Sie sind auf Seite 1von 193

DOI: 10.5958/2319-5886.2015.00144.

Available online at: www.ijmrhs.com

Research article

Open Access

HIV/AIDS KNOWLEDGE AND PATTERNS OF SEXUAL BEHAVIOR AMONG ADULT


SLUM DWELLERS IN MUMBAI, INDIA
1

Saba Syed , Sukhdas Gangam

ARTICLE INFO
Received: 4th Apr 2015
Revised: 23rd May 2015
Accepted: 29th Jun 2015
Authors details: 1Assistant Professor,
Department of Community Medicine,
Apollo Institute of Medical Sciences and
Research, Mumbai, Maharashtra, India
2
Assosicate Professor, Department of
Community Medicine, Apollo Institute of
Medical
Sciences
and
Research,
Mumbai, Maharashtra, India
Corresponding author: Saba Syed
Apollo Institute of Medical Sciences and
Research, Mumbai, Maharashtra, India
Mumbai, Maharashtra, India
Email: sabasyeddr@gmail.com
Keywords: HIV/AIDS Knowledge, Sexual
behaviour, Slum dwellers

ABSTRACT
Background: In India, currently 2.1 million people are living with HIV.
Prevention is the mainstay of the strategic response to HIV/AIDS in India.
Awareness rising brings behaviour change. People inhabiting slums have low
awareness and are more vulnerable to RTI/STIs and HIV/AIDS. Aims: To
assess HIV/AIDS knowledge, sexual behaviour, reported symptoms of
STI/RTIs along with the socio demographic profile of adult population of
urban slum dwellers. Methods: A cross sectional, qualitative study. The study
area, chosen by convenience sampling was an urban slum located in M East
Ward of Greater Mumbai. The study was finally conducted with 104
participants. Results: The mean age of surveyed participants was 23.5yrs
and nearly 38(40%) of participants were illiterate Age at first sexual
intercourse among the study participants was between 12-16 years for
23(22.10%) participants. Among study participants; 30(29%) of participants
do not have any knowledge about prevention and transmission of HIV/AIDS.
Conclusions: Urban slum residents in Mumbai have knowledge gap
regarding HIV/AIDS transmission and prevention. Initiation of sexual
intercourse is at an early age, a high percentage report symptoms of
STI/RTIs.

INTRODUCTION
[1]

HIV/AIDS was first identified in India in 1986 when


serological testing found that 10 of 102 female sex
workers in Chennai were HIV positive. In the face of
increasing numbers of people being identified with HIV,
the Government of India (GOI) established the National
AIDS Committee (NAC) and in 1992, the National AIDS
[1]
Control Organization (NACO). In India, currently 2.1
[2]
million people are living with HIV.
The four high
prevalence states Andhra Pradesh, Maharashtra,
Karnataka, Tamil Nadu account for 55% of all HIV
[3]
infections in the country
In National AIDS Control Programme (NACP IV);
prevention is the mainstay of the strategic response to
HIV/AIDS in India as 99% population of the country is
uninfected; prevention strategies include expanding IEC
services for (a) general population and (b) high risk groups
with a focus on behaviour change and demand
generation. Among the general population, women, youth
and adolescents are seen as most vulnerable. Also, lack
of access to correct information can pose a possible
barrier in HIV/AIDS prevention programmes. Interventions
for general population are about raising their awareness of
HIV. Awareness raising brings behaviour change.
Changing knowledge, attitudes and behaviour as a
prevention strategy of HIV/AIDS thus is a key thrust area
of the National AIDS Control Programme. Through this
route the programme aims to reach out to 80 percent of
the high risk groups and 95 percent of the young people.

In metropolitan cities; the rising rate of urbanization and


the accompanying disproportionate growth in the
proportion of poor city residents pose new challenges for
health care in urban slums. They may start sexual
intercourse at earlier ages, have more sexual partners,
and are less likely than other city residents to know of or
adopt preventive measures against contracting Sexually
Transmitted Infections/Reproductive Tract Infections
[5]
STIs/RTIs and HIV/AIDS . Mumbai, the most populous
city in India is unique in having a huge migrant population;
largely young as it offers opportunities for all to earn a
living. Slums too are a ubiquitous feature of Mumbais
geographical landscape. Socio-economic determinants
that make a person vulnerable also increase the risk of
exposure to HIV. People inhabiting slums have low
awareness and are more vulnerable to RTI/STIs and
[5]
HIV/AIDS . As HIV infection is entirely preventable
through awareness raising about its occurrence and
spread, it is very significant in protecting the people from
the epidemic. Thus, the present study was planned to
assess HIV/AIDS knowledge and sexual behaviour,
reported symptoms of STI/RTIs along with the socio
demographic profile of adult population of urban slum
dwellers. Information regarding age at first sexual
intercourse, reasons for not using condoms during
intercourse may give insights into novel approaches of
applying HIV/AIDS prevention strategies.

