthat although it is more frequently
unilateral and seen among the postmenopausal nullipara women, malignant mixed mllerian tumors can also be
bilateral and seen among multiparas in the reproductive period as with this case report.
Keywords: Bilateral, Carcinosarcoma, Mixed Tumor, Ovarian Neoplasms.
INTRODUCTION
Ovarian carcinosarcoma, also called malignant mixed
mulleriantumour (MMMT), is a very rare ovarian
neoplasm, with an incidence of less than 1% of all
ovarian tumors, and less than 400 case reports in
literature1.Histologically, carcinosarcomas comprise
of epithelial(carcinomatous) as well as mesenchymal
(sarcomatous) components both, which are either
homologous (normally found in ovary) or
heterologous (not normally seen in ovary)2,3These
tumors are often seen in the 5th to 7th decadeie in
postmenopausal women who are nulliparous. They
are usually asymptomatic. Only 10% of them are
bilateral.2-4Despite aggressive treatment which
includes surgery and chemotherapy, patients have an
increased risk of death compared to women with
epithelial ovarian cancer4. Here we report a case of
malignant mixed mullerian tumour of the bilateral
ovaries in a 50 year old female with complains of
abdominal distension where a total abdominal
hysterectomy and bilateral salpingo-oophorectomy

was performed.
CASE REPORT
A 50-year-old woman, gravida2, para2, consulted to
the outpatient department of Obstetrics and
Gynecology with complaints of abdominal distention
since two months. Physical examination was
unremarkable except for bilateral massesper
abdomen. There were no other complaints and she
was previously doing well. History of irregular
bleeding or any such significant past history was
negative. Blood, urine and biochemical investigations
of patient were within normal limits. However only
an increase in CA-125 (60.2m/ml) and CA-199(20.4m/mL) was noted. USG revealed cystic lesions
in both ovaries left ovary measuring 14x7cms and
right ovary measuring9x7 cms.
Ovarian cancer was suspected, so the patient
underwent
exploratory
laparotomy.
Optimal
debulking surgery was performed, and specimen was
sent for histopathological study.
242
Prachi e al.,
Pathology: On gross appearance, an already cut open

unoriented specimen of both ovaries was received
which was fleshy, bulky and polypoidal, larger mass
measuring 13x9x6cms and smaller mass measuring
9x7x4cms. External surface showed numerous
fragmented pieces which were soft, encephaloid,
grey, black, glistening with areas of blackish
discoloration and focal areas of hemorrhage. Cut
section -Solid, grey white fragments showing
variegated appearance with areas of hemorrhage,
necrosis and multiple small cysts were noted. No
normal ovarian tissue was noted.
blood vessels, dense areas of necrosis and focal areas

of chronic inflammation were seen.
Fig3: Microphotograpah showing high grade

tumor cells with mitotic activity.(arrow head)
(H&E 40x)
Immunohistochemical analysis revealed positivity for
viment in confirming stromal component and for
EMA confirming the epithelial component.
Fig 1: Gross photograph of the ovary showing areas of

hemorrhage and necrosis.
On light microscopy, the tumor had a biphasic

pattern, which consisted of two components:
poorlycarcinomatoid and dominantly sarcomatoid.
Carcinomatoid component consisted mostly of
glandular formations of pleomorphic large-round
cells, polygonal hyperchromatic nuclei and
inconspicuous nucleoli with moderate amount of
vacuolated light cytoplasm.
4a
4b
Fig4:(a)Epithelial component showing positivity with

epithelial membrane antigen (EMA)4(b)Stromal
component showing positivity with vimentin (Vim)
Based
on
these
histopathological
and
immunohistochemical characteristics of the tumor
cells, Malignant Mixed Mullerian Ovarian tumor was
confirmed. (Carcinosarcoma)
DISCUSSION
Fig 2:Microphotograph showing both carcinomatous

(brown arrow) and sarcomatous components (yellow
arrow) components.( H&E 10x)
In the sarcomatoid component, individual and small
groups of trapped malignant cells were found, as well
as multi-nucleated (bizarre) cells next to the areas of
tumor necrosis. High mitotic activity, proliferating
Mixed mullerian tumors are extremely rare turmous

of genital system seen in postmenopausal women
with a peak incidence in the sixth decade of life. They
are often localized in the uterine corpus, but can also
be found in the uterine cervix, the tubes and the
ovaries. They develop from mesenchymal (Mullerian)
cells that can be differentiated into epithelial and
stromal elements4. The tumor consists of homologous
or heterogeneous epithelial (carcinomatoid) and
mesenchymal (sarcomatoid) components of cells in
243
Prachi e al.,
different mutual relationships. The heterologous

sarcomatous component arises fromnonnative
elements such as rhabdomyoblastic, osteogenic,
chondroblastic, or lipoblastic elements. The epithelial
component can be endometrioid, undierentiated,
clear cell, or serousconsisting of one or more types of
carcinomas, the most common being adenocarcinoma
(serous, mucous, papillary, endometrial or the lightcell type), or anaplastic carcinoma. On the other
hand, within the group of malignant mesenchymal
component, the most common are the homologous
sarcomas
(fibrosarcoma,
angiosarcoma
and
leiomyosarcoma), although some cases of
heterologous sarcoma were also described.4,5
The histogenesis is not clear yet. Some authors are of
the opinion that there is transformation of the
epithelial cells into sarcomatoid ones (metaplastic
theory), while the others by the usage of the
immunohistochemical analysis and the cell culture,
point out the epithelial like characteristics of both
kinds of tumor cells. The cellular heterogeneity of
tumor by the co-expression of some of the epithelial
(Cytokeratin, CEA, EMA) and mesenchymal antigens
(Vimentin, Desmin) was proved. Such co-expression
of the antigens supports the hypothesis that the
epithelial and mesenchymal elements, which create
the MMMT of the ovaries, descend from a common
cellular precursor - the stem cell.6
MMMTs usually occur in postmenopausal women,
but occasionally occur in relatively younger patients.
Some ovarian germ cell tumours can sometimes be
quite challenging in histological diagnosis. Mixed
GCTs can mimic malignant mixed Mullerian tumors.
Yolk sac tumours can display multiple morphological
patterns and can mimic different types of carcinoma
such as clear cell carcinoma or endometrioid
adenocarcinoma. Cytoreduction has proven to have
an impact on survival. Chemotherapy does not appear
to be beneficial. 5
To summarize, malignant mixed mullerian tumors or
carcinosarcomas of the ovaries are very aggressive
tumors with a very poor prognosis. They are
diagnosed at an older age of about 5-7th decade in
post menopausal women. As in this case, MMMT
usually have reached an advanced stage at the time of
diagnosis, and survival varies with stage and
histological type. Despite aggressive treatment which
includes surgery and chemotherapy, patients have an
Prachi e al.,
increased risk of death compared to women with

epithelial ovarian cancer.7,8
CONCLUSION
In conclusion, we have described a rare case of
carcinosarcoma (homologous type of malignant
mullerian tumor) of bilateral ovaries that presented
with abdominal distension for two months. These
tumors are usually seen in the 5th to 7th decade and
are usually asymptomatic. Only about 10 % of them
are bilateral and are frequently encountered in
nulliparous women. More than 80% of the patients
had an extra ovarian abdominal spread at the time of
diagnosis3,8.
We wanted to throw light that although it is more
frequently unilateral and seen among the
postmenopausal nullipara women, malignant mixed
mllerian tumor can also be bilateral and seen among
multiparas in the reproductive period as with this case
owing to its rarity.
Conflict of Interests: Nil
REFERENCES
1. Harris MA, Delap LM, Sengupta PS, Wilkinson
PM, Welch RS, Swindell R, Shanks JH, et al.
Carcinosarcoma of the ovary. Br J Cancer
2003;88(5):654-57.
2. McCluggage WG. Malignant biphasic uterine
tumours:
carcinosarcomas
or
metaplastic
carcinomas? J ClinPathol 2002;55(5):321-25.
3. Brown E, Stewart M, Rye T, Al-Nafussi A,
Williams AR, Bradburn M, Smyth J, et al.
Carcinosarcoma of the ovary: 19 years of
prospective data from a single center. Cancer
2004;100(10):2148-53.
4. Bratislav Stojiljkovic, Tatjana Ivkovic, Milana
Panjkovic,
Aleksandar
Mutibaric,
Olgica
Mihajlovic, Marija Tesic, et al. Malignant mixed
Mullerian ovarian tumor. Archive of Oncology
2001;9(1):43-5.
5. Zhanyong Bing, Theresa Pasha, Li-PingWang, and
Paul J. Zhang. Malignant Mixed Mullerian Tumor:
An Immunohistochemical Study. Pathology
Research International 2012; DOI: 10.1155/2012/
569609
6. Boucher D, Tetu B. Morphologic prognostic factors
of malignant mixed mullerian tumors of the
ovary:aclinicopathologic study of 15 cases. Int J
GynecolPathol 1994;13(1):22-28.
7. Barnholtz-Sloan JS, Morris R, Malone JM, Jr.,
Munkarah AR. Survival of women diagnosed with
malignant, mixed mullerian tumors of the ovary
(OMMMT). GynecolOncol 2004; 93(2):506-12.
8. YardimTurgut, OkmanTlay. Malignant Mixed
Mullerian Tumor Of Ovary. Tr. J. Of Medical
Sciences.1998;28:315-16
244
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th
Revised: 15thDec 2014
Case report
Copyright @2014
ISSN: 2319-5886
A LATE ONSET CASE OF SPORADIC DYSCHROMATOSIS UNIVERSALIS HEREDITARIA

*Meera Govindaraju1, Thilak Sundararaj2, Brindha Thangaraj3
1
Assistant Professor, 2Associate Professor, 3Post graduate student, Department of Dermatology, Meenakshi
Medical College & Research Institute, Kanchipuram
*Corresponding author email: meera.dr@gmail.com
ABSTRACT
Dyschromatosisuniversalishereditaria is an autosomal dominant inherited rare genodermatosis wherein patient
presents with hypopigmented and hyperpigmented macules of varying sizes in a reticulate pattern. We report a
rare case of Dyschromatosisuniversalishereditaria in a 23 year old male patient with no affected family members
suggesting the possibility of sporadic mutation. Patient born of non consanguineous marriage presented with both
hypopigmented macules and hyperpigmentedkeratotic papuleswith progressive diffuse hyperpigmentation over
the trunk and both the extremities. Other system examination was normal. Histopathological examination showed
pigment incontinence with collagenisation of the dermis. A diagnosis of Dyschromatosisuniversalishereditaria
(DUH) was made based on history, clinical morphology and histopathology.
Keywords: Dyschromatosisuniversalis, Reticulate, Genodermatosis, Pigmentation
INTRODUCTION
Dyschromatosisare
pigmentarydisorders
which
presents
with
both
hyperpigmented
and
hypopigmented
macules
clinically.
Various
conditions present with dyschromatosis like
genodermatosis, inflammatory skin diseases,
infections, drugs, chemical use and nutritional
disorders. Two types of dyschromatosis are described
namely dyschromatosisuniversalishereditaria and
dyschromatosissymmetricahereditaria
or
acropigmentation of Dohi, wherein there is
predominantly acral distribution as opposed to DUH
with generalized distribution.Autosomal dominant
DUH is a genodermatosis described first by Toyamo1
in Japan in 1929 and again in 1933 in Germany by
Ichikawa and Hiraga. Its been suggested that DSH
could be a subtype of DUH. Only if, cloning of the
unidentified causative genes is done, we can arrive at
a conclusion whether DSH is a subtype of DUH or
not.
Meera et al.,
CASEREPORT
A 23 year old unmarried male born of non
consanguineous marriage presented to us with
complaints of diffuse darkening of skin and multiple
black warty skin lesions along with whitish
discolouration over arms, trunk and legs of 5 years
duration. Initially, it started over both the legs and
gradually progressed to involve the thighs and trunk
over last two years. No history of burning or itching
sensation on sun exposure. There was no history
suggestive of any drug intake or chemical exposure.
No other family members suffer from similar skin
lesions.
Dermatological examination revealed diffuse
hyperpigmentation all over the body with multiple
hypopigmented macules and hyperpigmented
keratotic papules varying in size from a few mm to 3
mm in diameter (Figure 1,2). His palms, soles and
mucous membrane were normal. Ophthalmological
245
and ENT examinations were normal. Systemic

examination was normal. All other routine
investigations were within normal limits. VDRL and
HIV were negative. A biopsy was taken from two
sites: hyperpigmentedkeratoticpapule (A) and the
hypopigmented macule (B).
Fig 1: Hyperpigmentedkeratotic papules admixed

with hypopigmented macules over both the legs
Figure 2: Hypopigmented macules over the trunk
Fig3: Histopathological examination A Low power

(10X): Hyperkeratotic squamous epithelium with
increased
basal
pigmentation
&
pigment
incontinence in the dermis
Histopathological
examination
of
the
hyperpigmentedkeratotic papule (A) (Figure 3,4)
showed hyperkeratotic squamous epithelium with
increased basal pigmentation and pigment

incontinence in the dermis with collagenisation of
dermis, whereas hypopigmented macule (B) (Figure
5,6) showed thinning of epidermis with blunting of
rete pegs. Collagenisation of dermis is noted.
Fig 4: Histopathological examination A Low

power(10X): Collagenisation of dermis
Fig 5: Histopathological examination B: Low

power(10X): Epidermal thinning and dermal
collagenisation
Fig6: Histopathological examination B: High

power(40X): Blunting of rete pegs
A diagnosis of Dyschromatosisuniversalishereditaria
(DUH) was made based on history, clinical
246
Meera et al.,
morphology and histopathology and the patient was