[4]

Syed et al.,

740
Int J Med Res Health Sci. 2015;4(4):740-743

MATERIAL AND METHODS


Study design: It was a cross sectional, qualitative study.
Ethical approval & Consent: Approval from institutional
ethics committee (IEC) was obtained prior to initiation of
the study. Informed verbal consent of the participants
was taken after explaining to them that the
information revealed by them would be kept strictly
confidential and those who gave consent were enrolled as
study participants
Mumbai is divided into administrative zones and wards.
The study area, chosen by convenience sampling was an
urban slum located in M East Ward of Greater Mumbai. It
has a population of approximately one lakh, which is
predominantly migrant. Inhabitants of the slum reside in
dwellings in multiple lanes, parallel to each other.
Sampling technique: By systematic random sampling
technique initially, ten lanes were selected by choosing
every fifth lane of the study area. All dwellings in the
selected lane were enlisted; following which every fifth
household was selected, until the number of study
participants equalled ten in each lane. Locked houses
were excluded and the next fifth house on the list was
selected.
Inclusion criteria: Individuals with chronological age
eighteen years and above; residing in these households
were eligible to be enrolled as study participants.
Sample size: Assuming HIV prevalence of between
0.25%- 0.3% in general population; the required sample
2
size was calculated to be 104 using formula [s=4 PQ/ E ].
Study was finally conducted with 104 participants.
Methodology
A self designed, semi- structured questionnaire was
prepared comprising questions pertaining to the
demographic and socioeconomic Profile, their knowledge
regarding HIV /AIDS prevention and transmission,
misconceptions regarding HIV/AIDS transmission. It also
included questions on age at first sexual intercourse,
reported symptoms of Sexually Transmitted Infections
(STIs) /Reproductive Tract Infections (RTIs) and means of
protection of themselves from an intimate partner who has
symptoms of STI/RTIs and their sexual Practices. All
participants reporting symptoms of STI/RTI were referred
to the nearest health care centre. Socioeconomic
classification of study participants was done using B. G
[6]
Prasads classification. A pilot study was carried out
prior to the final study with thirty participants to test the
accuracy and completeness of the questionnaire
Data collection was done by administration of the
questionnaire through personal interviews and in depth
discussions with the participants.
Statistical analysis: Data was collated and qualitative
data analysis (frequencies & percentages) done by using
MS Excel.
RESULTS

23.5yrs .Table 2 depicts knowledge regarding HIV/AIDS


prevention & transmission among study participants and
30(29%) of participants do not have any knowledge about
prevention and transmission of HIV/AIDS. Table 3 depicts
Misconceptions Regarding HIV/AIDS transmission. Table
4 shows Reported symptoms of STI/RTIs in study
participants.
Age at first sexual intercourse among the study
participants was between 12-16 years for 23(22.10%)
participants and between 17-21yrs for 62(59.60%)
participants whereas it was between 22-26 yrs for
14(13.50%) participants and in 4(3.84%) participants it
was between 27-31 yrs. Partner during first sexual
intercourse for 85(81.20%) participants was their spouse,
for 2(1.9%) it was an acquaintance, for 5(7.14%) male
participants it was a commercial sex worker, for 3(2.88%)
partner was a relative and for 8 (7.70%) male participants
it was their intimate partners. Regarding condom usage
during first sexual intercourse; only 3(2.90%) participants
had used a condom and 100(96.20%) had not used a
condom. Among the reasons for not using condoms,
9(8.70%) revealed they had no knowledge of how to use a
condom, 6 (5.8%) revealed that a condom was not
available at that time, two revealed that they did not feel it
was required.
Regarding means of protection of themselves from an
intimate partner who has symptoms of STI/RTIs,
31(29.80%) said they would insist on condom usage is
preferable, 17(16.30%) said refusal for intercourse and
9(8.70%) participants said they would take treatment for
the symptoms, whereas 47(45.20%) did not know how
they would protect themselves if their partner had
symptoms of STI/RTIs.
Table 1: Demographic profile of study participants:
Demographic factors
Number
(%)
Gender
Male
70
67.30
Female
34
32.70
Age group(yrs)
21-25
15
14.80
26-30
33
32.91
31-35
25
24.82
36-40
17
16.81
41-45
12
10.76
Educational
Illiterate
40
38.50
status
Primary
12
11.50
Secondary
48
46.20
1.90
H. Secondary
2
Marital status

B.G.Prasad
Socioeconomic
Classification

Graduate
Married
Unmarried
Separated
Widow
a)Class I
b)Class II
c)Class III
d)Class IV

2
4
97
2
1
3
38
46
17

1.90
3.80
93.30
1.92
0.96
2.88
36.53
44.23
16.30

Table 1 depicts the demographic profile of study


participants. The mean age of study participants was

Syed et al.,

741
Int J Med Res Health Sci. 2015;4(4):740-743

Table 2: Knowledge regarding HIV/AIDS prevention & transmission among study participants
Knowledge of regarding HIV/AIDS Prevention and transmission
Yes
No

Dont know

Is HIV/AIDS Curable
HIV/AIDS Prevented By Consistent Condom Use

14(13.5%)
81(77.90%)

45(43.30%)
2(1.90%)

45(43.30%)
21(20.20%)

HIV/AIDS Prevented By Single Uninfected Sexual Partner


HIV/AIDS Prevented By Sterilized Needles And Syringes

84(80.80%)
75(72.10%)

0(0.00%)
1(0.96%)

20(19.20%)
28(26.90%)

HIV/AIDS Prevented By Blood/Blood Products Tested For HIV


HIV/AIDS transmission can occur By Sexual Intercourse Without A
Condom

76(73.10%)

0(0.00%)

28(26.90%)

84(80.80%)

0(0.00%)

20(19.20%)

HIV/AIDS transmission can occur by Infected blood/blood products

77(74.00%)

0(0.00%)

27(26.00%)

HIV/AIDS transmission can occur By Needles Syringes Infected With HIV


HIV/AIDS transmission can occur from Mother To Child During
Pregnancy

75(72.10%)

1(0.96%)

28(26.92%)

65(62.50%)

7(6.70%)

32(30.80%)

HIV/AIDS transmission can occur from Mother To Child During delivery


48(46.20%)
12(11.50%)
44(42.30%)
HIV/AIDS transmission can occur from Mother To Child through breast
milk
52(50.00%)
9(8.70%)
43(41.30%)
Table 3 Misconceptions Regarding HIV/AIDS
there is a cure for HIV/AIDS at present; almost similar to
[8, 9]
transmission
12% and 14 % participants seen in other studies.
A
considerable
knowledge
gap
is
seen
among
study
Misconceptions Regarding HIV/AIDS transmission
participants as 30(29%) of participants do not have any
Dont
knowledge about prevention and transmission of
know
[10]
HIV/AIDS. Similarly in a study
in 13 states of India, low
Yes (%)
No (%) (%)
rates of knowledge and awareness were reported more
Person Get Infected By
among rural women. This could be associated with lack of
Kissing On The Mouth
22(21.2) 16(15.4) 66(63.5)
.
formal education and media exposure A study done
Person Get Infected
among slum-dwellers in another metropolitan city of India
By Mosquito Bites
23(22.1) 34(32.7) 47(45.2)
[11]
showed 67% males and 55% females were aware of
Person Get Infected By
the sexual mode of transmission, as compared to 84% in
Sharing A Common
our study population.
Toilet
12(11.5) 39(37.5) 53(51)
About one fifth of the study population had misconceptions
Person Get Infected
regarding HIV/AIDS transmission as seen in table 3. Only
By Bug Bites
15(14.4) 38(36.5) 51(49)
23% of participants in our study thought AIDS could
Table 4: Reported symptoms of STI/RTIs in study
spread through mosquito bites, as compared to45% males
[11]
participants
and 62% females in the above study.
Reported Symptoms of STI/RTIs
No. (%)
Since Information education and communication (IEC)
Urethral discharge
22 (31.42%)
strategies are important as components of behaviour
change in HIV/AIDS prevention among the general
Burning Micturition
42 (41.20%)
population; possible interventional areas to address the
Genital ulcers
8 (7.69%)
knowledge gap could be consistent involvement of visual
Itching In Genital Area
33 (32.40%)
and print media, health education at each level of their
Inguinal Lymph nodes
17 (16.70%)
interaction with the formal health system along with
Chronic Lower Abdominal Pain
9 (8.80%)
involvement of informal health care providers (unqualified
practitioners). Health education through all the above
Vaginal Discharge
21(61.76%)
channels may also dispel misconceptions regarding
HIV/AIDS transmission and act also aid in reducing stigma
DISCUSSION
and
discrimination
against
people
living
with
HIV/AIDS(PLHA) in families and general population.
The education status of study participants shows that
Age at first sexual intercourse was less than 21 years for
nearly 38(40%) of participants were illiterate, and only
85(81.70%) of participants which includes the 12-16 years
4(3.84%) had studied beyond secondary school. Lack of
age group in 23(22.10%) participants, similarly is also
[12]
formal education may be one of possible causes of
seen in other studies.
This observation may lead to
migrating to Mumbai and it may influence sexual
suggestion of initiation of sex education/family life
behaviour choices. In National Behavioural Surveillance
education both in formal and informal setups at an earlier
Survey, 2006 carried out by NACO, it was seen that level
age group possibly at eight to nine years of age. In
of awareness about HIV / AIDS was lower in illiterates
informal setups; for out of school children different
(45.8%) as compared to primary (77.7%), middle (91.6%),
strategies may have to be explored for e.g. peer
secondary and higher secondary (98.2%) and graduate
facilitators, adolescent groups for girls etc.
[7]
and above (99.8%).
On exploring the reasons for not using condoms, 9(8.70%)
As seen in table 2; by studying responses regarding the
revealed they had no knowledge of how to use a condom,
existence of a cure for AIDS, 13.4% of participants thought
indicating further strengthening of IEC and health