counseled on the benign course of the disease.
DISCUSSION
Pigmentarydermatosis of reticulate type includes a
group of disorder clinically presenting with
hypopigmentedandhyperpigmented macules. The two
major forms are Dyschromatosis symmetrica
hereditaria (DSH) and Dyschromatosis universali
shereditaria.Usually DUH has an autosomal dominant
inheritance but sometimes it can be inherited
recessively also. This disease is most commonly seen
in Japan; though there are few case reports from
Europe, India and China, fewer cases show familial
involvement. The absence of family history in our
case suggests a sporadic mutation. Cutaneous clinical
morphology
shows
scattered
hypo
and
hyperpigmented mostly,guttate macules of varying
sizes and shapes2 with irregular border spanning the
entire body. Disease presentation is usually during
the first few years of life and few cases show late
onset of this disease. Most commonly trunk and
extremities are affected, the face is rarely involved,
though our case presented with diffuse
hyperpigmentation. Palms, soles and mucous
membrane tend to be spared as in our case, although
few isolated cases of palms, soles, oral mucosa and
nail involvement have been reported. Various
conditions associated with DUH are tuberous
sclerosis3, Dowling degos disease3, X linked ocular
albinism3, photosensitivity, learning difficulties,
insulin- dependent diabetes mellitus, mental
retardation and erythrocyte, platelet and tryptophan
metabolism abnormalities. Other associations include
grand mal epilepsy, high tone deafness and small
stature. Most cases of DUH run a benign course.
The pathogenesis of DUH remains unclear. In a
genetically prone individual, during the early stages
of embryo formation there is a hindrance in the
neuralmelanocytic interaction. Other explanations
put forth for the pigment anomaly in DUH are
defective melanosome production and distribution in
epidermal melanin units3 or because of the small
number of melanocytes. The ultra structure
investigations have shown different levels of
melanocyte activity without abnormal pigment
production or transfer. CausativeDUH gene was
mapped to 6q24.2-q25. 2 (OMIM 127500). One of
the main differential diagnosis to be considered in
cases of DUH is xerodermapigmentosum as both the

condition shows the involvement of sun exposed
areas. But in DUH, lesions occur in unexposed sites
as well. There is no atrophy or telangiectasia. Most
cases dont progress or worsen with age4.
Once the disease was thought to be confined to
Japanese, now DUH is being increasingly reported in
other races as well. This disorder has been reported in
two Bantu females by Findlay and whiting5 and in an
Iraqi girl by Rycroft et al6. In view of ruling out
another
important
genodermatosis
namely
xerodermapigmentosum, DUH gains its importance.
Only few isolated case reports have been notified in
India so far7,8.
CONCLUSION
As there are only a few case reports from India with
no familial involvement and with late onset of disease
presentation, our case report of DUH assumes
paramount significance
ACKNOWLEGEMENT
We would like to thank our Department of
Dermatology for helping us with this article and our
families for their constant support.
REFERENCES
1. Toyama J.Dyschromatosissymmetricahereditaria.
Jap J Dermatol 1929; 29: 95-96.
2. Sethuraman G, Srinivas CR, DSouza M, Thappa
DM,
Smiles
L.
Dyschromatosisuniversalishereditaria.
ClinExp
Dermatol.2002;27(6):477-9
3. Binitha MP, Thomas, Asha LK. Tuberous sclerosis
complex
associated
with
Dyschromatosisuniversalishereditaria. Indian J
DermatolVenereolLeprol. 2006;72(4);300-2
4. Kim
NS,
Im
S,
Kim
SC.
Dyschromatosisuniversalishereditaria. J Dermatol
1977; 24: 161-64
5. Findlay
GH,
Whiting
DA.
Universal
dyschromatosis. Br J Dermatol 1971; 85; 66-70
6. Rycroft
RJ,Calnan
CD,
Wells
RS.
Universaldyschromatosis. Br J Dermatol 1971; 85:
66-70
7. Gharpuray MB, Tolat SN, Patwardhan SP.
Dyschromatosis: its occurrence in two Indian
families with unusual features.Int J Dermatol 1994;
33:391-92.
8. PavithranK.Dyschromatosisuniversalishereditaria
with epilepsy. Indian J Dermatol 1991;57: 102
247
Meera et al.,
DOI: 10.5958/2319-5886.2015.00045.4

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th
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BRENNER TUMOR WITH SEROUS CYSTADENOMA- AN UNUSUAL COMBINATION: A CASE

REPORT
*Syam Sundar B1, Shanthi V1, Mohan Rao N1, Bhavana Grandhi2, Chidananda Reddy V 2, Swathi S2
1
Associate Professor, 2Assistant professor, Department of Pathology, Narayana Medical College, Nellore, A.P,
India
*Corresponding author email: syam.byna&gmail.com
ABSTRACT
Surface epithelial tumors are most common, which comprise 58% of all ovarian tumors. Serous and mucinous
cystadenoma are the most common epithelial tumors which accounts for about 35% of ovarian tumors. Different
combinations of epithelial tumors can occur in ovary most common among them is Mucinous cystadenoma and
Brenner tumor. We report a case of an ovarian tumor with rare combination Brenner tumor with serous cyst
adenoma of ovary in 56 year old female patient. Only a few cases with this combination are very rarely reported
in the literature.
Keywords: Brenner Tumor, Serous cystadenoma.
INTRODUCTION
Surface epithelial tumors are the most important
group of neoplasm of ovary which are namely serous,
mucinous, endometroid, clear cell and Brenner along
with combinations of these types1. Surface epithelial
tumors occur at all ages with a peak incidence in 2nd
to 5th decade of life. Serous tumors represent 46% of
all surface epithelial ovarian neoplasm of which 50%
are benign serous tumors1.They are usually cystic
with the lack of solid areas and with a few papillary
excrescences. Brenner tumor is known to coexist with
mucinous ovarian tumors2. Seidman and khedmati3
observed 1.3 4% incidence of coexisting Brenner
tumor and mucinous cystadenoma. Most Brenner
tumors occur in women between the ages of 40 and
60 years. Most are small and are incidental findings4.
Here we report a case of a benign cystic tumor of
ovary with focal solid areas which showed a
combination of serous cystadenoma with a Brenner
tumor.
CASE REPORT
A 56 year old female patient presented with a
swelling in the lower abdomen with intermittent
abdominal pain over a period of 1 year. Clinically,
her general condition was good. On a routine physical
examination no abnormality was detected. On
ultrasound abdomen a cystic ovarian neoplasm was
suspected. Hysterectomy with salpingo opherectomy
was done and the specimen was sent to pathology
department for further evaluation. Macroscopically
hysterectomy specimen measuring 8x5x3 cm and
ovarian cystic mass measuring 4x3x2 cm(fig-1) and
tube measuring 4cm. Ovarian cystic mass surface was
smooth and grey white. On cut section it shows
unilocular cyst containing brownish material and
periphery of the cyst showed 2 x 1cm solid hard grey
white area. The inner wall of the cyst was smooth
with papillary excrescences. Microscopically uterus,
cervix showed proliferative endometrium and chronic
cervicitis. Fallopian tube grossly and microscopically
248
Syam et al.,
was unremarkable. Microscopic examinations from

the ovarian cyst wall shows cyst lined by benign
looking columnar epithelium (fig-2) and focal
papillary formations. Sections from the solid areas
show nests of transitional epithelial cells with foci
cystic change. The epithelial cell is round to with
nucleus showing grooving and moderate cytoplasm.
Surrounding stroma shows dense fibrocollagenous
tissue.
Fig1: Cut surface of cyst showing grey, brown

material with tiny grey white area
Fig: 2 Cyst wall lined by columnar epithelium, foci

of transitional nests (H& E 400X)
DISCUSSION
Surface epithelial tumors are most common ovarian
tumors. Serous tumors constitute 30% of all ovarian
tumors which making them the single most common
group. Brenner tumor comprises around 2% of all
ovarian tumors5. Most common mixed ovarian
tumors are mucinous cystadenoma with combination
of Brenner tumor, mature cystic teratoma, sertoliLeydig cell tumor or even a serous cystadenoma may
be seen6. A serous tumor is rarely found coexisting
with a benign Brenner tumo7. The combination of
serous cystadenoma with Brenner tumor suggests
common mullerian histogenesis. We believe that
rarely Brenner tumor as a result of mullerian

metaplasia, can also lead to development of surface
epithelial tumors. About 20% Brenner tumors occur
together with a mucinous or serous cystadenoma or a
benign cystic teratoma8. Serouscystadenoma may be
unilocular or multilocular. It has a thin wall and
contains clear fluid. The interior and exterior surfaces
are usually smooth with focal small papillary
excrescences may be present on the interior surface of
the ovary. In our case there was a papillary
excrescence on the interior surface of cystic
component of the ovary. Microscopically serous
cystadenomas are lined by ciliated and non ciliated
low columnar cells with bland ovoid nuclei. Although
benign serous tumors are typically lined by an
epithelium similar to that of the fallopian tube with
ciliated and less frequently non ciliated secretory
cells, cysts with flattened lining may be seen which
represent desquamation of the lining epithelium9.
Brenner tumor is usually sited in the ovarian cortex
and may also occur as a mural nodule in a mucinous
or serous cystadenoma and mature cystic teratoma.
The Brenner tumor is a type of adenofibroma in
which nests of transitional epithelium grow in a
fibrous stroma10. Grossly Brenner tumors are
circumscribed, firm, pale yellow or grey white solid
fibrous tumors. Many are of microscopic size and
most measure less than 2 cm in diameter. On section
they are formed of hard whitish grey tissue with a
slight whorled appearance. Microscopically the lesion
is composed of well delineated epithelial nests set in
a fibrous stroma. The epithelial cells are round or
polygonal with round or oval nuclei and have small
nucleoli and the cytoplasm ranges from clear to
eosinophilic. The central portion of the cell nests is
cystic which often is lined by flattened endothelial
like cells to cuboidal or columnar cells .Coexistence
of Brenner and serous cystadenoma supports the
theory of a common origin either from celomic
epithelium or remnants of the embryonic
mesonephric system. Extensive search of literature
showed only one such case report by Pschera H and
Wikstrom B titled Extra ovarian Brenner tumor
coexisting with serous cystadenoma was published
in 19917. To the best of our knowledge, this is the
second case with this combination to be reported in
our pathology department.
249
Syam et al.,
CONCLUSION
We are reporting this case for creating awareness
among the pathologists and gynaecologists about the
occurrence of this rare combination of ovarian tumor
so that misdiagnosis and mismanagement can be
avoided.
REFERENCES
1. Longacre TA, Blake Gilks C. Surface epithelial
stromal tumor of the ovary in Gynaecologic
pathology, J.R Goldblum, Ed.,
, churchill
st
LivingStone Elsevier, 1 edition, 2009;393-395
2. Kotsopoulos IC, Xirou PA, Deligiannis DA.
Tsapanas VS coexistence of three benign and a
borderline tumor in the ovaries of 52- year old
women. Eur J Gynaecol oncol 2013; 34 : 186-8
3. Seidman JD, Khedmati F. Exploring the
histogenesis of ovarian mucinous and transitional
cell (Brenner) neoplasms and their relationship
with walthard cell nests: A study of 120 tumours.
Arch pathol Lab Med 2008 ; 132 : 1753-60
4. Ehrlich CE, Roth LM - The Brenner tumour : A
clinico pathologic study of 57 cases cancer1971;
27: 332-42
5. Balasa RW, Adcock LL, Prem k Actal . The
Brenner tumor : A clinicopathologic review
obstetric Gynaecol 1977;50: 120-28
6. Fox H, Wells M. Surface epithelial stromal
tumor of the ovary, in Haines & Taylor
obstetrical and Gynaecological pathology, H. Fox
and M. Wells, Eds., churchill Livingstone,
Madrid, Spain, 2003;1:42
7. Pschera H, Wikstrom B. Extra ovarian Brenner
tumor coexisting with serous cystadenoma. Case
report Gynaecol obstetric Invest 1991; 31: 185-7
8. Waxman M pure and mixed Brenner tumor of
the ovary: clinicopathologic and histogenetic
observations cancer1979; 43: 1830-39
9. Lee KR, Tavassoli FA. Prat J. Surface epithelial
stromal tumor, in pathology & Genetics of
tumours of the Breast and Female Genital organs,
F.A. Tavassoli and P. Deville, Eds., IARC Press,
Lyon, France, 2003;32:124
10. Yoonessi M, Abell MR. Brenner tumor of the
ovary. Obstetric Gynecol1979; 54: 90-96
250
Syam et al.,
DOI: 10.5958/2319-5886.2015.00046.6

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Coden: IJMRHS
th
Case report
Copyright @2014
ISSN: 2319-5886
TAKAYASUS ARTERITIS: AN UNUSUAL PRESENTATION OF A RARE DISEASE

*Jivesh Mittal
Department of Medicine, MMMCH, Kumarhatti (Solan), Himachal Pradesh, India
*Corresponding author email: embracelove34@gmail.com
ABSTRACT
Takayasu's arteritis, also called tak, aortic arch syndrome, pulse less disease or occlusive thromboaortopathy is a
rare chronic, progressive, autoimmune, idiopathic disease involving inflammation in the walls of the largest
arteries in the body: the aorta and its main branches that affect primarily adolescent girls and young women. It
most often occurs in people ages 1540 years, but sometimes affects younger children or middle-aged adults. Here
is a case of a young girl diagnosed with takayasus arteritis whose initial complaints were predominantly high
grade fever and malaise with minimal signs of vascular insufficiency.
Keywords: Takayasus arteritis, American rheumatological society, Fever of unknown origin, CT angiography
INTRODUCTION
Takayasus arteritis (TA), also known as aortoarteritis
and pulse less disease, is a rare condition. The cause
of TA is unknown. It is a form of granulomatous
arteritis, which affects large- and medium sized
arteries, primarily the aorta and its large branches as
well as proximal portions of pulmonary, coronary,
and renal arteries. It was first described in 1908, in a
Japanese patient with retinal abnormalities1,2. TA
affects women eight times more frequently than men.
Here is discussing a case of a girl who was diagnosed
with TA at 23 years of age, the course of the disease
during the previous 3 years prior to diagnosis, and
different treatments for the rare disorder.
CASE REPORT
In September 2014, a young 23 year old girl presented
with only complaint of marked generalized fatigue. On
enquiry, she revealed that she had a high grade fever 3
years back along with joint pains (which were not
marked) for which she was given a prolonged course
of antibiotics but with minimal relief. She was then
evaluated for infectious pathology but most of her tests
were unremarkable except for her erythrocyte
sedimentation rate (ESR) which was 189 mm/hr and
her complete blood count which showed severe
Jivesh
anaemia (7gm %) of dimorphic origin. She was