Syed et al.,

742
Int J Med Res Health Sci. 2015;4(4):740-743

education component. Cultural beliefs might moderate the


way in which STI/HIV is perceived and therefore
[13]
addressed in that particular context.
Addressing risky
sexual practices such as early sexual debut is one
strategy which could lead to lower risk for RTI/STIs and
HIV/AIDS among slum dwellers.
Reported symptoms of STI were seen in both males
(31.4%) and females (61.76%), compared to a study in
Nigeria[14] where 27% of males and 10% of females
reported symptoms of STI/RTIs .Women are more
vulnerable to RTI/STIs. Out of 47(45.20%) study
participants who did not know how they would protect
themselves if their partner had symptoms of STI/RTIs, 30
(88.23%) were women. Teaching assertiveness skills in
sexual and reproductive health areas for women in slums
can an important interventional area.
Lack of awareness of symptoms of STI/RTIs coupled with
less priority given to women and their health could be
possible reasons for high reported prevalence seen in
women participants.
CONCLUSION
Urban slum residents in Mumbai have knowledge gap
regarding HIV/AIDS transmission and prevention. Initiation
of sexual intercourse is at an early age, they report
symptoms of STI/RTI and are making unsafe sexual
behavioural choices. These findings highlight the need to
possibly treat slum residents as a sub-population
vulnerable to reproductive health problems and may
require allocation of more/special innovatively packaged
resources for interventions in slums. At individual level, the
interventions would focus on behaviour change; aimed at
HIV / AIDS prevention and at community level they may
focus on raising awareness and reducing stigma regarding
both STI/RTI and HIV/AIDS, thus empowering
communities in fighting the battle against HIV/AIDS.

22nd

7.

8.

9.

10.

11.

12.

13.

14.

edition M/S Banarasidas Bhanot publishers;2013;


399-05.
National Behavioral Surveillance Survey General
population. National AIDS Control Organization,
Ministry of Health and Family Welfare, Government of
India. 2006;36:108
Unnikrishnan B, Mithra PP, T R, B R. Awareness and
attitude of the general public towards HIV/AIDS in
Coastal
Karnataka. Indian
J
Community
Med. 2010;35:1426.
Sobhan K, Kumar TS, Kumar GS, Ravikanth R,
Adarsha S, Mohammad AS, et al. HIV and AIDS:
Awareness and attitudes among males in a rural
population. Indian J Community Med 2004;29:141 -2.
Balk D, Lahiri S. Awareness and knowledge of AIDS
among Indian women: Evidence from 13 States.
Health Transit Rev. 1997; 7:421-65
Kalasagar M, Sivapathasundharam B, Einstein T,
Bertin A. AIDSs awareness in an Indian metropolitan
slum dweller: A KAP (knowledge, attitude, practice)
study. Indian J Dent Res 2006;17:66-9.
Zulu E, Dodoo F, Ezeh A. Sexual risk-taking in the
slums of Nairobi, Kenya, 199398. Population
Studies. 2002;56(3):31123
UNESCO
UNAIDS:
Handbook
appropriate
communication
for
behavior
change:
Information/Education/Communication. A
cultural
approach
to
HIV/AIDS
Prevention
and
Care.2001. http://unesdoc.unesco.org/images/0012/0
01255/125589e.pdf.
Adedimeji AA, Omololu FO, Odutolu O. HIV risk
perception and constraints to protective behaviour
among young slum dwellers in Ibadan, Nigeria. J of
Health, Popu & Nutri.2007; 13(2):14657.

ACKNOWLEDGMENT: Nil
Conflict of Interest: Nil
REFERENCES
1.

International Institute for Population Sciences (IIPS)


and Macro International. 2007. National Family Health
Survey (NFHS-3), 200506: India: Volume I. Mumbai:
IIPS.

2.

AIDS control program. http://www.naco.gov.in/

3.
4.
5.

6.

NACO/National_AIDS_Control_Program/Prevention_
Strategies/ [Last accessed on March30 2015]
http://www.unaids.org/en/regionscountries/countries/i
ndia[Last accessed on February 28 2015]
http://www.worldbank.org/en/news/feature/2012/07/10
/hiv-aids-india[Last accessed on March30 2015]
Madise N. J. Are slum dwellers at heightened risk of
HIV infection than other urban residents? Evidence
from population-based HIV prevalence surveys in
Kenya. Health Place. 2012;18(5): 1144152.
K. Park, Epidemiology of Communicable Diseases,
Parks Textbook of Preventive and Social Medicine,

Syed et al.,

743
Int J Med Res Health Sci. 2015;4(4):740-743

DOI: 10.5958/2319-5886.2015.00145.9

Available online at: www.ijmrhs.com

Research article

Open Access

COST ANALYSIS OF LONG ESTABLISHED AND NEWER ORAL ANTIEPILEPTIC


DRUGS AVAILABLE IN THE INDIAN MARKET
1

*Phatak Abhishek M , Hotwani Jitendra H , DeshmukhKiran R , Panchal Sagar S , Naik Madhura S