labeled as fever of unknown origin (FUO) and started
on anti-tubercular therapy (ATT) without any evidence
of the same. Meanwhile, she visited a higher centre
where her ATT was stopped after 1 month, and again
started on intravenous antibiotics but remained febrile.
She was intensively investigated there, but apart from
persistently high ESR and anaemia, most of the tests,
including rheumatoid factor, antinuclear antibodies
(ANA),
thyroid
profile,
x-ray
chest
and
echocardiography came out to be negative. Finally, she
was discharged on tab doxycycline 100mg twice a day
for 40 days. Her fever and joint pains subsided over a
period of time. However, she continued to have
persistently raised ESR and moderate to severe
anaemia with relapsing and remitting complaints of
generalized fatigue and weakness until she presented
to me in September 2014 with the above mentioned
complaints. She denied any current history of fever,
joint pains, claudication, dizziness, headache, visual
blurring and breathlessness.
On physical examination, the patient was comfortable
and was not in any distress. She was a febrile with a
regular pulse rate of 86 beats per minute with unequal
radial pulses, left radial pulse being markedly
251
diminished. Blood pressure was 110/90 mm Hg in the

right arm while it was difficult to auscultate on left
arm with a blood pressure of approximately 90/70
mm Hg, and respiratory rate of 16 breaths per minute.
Her cardiovascular examination revealed bilateral
carotid and subclavian artery bruit, more prominent
on the left side. Cardiac auscultation revealed normal
sounds. There was no abdominal aortic bruit. The
femoral and pedal pulses were normal, equal and
palpable bilaterally.
The initial workup included complete blood cell
count (CBC), basic metabolic panel, coagulation
profile, erythrocyte sedimentation rate, C-reactive
protein, hepatitis panel and tests for human
immunodeficiency virus. She had a white blood cell
(WBC) count of 6000, haemoglobin (Hb) of 10.4
gm% and platelets (PLTs) of 1.94 lakhs/cumm. Her
basic metabolic, renal and liver function tests as well
as coagulation panel were unremarkable. Serology for
antiHIV, antiHCV and HBsAg was negative. Her
Doppler abdomen was unremarkable. Her
inflammatory biomarkers such as C-reactive protein
(CRP) and erythrocyte sedimentation rate (ESR) were
both elevated, with >5ug/ml and 35mm/h (0 to
20mm/h) respectively. Her electrocardiogram (EKG)
and echocardiogram were both normal.
Carotid Doppler suggested diffuse intima-media
complex thickening involving both common carotid
arteries (L>R). Flow through left brachial artery
showed parvus and tardus kind of spectral waveform
s/o proximal occlusion. CT angiography showed
diffuse intima-media thickening of the wall of arch
and descending aorta. Similar diffuse thickening was
also noted of the walls of carotid artery bilaterally
with complete occlusion noted at the origin of left
subclavian artery; features suggestive of takayasus
arteritis.
DISCUSSION
Although TA has been described worldwide, it occurs
most commonly in Japan, China, India and Southeast
Asia. It is an autoimmune disease involving the arterial
walls of large arteries, causing Panarteritis3. Takayasu
arteritis is a systemic disorder that affects multiple
organs. The diagnosis of TA can be a challenge,
especially in its initial phases. Clinicians divide TA
into two phases: Systemic and Occlusive. Patients may
have features of both phases at the same time. In the
early or the systemic phase of TA, clinical features
include fatigue, low grade fever, weight loss and

lethargy. As the disease progresses into the occlusive
phase, vascular involvement and insufficiency become
apparent due to dilatation, narrowing and occlusion of
the main vessels like the aorta and its branches4. These
may include pain in limbs, claudication, dizziness
upon standing up, headaches, and visual disturbances.
Lung involvement is a rare presenting feature, but
involvement of the pulmonary arteries has been
reported. 5
The American Rheumatological Society considers
three of the following six criteria necessary for a
definite diagnosis of Takayasus disease.6 The
presence of any three or more criteria yields a
sensitivity of 90% and a specificity of 97.8%.7
1. Onset before 40 years
2. Claudication of the extremities
3. Decrease in the brachial pulse in one or both arms
4. A difference of 10 mm Hg or more in blood
pressure measured in both arms
5. Audible bruit on auscultation of the aorta or
subclavian artery
6. Narrowing at the aorta or its primary branches on
arteriogram
However, in clinical practice, the diagnosis of TA is
almost always secured by an imaging procedure that
demonstrates the characteristic abnormalities of the
aorta and its major branches. The current patient
fulfilled 5/6 criteria (including an imaging procedure)
at the time of the diagnosis.
Unfortunately, the diagnosis of TA is often delayed.
One of the reasons for this is that some patients have
striking features of inflammation that camouflage or
overshadow the somewhat more familiar vascular
abnormalities. Indeed a few patients with TA present
chiefly with FUO as in this case. Most of these
patients have other, albeit subtle, manifestations of
TA such as bruits, diminished pulses, unequal arm
blood pressures or aortic regurgitation. Thus the most
frequent impediment to a speedy diagnosis is a
physicians failure to consider TA in the differential
diagnosis. Delays in diagnosis can be reduced by
carefully searching for unequal or absent upper
extremity pulses and by listening for bruits not only
over the carotid arteries, but also above and below the
clavicle for subclavian artery bruits and over the
abdomen and flanks for renal and other mesenteric
artery bruits.
252
Jivesh
The differential Diagnosis of TA includes infection