ARTICLE INFO
Received: 2nd May 2015
Revised : 14th July 2015
Accepted: 29th July 2015
Authors details: 1Third Year Junior
Resident, 2Associate Professor, 3Second
Year Junior Resident, Department of
Pharmacology,
Topiwala
National
Medical College and B. Y. L. Nair
Charitable Hospital, Mumbai Central,
Mumbai, Maharashtra, India
Corresponding
author:
Phatak
Abhishek M.
Topiwala National Medical College and
B. Y. L. Nair Charitable Hospital,
Mumbai Central, Maharashtra, India
Email: abhishekphatak9288@gmail.com
Keywords: Therapeutic drug
monitoring, Bioavailability,
Carbamazepine, Topiramate. Treatment
gap

ABSTRACT
Background: Large number of pharmaceutical companies manufactures
antiepileptic drugs in India. The price variations among the marketed drugs are
wide. Aims: The present study was aimed to find the cost of different oral
antiepileptic drugs available in Indian market as monotherapy, combination
therapy and number of manufacturing companies for each, to evaluate
difference in cost of different brands of same dosage of same active drug by
calculating percentage variation of cost. Methods and Materials: Cost of a drug
being manufactured by different companies, in the same strength and dosage
forms was obtained from Indian Drug Review Vol. XXI, Issue No.4, 2014 and
Current Index of Medical Specialties July-October 2014. The difference in the
maximum and minimum price of the same drug manufactured by different
pharmaceutical companies and percentage variation in price was calculated.
Results: The percentage price variation noted of long-established drugs was
Phenytoin (50mg): 140%, Carbamazepine (100mg): 1033%, Phenobarbital
(30mg) : 730%, Valproic acid (300mg) : 420%. Newer drugs Levetiracetam
(250mg): 75%, Lamotrigine (25mg): 66%, Topiramate (50mg): 108%,
Zonisamide (100mg): 19%. Combination drugs Phenobarbital + Phenytoin
(30+100) mg: 354.55%. Conclusion: The percentage price variation of different
brands of the same commonly used long-established oral antiepileptic drug
manufactured in India is very wide. The formulation or brand of Antiepileptic
drugs (AEDs) should preferably not be changed since variations in
bioavailability or different pharmacokinetic profiles may increase the potential for
reduced effect or excessive side effects. Hence, manufacturing companies
should aim to decrease the price variation while maintaining the therapeutic
efficacy.

INTRODUCTION
Epilepsy is a chronic non-communicable disorder of the
brain that affects people of all ages often interfering with
education and employment. Epilepsy is defined by
International League Against Epilepsy (ILAE) as a
condition characterized by recurrent (two or more)
epileptic seizures, unprovoked by any immediate
[1]
identified cause.
According to the World Health
Organization (WHO), of the 50 million people with
[2]
epilepsy worldwide, 80% reside in developing countries.
It is estimated that there are more than 10 million persons
with epilepsy in India. Its prevalence is about 1% in Indian
[3]
population. The prevalence is higher in the rural (1.9%)
[4,5]
compared to urban population (0.6%). The estimated
burden of epilepsy using the disability adjusted life years
(DALYs) accounts for 1% of the total burden of disease in
the world, excluding that due to social stigma and
[6]
isolation, which further add to the disease burden.
In many developing countries, people with epilepsy do not
receive appropriate treatment for their condition, a
phenomenon called treatment gap (TG), which is defined
as the number of people with active epilepsy not on
treatment (diagnostic and therapeutic) or on inadequate
treatment, expressed as a percentage of the total number
[7]
with active epilepsy.
The magnitude of epilepsy

treatment gap in India ranges from 22% among urban,


[8]
middle-income people to 90% in rural India.
In order to reduce this gap in the context of limited
resources, it would be necessary to specify the important
causes of gap for a particular community and the most
cost-effective resource
[9,10-12]
for a particular situation.
The Indian pharma market
size is expected to grow to US$ 85 billion by 2020. The
growth in Indian domestic market will be on back of
increasing consumer spending, rapid urbanization, and
[13]
raising healthcare insurance and so on.
The cost of drug plays a crucial role in patients care
especially in developing countries and constitutes an
essential part of rational drug prescription. In recent years
more emphasis has been given on cost effective practice
which should be adopted by clinicians. Cost of drugs is an
[14]
important factor influencing compliance with treatment.
The epileptic seizures are a common disorder for which
patients have to take medication for a prolonged period,
sometimes even life-long. It is necessary for the clinicians
to prescribe most effective, appropriate and economical
treatment regimen available.
Estimation of the economic burden of epilepsy is of pivotal
relevance to enable a rational distribution of healthcare
resources. Being one of the common brain disorders with

744
Phatak et al.,

Int J Med Res Health Sci. 2015;4(4):744-748

varying etiologies, which can present at any age, requiring


prompt therapy and with the aim to promote rational
pharmacotherapy we decided to study the cost of different
brands of antiepileptic drugs available in Indian market.

companies and percentage variation in price was


calculated.
[14]
Percentage cost variation was calculated as follows:

MATERIALS AND METHODS


Study design: This was an analytical study.
Exclusion criteria: The drug formulation being
manufactured by only one company was excluded.
The study was conducted by the Department of
Pharmacology, Topiwala National Medical College &
B.Y.L. Nair Charitable Hospital, Mumbai.
Methodology: Price in Indian rupees (INR) of oral
antiepileptic
drugs
manufactured
by
different
pharmaceutical companies in India, in the same strength
was obtained from Indian Drug Review (IDR) Vol. XXI,
Issue No.4, 2014 and Current Index of Medical
(15)
Specialties(CIMS) July-October 2014. The prices of 18
oral antiepileptic drugs (16 single and 2 combinations),
available in 56 different formulations were analyzed.
Cost of the oral antiepileptic drug formulation was
calculated for an average of 10 tablets as the number of
tablets available per strip varied. Difference in the
maximum and minimum price of the same drug
formulation manufactured by different pharmaceutical

(CV= Cost variation)


Statistical analysis: Findings of our study were
expressed as absolute numbers as well as percentage.

%CV= Price of most expensive brand least expensive brand 100


Price of least expensive brand

RESULTS

Table 1 shows variation in cost of long - established oral


antiepileptic drugs used as a single drug therapy. The
percentage variation noted in the cost was Carbamazepine (100 mg): 1033%, Phenobarbital (30 mg):
730%, Valproic acid (300 mg): 420%, Divalproax sodium
(500 mg): 378% and Diazepam (5 mg): 374%.
Table 2 shows variation in cost of oral antiepileptic drugs
used in combination. The percentage variation noted in
the cost was Sodium valproate + Valproic acid (333+145
mg): 76.67%, Phenobarbital + Phenytoin (30+100 mg):
354.55%.
Table 3 shows variation in cost of newer oral antiepileptic
drugs used as single drug therapy. The percentage
variation noted in the cost was - Pregabalin (75 mg):
143%, Topiramate (50 mg): 108%, Levetiracetam(250
mg): 75%, Oxcarbazepine (150 mg): 59%.
Table 1: Price variation in long-established oral antiepileptic drugs
Drug
Formulation Doses(mg)
No.of
Manuf. Minimum price Maximum price
%
Price
Companies
(INR)
(INR)
variation
Carbamazepine
4
100
13
6.18
70.00
1033
200
22
11.17
120.00
974
300
5
18.24
28.28
55
400
11
24.24
37.71
56
Phenytoin
3
50
3
7.49
18.00
140
100
9
8.36
21.10
152
300
2
50.19
56.66
13
Phenobarbitone
2
30
3
4.95
41.08
730
60
3
8.25
28.02
240
Divalproex
7
125
7
17.00
30.30
78
sodium
250
21
24.00
84.00
250

Valproic acid

Diazepam

Lorazepam

Clonazepam

Clobazam

500
750

25
9

32.00
85.00

153.00
106.05

378
25

1000

99.00

115.00

16

200

29.50

35.00

19

300

41.00

55.00

34

200
300
500
2
5
10
1
2

15
8
9
3
9
8
11
10

19.50
25.90
39.90
12.65
7.00
11.75
7.80
10.59

42.00
56.00
93.00
20.20
33.21
40.85
30.00
35.00

115
420
133
60
374
248
285
230

0.25
0.5
1
2
5
10
20

9
23
13
16
9
9
4

7.00
9.63
12.50
31.68
23.00
43.00
79.90

16.25
45.00
37.00
67.00
53.52
106.37
146.00

132
367
196
111
133
147
83

745
Phatak et al.,

Int J Med Res Health Sci. 2015;4(4):744-748

INR: Indian rupees. The prices of 18 oral antiepileptic drugs (16 single and 2 combinations), available in 56 different
formulations were analyzed.
Table 2: Price variation among combination therapy
Drug
Formulation Doses
No of Manufa.
(mg)
Companies
Na valproate+ 2
200+87
7
valproic acid
333+145
7
Phenobarbital+ 1
30+100
3
phenytoin
INR: Indian rupees, Na: sodium
Table 3: Price variation in newer oral antiepileptic drugs
Drug
Formulation Doses
No.
of
(mg)
Manufacturing
Companies
Lamotrigine
3
25
4

Minimum
price (INR)
36.50

Maximum price
(INR)
62.50

% Price
variation
71.23

60.00
6.60

106.00
30.00

76.67
354.55

Minimum price
(INR)

Maximum price
(INR)

%
Price
variation

30.00

50.00

66

50
100

7
7

54.50
98.00

90.00
158.00

65
61

Gabapentin

100
300
400

3
10
5

36.20
98.75
119.50

44.00
131.00
152.00

22
33
27

Pregabalin

50

58.20

59.00

75
150
25

17
14
4

56.83
114.14
19.00

138.00
169.00
38.00

143
48
100

50
100
250

4
2
5

36.00
108.00
55.00

75.00
158.00
96.00

108
46
75

500

110.00

189.00

72

750
1000
50
100
150

4
2
2
3
11

168.00
290.00
57.00
87.79
26.39

280.00
360.00
59.40
104.70
42.00

67
24
4
19
59

300

12

48.33

75.00

55

450

110.00

120.00

600

10

90.00

134.00

49

Topiramate

Levetiracetam

Zonisamide

Oxcarbazepine

INR: Indian rupees


DISCUSSION
The epilepsies are a spectrum of brain disorders ranging
from mild, benign forms to severe, life-threatening and
disabling ones. Epilepsies can occur in children, adults
and the elderly, as well as following brain trauma, stroke,
and brain tumors. There is lack of sufficient data in India
comparing the cost of the same antiepileptic drug sold
under different brand names by different pharmaceutical
[15]
companies.
The drug prices available in CIMS and IDR were
compared as they are one of the available sources of
drug information that are updated on a regular basis.
In our study, we have found that there were 56
formulations of antiepileptic drugs of which 31 were of
long-established antiepileptic drugs, 22 of newer and 3 of
combination drugs. So it is not practically possible for any

health care provider to remember the prices of all these


brands.
Variations in costs were found to be significant. The ones
with significant variations were the cost of the brands of
Carbamazepine 100mg varied from Rs.6.18 to Rs.70.00;
Phenobarbital 30mg varied from Rs.4.95 to Rs.41.08.
Valproicacid 300mg cost varied from Rs.25.90 to Rs.
56.00. Among newer antiepileptics, Pregabalin 75mg
varied from Rs.56.83 to Rs. 138.00; Topiramate 50 mg
cost varied from Rs. 36.00 to Rs. 75.00. Among the
combination therapy, Phenobarbital + Phenytoin (30
mg+100 mg) showed maximum price variation i.e.
354.55%.
Thus, in our study of cost-analysis of various anti-epileptic
brands, it has been observed that there is substantial
variation in the cost of different brands of same generic

746
Phatak et al.,

Int J Med Res Health Sci. 2015;4(4):744-748

drugs. Anand Krishnan, Ritvik, DebashishChowdhary


(2007) have also observed a lot of variation in the cost of
[16]
anti-epileptic drugs. Findings of our study is similar to
their studies. The intrabrand comparison of newer antiepileptic drugs also showed wide variation in the cost. Our
study is in agreement with the study of Beghi, Ettore, et al
(2008) as they have noticed a higher cost of newer anti[17]
epileptic drugs.
[18]
The reasons for this price variation could be as follows1. Government regulations and pricing policies
2. The existing market structure of the pharmaceutical
industry
3. Industry costs
Drugs are the mainstay of treatment for epilepsy, and are
effective for most patients. It is switching from brandname to generic antiepileptic or from one generic
antiepileptic to another that should be avoided in clinical
practice, since subtle differences in bioavailability may
disturb optimal degree of seizure control to which the
[19]
patient was previously successfully titrated. Even using
a parent compound, antiepileptic medication levels can
fluctuate if the product source has changed, resulting in
[20]
toxicity.
In this regard, therapeutic drug monitoring
becomes essential specially for phenytoin since it has
narrow therapeutic index. It is vital therefore those
patients should receive the same brand consistently to
avoid loss of control.
In India, a large number of patients are not covered under
any individual or government medical insurance. Hence,
the patients have to purchase the prescribed drugs by
themselves. These wide variations in the prices of
different formulations of the same drug have severe
economic implications on the Indian Population.
The Government of India has unveiled 'Pharma Vision
2020' aimed at making India a global leader in end-to-end
drug manufacture. It has reduced approval time for new
facilities to boost investments. Further, the government
has also put in place mechanisms such as the Drug Price
Control Order (DPCO) and the National Pharmaceutical
Pricing Authority (NPPA) to address the issue of
affordability and availability of medicines.
There are few antiepileptic drugs included in The National
list of essential medicines but still there are many drugs
especially the newer antiepileptic drugs such as
oxcarbazepine, topiramate etc. having better safety,
[21-24]
efficacy profile but not included in the list.
Limitations of this study: Being sources of information
were limited to IDR and CIMS. There are various other
brands which are marketed in India but not published in
the above mentioned sources. Also we have not
assessed the prices of parenteral preparations.

which is cost-effective, tolerable as well as efficacious in


accordance to the principles of rational pharmacotherapy.
Acknowledgment: We Acknowledge Department of
Pharmacology and Central library, Topiwala National
Medical College & B.Y.L. Nair Charitable Hospital,
Mumbai, for their support.
Source of Support: Nil
Conflict of Interest: None
REFERENCES
1.

2.

3.
4.
5.

6.

7.

8.

9.

10.

11.
12.

13.

CONCLUSION
The percentage price variation of different brands of the
same antiepileptic drug manufactured in India is very
wide. Considering the prevalence of epilepsy especially in
rural India where there are limited resources and poverty,
providing a broad overview of available antiepileptic drugs
and their prices is of utmost importance.There should be
education programs and marketing strategies so that
prescribers can select proper medication for their patients

14.