(tuberculosis, mycoses and syphilis), congenital
collagen
disorders
(Ehlers-Danlos,
Marfans
syndrome), Fibrous Dysplasias (FD), and rheumatic
diseases (Giant cell arteritis, Rheumatoid arthritis,
cogans syndrome, SLE, Buergers disease,
Sarcoidosis, and Spondyloarthropathies). Imaging is
very useful in differentiating most of the possible
diagnoses except for giant cell arterititis. Giant cell
arteritis like TA involves large arteries showing
granulomatous vasculitis on histologic examination.
A distinction can be made based on the age of the
patient and distribution of lesions. 8,9
The course of the disease is variable, and although
spontaneous remissions may occur, TA has been most
often chronic and relapsing. Corticosteroids are the
cornerstone of treatment of active TA. Prednisolone,
at a dose of 0.5 to 1 mg/kg per day, is indicated for
the treatment of active disease. Open trials have
suggested that weekly oral methotrexate is a
moderately effective corticosteroid sparing agent.10
TA is the form of vasculitis most frequently requiring
revascularization procedures.11,12,13 In the presence of
symptomatic stenotic or occlusive lesions,
endovascular revascularization procedures like
bypass grafts, patch angioplasty, endarterectomy,
percutaneous transluminal angioplasty, or stent
placement should be taken into consideration14.
CONCLUSION
Takayasu arteritis is a relatively rare disease with
various and sometimes initially only systemic clinical
manifestations, such as FUO leading to delay in
diagnosis as in our case. As early, appropriate
diagnosis and initiation of proper therapy could avoid
further progression and reduce complications of the
disease, many of these delays can be prevented by
remembering that TA should be included in the
differential diagnosis of any person younger than 40
years who presents primarily with FUO,
musculoskeletal and other symptoms of systemic
inflammation.
REFERENCES
1. Numano F, Kakuta T. Takayasu arteritisfive
doctors in the history of Takayasu arteritis. Int J
Cardiol 1996; 54:110.
2. Ohta K. Ein seltener, Fall von beiderseitigem

Carotis-Subclavia verschluss: ein Beitrag zur
pathology der Anastomosis peripapillaris des
Auges mit fehlendem. Trans Soc Pathol Jpn
1940; 30: 68090.
3. Chun YS, Park SJ, Park IK.The clinical and
ocular manifestations of Takayasu arteritis.
Retina. 2001; 21:132-140.
4. Kerr GS. Takayasu arteritis. Rheum Dis Clin
North Am 1995; 21:1041-58.
5. Nakabayashi K, Kurata N, Nangi N, Miyake H,
Nagasawa T. Pulmonary artery involvement as
first manifestation in three cases of Takayasu
arteritis.
International
Journal
of
Cardiology.1996; 54:177-83.
6. Worrall M, Atebara N, Meredith T, Mann E.
Bilateral ocular ischemic syndrome in Takayasu
disease. Retina. 2001;21:75-76
7. Arend WP, Michel BA, Bloch DA, Hunder GG,
Calabrese LH, Edworthy SM, et al. The American
College of Rheumatology 1990 criteria for the
classification of Takayasu arteritis. Arthritis &
Rheumatism. 1990; 33:1129-34.
8. Hunder GG. Giant cell arteritis in polymyalgia
rheumatica. American Journal of Medicine. 1997;
102:514-6.
9. Michel BA, Arend WP, Hunder GG. Clinical
differentiation between giant cell (temporal)
arteritis and Takayasu's arteritis. Journal of
Rheumatology. 1996; 23:106-11.
10. Hoffman GS, Leavitt RY, Kerr GS, et al:
Treatment of glucocorticoid-resistant or relapsing
Takayasu arteritis with methotrexate, Arthritis
Rheum1994; 37:578.
11. Kerr GS, Hallahan CW, Giordano J, et al:
takayasu arteritis, Ann Intern Med1994; 120:919.
12. Miyata T, Sato O, Koyama H, et al: Long-term
survival after surgical treatment of patients with
Takayasu's arteritis, Circulation2003; 108:1474.
13. Matsuura K, Ogino H, Kobayashi J, et al:
Surgical treatment of aortic regurgitation due to
Takayasu arteritis: long-term morbidity and
mortality, Circulation2005; 112: 3707.
14. Tyagi S, Khan AA, Kaul UA, Arora R.
Percutaneous transluminal angioplasty for
stenosis of the aorta due to aortic arteritis in
children. Pediatric Cardiolol. 1999; 20:404-10.
253
Jivesh
DOI: 10.5958/2319-5886.2015.00047.8

&
Health Sciences
www.ijmrhs.com
Volume 4 Issue 1
rd
Coden: IJMRHS
Copyright @2014
ISSN: 2319-5886
th
st
Accepted: 31 Dec 2014
Case report
SINUS HISTIOCYTOSIS AND MASSIVE LYMPHADENOPATHY (ROSAI-DORFMAN DISEASE) IN
AN 8 YEAR OLD FEMALE CHILD: A RARE CASE REPORT
*Uppin Narayan Reddy1, Swathi Chacham2, Janampally Ravikiran3, Jillalla Narsing Rao4, Jakkampudi
Nagasravani 5, Abhijeet Ingle6
1
Professor and Head, 2Associate Professor, 3,5Junior Resident, 4Professor, Department of Pediatrics Princess Esra
Hospital, Deccan College of Medical Sciences, Hyderabad, Telangana, India
6
Department of pathology, Yashoda Hospital, Malakpet, Hyderabad, Telangana, India
*Corresponding author email: janampalli.ravikiran@gmail.com
ABSTRACT
Introduction: Sinus histiocytosis with massive lymphadenopathy is an infrequent, self-resolving histoproliferative disorder of benign nature, also known as RosaiDorfman Disease. The typical manifestation of this
disease includes bilateral, progressive cervical lymphadenopathy along with pyrexia. Laboratory manifestations
consist of raised erythrocyte sedimentation rate, leukocytosis and hypergammaglobulinemia. Case report: An 8
year old female child presented with progressive, painful cervical and submandibular lymphadenopathy of three
months duration. There was polymorphic leukocytosis and anemia along with raised Erythrocyte sedimentation
rate and hypergammaglobulinemia. Fine Needle Aspiration cytology revealed sinus histiocytosis with massive
lymphadenopathy, which was confirmed by the cervical lymph node biopsy. The histopathology revealed dilated
sinuses filled with lympho plasma cells, large histiocytes and engulfed neutrophils (Emperipolesis). Conclusion:
Massive, progressive bilateral cervical and sub mandibular lymphadenopathy, suggesting Sinus histiocytosis and
massive lymphadenopathy-RosaiDorfman Disease. This was confirmed by Cytology, histopathology and
immunohistochemistry.
Keywords: Emperipolesis, Hypergammaglobulinemia, Lymphadenopathy, Fine needle aspiration cytology
INTRODUCTION
The Rosai-Dorfman disease (RDD), also known as
Sinus histiocytosis with massive lymphadenopathy
(SHML) is a lympho phagocytic disorder first
described in 19691. It usually occurs in children and
young adults and males are more frequently affected
than females2. The most frequently affected lymph
nodes are cervical lymph nodes and the usually
involved extranodal sites are upper respiratory tract,
skin, nasal cavity and bone2. SHML also involves
eyes, ocular adnexa, head and neck, subcutaneous
tissue and skeletal muscle (including heart and
breast). Even the central nervous system,
gastrointestinal tract, including liver, salivary glands,
genitourinary tract (kidney and uterine cervix) and
thyroid may be affected2. The characteristic

presentations comprise febrile onset multiple,
painless, bilateral cervical lymphadenopathy. Raised
erythrocyte sedimentation rate (ESR), elevated white
blood cell count and hypergammaglobulinemia are
distinct features of SHML. Though, the fine needle
aspiration cytology (FNAC) identifies majority of the
SHML, biopsy is indicated in some, where the
cytomorphology is inconclusive.
CASE REPORT
An 8 year-old female child presented with
progressive cervical lymphadenopathy of three
months duration. It was associated with fever spikes
254
Uppin et al.,
and profound sweating for one month. The lesions

initially started over the posterior aspect of the neck
which gradually extended all over the neck in three
months. These were accompanied by pain which
subsided with antimicrobial administration. No
history of contact with tuberculosis and there was no
weight loss. Clinical examination revealed multiple,
bilateral,
cervical
and
submandibular
lympadenopathy of 1.5cm to 3 cm size (as shown in
figure 1). They were non-tender, discrete, firm and
immobile. The skin over the lesions was smooth and
shiny. This was not accompanied by lympadenopathy
in other regions or organomegaly. The peripheral
blood cell count showed anemia (hemoglobin10.8gms %), polymorphic leukocytosis (21,000/cu.
mm) and Erythrocyte sedimentation rate (ESR) was
elevated (75 mm at the end of one hour). Likewise,
serum gamma globulins were raised. Abdominal
ultrasongraphy
delineated
mesenteric
lymphadenopathy, but there was no organomegaly.
Also, there was no mediastinal lympadenopathy on
Chest radiograph. Retro-viral serology was negative
and hepatits B surface antigen was also negative.
Important causes of massive lymphadenopathy in
children contain tuberculosis, lymphoreticular
malignancy and reactive histiocytosis. Hence the
child was subjected to FNAC of cervical and
submandibular lymph nodes. This was done with
multiple passes from different sites and some of the
smears were highly cellular consisting of many large
histocytes,
along
with
lymphophagocytosis
(emperipolesis) by these histiocytes. There were
reactive polymorphs, lymphocytes and few plasma
cells in the background (as shown in figure-2, (H&E
400X)).
This
distinct
cytomorphology
is
phathognomic of SHML/RDD. The child was further
investigated with cervical lymph node excision
biopsy for additional confirmation. Histopathology
disclosed thickened capsule, perinodal fibrosis and
dilated sinuses upon reactive lymphoid background.
These sinuses were distended with lympho plasma
cells, large histiocytes containing vesicular nuclei and
engulfed
lymphocytes
and
polymorphs
(emperipolesis) (as shown in figure-3, H&E 200X).
Some of the histiocytes showed nuclear debris,
however, there were no eosinophils, granulomas and
necrosis was absent. Immunohistochemistry, S100
highlights histiocytes (SHML cells) in the distended
sinuses (as shown in figure-4, (400X, S100)),
ascertaining the diagnosis of RDD. The child showed

a dramatic response to oral steroids in follow-up in
the form of lymphnodes regression.
Fig 1: Clinical photograph revealing cervical

lymphadenopathy- as shown with arrows.
Fig2: Cytology smear (H&E 400X) revealing many

large
histocytes, with
lymphophagocytosis
(emperipolesis) (As shown with arrows. Background
showed reactive polymorphs, lymphocytes and few
plasma cells)
Fig 3: Histopathology revealed thickened capsule,

perinodal fibrosis and dilated sinuses. Background
shows reactive lymphoid population. These sinuses
were distended with lympho plasma cells, large
histiocytes with vesicular nuclei and engulfed
lymphocytes and polymorphs (emperipolesis) - as
shown with arrows. (H&E 200X)
255
Uppin et al.,
Fig 4: Immunohistochemistry, S100 (400X, S100)

highlights histiocytes (SHML cells) in the
distended sinuses- as shown with arrows.
DISCUSSION
The RDD is an unusual disorder of bone marrow
stem cell origin3. Although, any age group can be
affected, majority of these cases are reported in
second decade of life. Males are more commonly
affected than females4.The index case being a female
child and manifesting before first decade of life
makes this case a rare presentation. The salient
clinical features include painless, bilateral,
progressive cervical lymphadenopathy. This is
frequently associated with fever, anemia (66%)
leukocytosis (59%), neutrophilia (68%), elevated
ESR (88 %), and hypergammaglobulinemia (90%)
which were noted in the index case. Also, a varied
extranodal manifestation has been reported4 in
SHML, the most common being eyed, ocular adnexa,
salivary glands and gastrointestinal tract. Likewise,
central nervous system and genitourinary tract can
also get affected4. There was associated mesenteric
lymphadenopathy in this case, but mediastinal
lymphadenopathy and organomegaly were absent.
Although the accurate etio-pathogenesis of SHML is
unknown, infectious etiology coupled with immuno
compromised status have been implicated. Human
herpes virus (HSV) 6 (as detected by fluorescent in
situ hybridization (FISH)), Epstein-Barr virus and
cytomegalovirus (CMV) have been reported to be the
etiological factors. Likewise,
bacterial pathogens
like Klebsiella and Brucella also have been
attributed4, 5. The index case had polymorphic
leukocytosis with elevated ESR, but the blood culture
was sterile and the viral markers were negative for
retrovirus and CMV. However, Epstein -barr virus
and HSV-6 viral assay could not be done due to

financial constrains. The characteristic cytological
features of SHML include abundant large histiocytes
with
plentiful,
phagocytosed
lymphocytes
(emperipolesis) and pale cytoplasm lymphocytes,
plasma cells, and occasional neutrophils in the
background3,6,7. This emperipolesis, a hallmark of
SHML/RDD was seen in our case8. Humble et al., in
1956 defined emperipolesis as a biological
phenomenon in which an intact cell is penetrated by
another. It is different from phagocytosis as the viable
engulfed cell exists within another cell, can exit with
no morphological and physiological consequence for
either of them9. These histiocytes reveal positive
immunostaining for various markers like S100
protein, which was seen in the index child.
Immunostaining for other proteins as CD11c, CD14,
CD33, and CD684 have also been reported. Presence
of positive immunohistochemistry for S100 protein in
our case makes it a unique entity. Characteristic
histological features are well reported in the
literature; however the cytomorphology on FNAC is
less defined6. Along with histology, cytology was
also characteristic of SHML in our case, which makes
it further special.
The important histological differential diagnoses
include tuberculosis, hemophagocytic syndrome;
Langerhans cell histiocytosis, reactive sinus
histiocytosis and lymphoma4. Granulomatous
epithelioid cells and caseous necrosis, histological
features of tuberculous lymphadenitis are absent in
SHML, in our case. Presence of hemophagocytosis,
pancytopenia, hepatosplenomegaly and absence of
emperipolesis, suggest hemophagocytic syndromes
which were absent in our case. Langerhans cells with
pathognomnic Birbeck granules and eosinophilic
microabscess were absent in our case4,6,10. ReedSternberg cells and eosinophils, characteristic
histological features of Hodgkins lymphoma were
also absent in RDD, our case4,6.
The mainstay of treatment is supportive and
symptomatic as there is no ideal treatment. However,
various treatment modalities include surgery,
radiotherapy, steroids and chemotherapy11. The usual
course of this disease is indolent with 50% of the
patients showing a complete resolution without
squeale and one third of the patients have persisting
asymptomatic lymphadenopathy. Very few (17%)
continue to be symptomatic after 5 to 10 years11. The
256
Uppin et al.,
index child showed resolution of lymphadenopathy

with steroid therapy, within three months.
CONCLUSION
SHML/RDD in an 8 year old female child presenting
with massive progressive cervical, sub mandibular
lymphadenopathy and typical laboratory findings.
The presence of characteristic cytomorphology,
emperipolesis and positive immune reactivity for
S100 protein in the first decade of life makes this case
unique.
ACKNOWLEDGEMENTS
We very much appreciate the assistance of Dr. M. N.
Harshita (MD), Dr.Y.V.N.Karthik (DA) & Chaitanya
for helping with drafting.
REFERENCES
1. Rosai J, Dorfman RF. Sinus histiocytosis with
massive lymphadenopathy: a newly recognized
benign clinicopathological entity. Arch Pathol.
1969; 87:6370.
2. Warnke RA, Weiss LM, Chan JK, Cleary ML,
Dorfman RF. Sinus histiocytosis with massive
lymphadenopathy (Rosai-Dorfman disease). In:
Rosai J, eds. Atlas of Tumor Pathology, 3rd
Series: Tumors of the Lymph Nodes and Spleen.
Washington: Armed Forces Institute of
Pathology; 1995:34960.
3. Das DK, Gulati A, Bhatt NC, Sethi RG. Sinus
histiocytosis with massive lymphadenopathy
(RosaiDorfman disease): Report of two cases
with fine needle aspiration cytology. Diagn
Cytopathol. 2001; 24:4245.
4. Kumar B, Karki S, Paudyal P. Diagnosis of sinus
(RosaiDorfman disease) by fine needle
aspiration cytology. Diagn Cytopathol. 2008;
36:69195.
5. Lampert F, Lennert K. Sinus histiocytosis with
massive lymphadenopathy: Fifteen new cases.
Cancer. 1976; 37:78389.
6. Deshpande AH, Nayak S, Munshi MM. Cytology
of
sinus
histiocytosis
with
massive
lymphadenopathy (RosaiDorfman disease)
Diagn Cytopathol. 2000; 22:18185.
7. Iyer VK, Handa KK, Sharma MC. Variable

extent of emperipolesis in the evolution of Rosai
Dorfman disease: Diagnostic and pathogenetic
implipications. J Cytol. 2009; 26:11116.
8. Snehalatha R, Senthilnathan P, Prathiba Ramani,
Sherlin J Herald. The rosai dorfman syndromethe report of a rare case. Journal of Clinical and
Diagnostic Research. Available from http://
www. jcdr. net// back_ issues.asp2014.
9. Humble JG, Jaynee WHM, Pulvertaft RJ,
Biological interaction between lymphocyte and
other cells Br J Hematol 1956; 2:283.
10. Eisen
RN,
Buckley
PJ,
Rosai
J,
Immunophenotypic characterization of sinus
(Rosai-Dorfman disease) Semin Diagn Pathol
1990; 7(1):74-82.
11. Raveenthiran V, Dhanlaxmi M, Hayavadana Rao
PV, Vishwanathan P, Rosai dorfman disease:
report of a 3 year old girl with review of
treatment options Eur J Paediatric Surg 2003;
13:350-54.
257
Uppin et al.,

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DOI: 10.5958/2319-5886.2015.00001.

International Journal of Medical Research

HISTOLOGICAL CHANGES IN KIDNEYS OF ADULT RATS TREATED WITH MONOSODIUM

synapses.1, 4 Liver and kidney plays a crucial role in

Byck in 1968 3, they were the first people to draw

Medical College. Before conducting the study, the

Int J Med Res Health Sci. 2015;4(1):1-6

Table 1: Weight records of animals in study and

Fig. 1: Cross section of control rat (Group A) kidney

Fig. 2.a: Cross section of Study Group B kidney (3

Fig. 2.b: Tubular dilatation (PCT & DCT) with loss

Fig. 3.a: Cross section of Study Group C kidney (6

Int J Med Res Health Sci. 2015;4(1):1-6

Fig. 3.b: Showing Vascular congestion (VC) (H&E,

portion and distortion in the renal architecture. On the

Fig. 3.c: Interstitial chronic inflammatory infiltrates

Fig. 3.d: Renal tubules showing Tubular Necrosis (TN)

The findings on weight and histological changes in

Int J Med Res Health Sci. 2015;4(1):1-6

Findings, which are observed in sections of rat

In the present study, Infiltrated cells are identified in

Obese Rats. Food and Public Health. 2012; 2(5):

Int J Med Res Health Sci. 2015;4(1):1-6

International Journal of Medical Research

EFFECT OF PLYOMETRIC TRAINING ON VERTICAL JUMP HEIGHT IN HIGH SCHOOL

*Corresponding author email:victoryv2@yahoo.co.in

Standing vertical jump: refers to vertical jump

muscle action of eccentric to concentric or

Objectives: 1. To compare the effect of Plyometric

Fig. 1: Randomised distribution of subjects

Int J Med Res Health Sci. 2015;4(1):7-12

Vertical jump height was measured pre and post

The subjects were put on a Plyometric training

Fig 2: Vertical Jump Test

Int J Med Res Health Sci. 2015;4(1):7-12

Table 2: Comparison of effect of Plyometric

Inference: Improvement in vertical jump height was

Inference: Improvement in jump height is significant

Inference: There is no significant difference in the

_0.490(0.02) _0.172(0.55) _0.32(0.2)

Inference: A significant negative correlation is seen

events, basketball, football, volleyball etc. This study

Int J Med Res Health Sci. 2015;4(1):7-12

thawing. 23 Since, plyometric exercises involve this

vertical jump. This might be the cause of a significant

Int J Med Res Health Sci. 2015;4(1):7-12

6. Angus Burnett, The biomechanics of jumping,

17. Donald A Chu et al: Plyometrics in rehabilitation,

Int J Med Res Health Sci. 2015;4(1):7-12

International Journal of Medical Research

A RANDOMIZED CONTROLLED STUDY OF RISK FACTORS AND ROLE OF PROPHYLACTIC

towards extending range and complexity of surgical

Int J Med Res Heath Sci. 2015;4(1):13-21

spread use of antibiotic has frequently resulted in an

study were clean surgical cases and underwent

1 gm half an hour before surgery was administered.

patients) were corrected of their diabetic status prior

Int J Med Res Heath Sci. 2015;4(1):13-21

Table 2: Showing age distributions of patients in

Table 4: Duration of Surgery in the Present Study

Graph 1: Showing distribution of individual risk

Table 5: Showing timing operation and incidence

Table 6: Closed suction drain and wound infection

Table 7: Showing infection rate with and without