Hauser WA, Kurland LT. The epidemiology of


epilepsy in Rochester, Minnesota. Epilepsia. 1975;
16:1-66.
WHO. Neurological Disorders: Public Health
Challenges. Geneva: World Health Organization;
2006.
Sridharan R, Murthy BN. Prevalence and pattern of
epilepsy in India. Epilepsia. 1999; 40:631-636.
Leonardi M, Ustun TB. The global burden of epilepsy.
Epilepsia. 2002; 43(6):21-25.
Pahl K, de Boer HM. Epilepsy and rights. Atlas:
Epilepsy Care in the World. Geneva: WHO; 2005:7273.
Jain S, Satishchandra P. Epilepsy: A Comprehensive
Textbook. . In: Engel J Jr, Pedley TA, editors. New
York: Cambridge University Press, Lippincott
Williams and Wilkins; 2008. pp. 2885-2889.
Meinardi H, Scott RA, Reis R, Sander JW. ILAE
Commission on the Developing World. The treatment
gap in epilepsy: The current situation and ways
forward. Epilepsia. 2001; 42:136-149.
Meyer AC, Dua T, Ma J, Saxena S, Birbeck G. Global
disparities in the epilepsy treatment gap: A
systematic review. Bull World Health Organ. 2010;
88:260-266.
Bharucha NE, Bharucha EP, Bharucha AE, Bhise
AV, Schoenberg BS. Prevalence of epilepsy in the
Parsi community of Bombay. Epilepsia. 1988;
29:111-115.
Koul R, Razdan S, Motta A. Prevalence and pattern
of epilepsy (Lath/Mirgi/Laran) in rural Kashmir, India.
Epilepsia. 1988; 29:116-122.
Mani KS. Epidemiology of epilepsy in Karnataka,
India. Neurosci Today. 1997; 1:167-74.
Pal DK. Methodological issues in assessing risk
factors for epilepsy in an epidemiologic study in India.
Neurology. 1999; 53:2058-2063.
Consolidated FDI Policy, Department of Industrial
Policy & Promotion (DIPP), Press Information Bureau
(PIB), Media Reports, Pharmaceuticals Export
Promotion
Council.
Available
from
<www.ibef.org/industry/pharmaceuticalindia.aspx>[accessed on 25 April, 2015]
Ravi Shankar P, Subish P, Bhandari RB, Mishra P,
Saha
AC.
Ambiguous
pricing
of
topical
dermatological products: A survey of brands from two
South Asian countries. Journal of Pakistan
Association of Dermatologists. 2006; 16:134-140

747
Phatak et al.,

Int J Med Res Health Sci. 2015;4(4):744-748

15. Jadhav NB, Bhosale MS, Adhav CV. Cost analysis


study of oral antidiabetic drugs available in Indian
market. Int J Med Res Health Sci. 2013; 2(1): 63-69.
16. Sridharan R. Epidemiology of epilepsy. Current
Science. 2002; 82:664-670.
17. Goel D, Agarwal A, Dhanai JS, Semval VD, Mehrotra
V, Saxena V, et al. Comprehensive rural epilepsy
surveillance programme in Uttarakhand state of India.
Neurol India. 2009; 57:355-356.
18. Banerjee TK, Ray BK, Das SK, Hazra A, Ghosal MK,
Chaudhuri A, et al. A longitudinal study of epilepsy in
Kolkota, India. Epilepsia. 2010; 51:2384-2391.
19. Jancovic SM, Ignjatovic RD, Is bioavailability altered
in generic versus brand anticonvulsants? Expert
Opinion on Drug Metabolism Toxicology. 2015;
11(3):329-332.
20. Patel V, Cordato DJ, Dias M, Beran RG, Changed
constitution without change in brand name--the risk of
generics in epilepsy. Epilepsy Research. 2012; 98(23):269-272.
21. National
Pharmaceutical
Pricing
Authority,
Government
of
India.
Available
at
http://www.nppaindia.nic.in/
DPCO2013.pdf.[Accessed on 18 April 2015].
22. National
Pharmaceutical
Pricing
Authority,
Government of India, Current Price list. Available at
http://www.nppaindia.nic.in/ceiling/press28april14/so1
156e-28-4-14.html.[Accessed 18 April 2015].
23. National List of Essential Medicines of India.
Available at: http://www.mohfw.nic.in/WriteReadData/
l892s/7364497513National%20List%20of%20Essenti
al%20Medicine,%202011.pdf.[Accessed 18 April
2015].

24. Rang HP, Ritter JM, Flower RJ, Henderson G,


th
Rang& Dales Pharmacology. 7 edition, Elsevier
Churchill Livingstone, Spain; 2012, pp. 540-552.

748
Phatak et al.,

Int J Med Res Health Sci. 2015;4(4):744-748

DOI: 10.5958/2319-5886.2015.00146.0

Available online at: www.ijmrhs.com

Research article

Open Access

ROLE OF DIETARY DIVERSITY IN ENSURING ADEQUATE HAEMATOLOGICAL


STATUS DURING PREGNANCY
1

Mahama Saaka Abdulai Abdul Rauf

ARTICLE INFO
Received: 9th May 2015
Revised : 2nd Jun 2015
Accepted: 22nd Jul 2015
1

University for
Development Studies, School of
Medicine and Health Sciences,Ghana
2
Ghana Health Service, TamaleGhana
Authors

details:

author:
Mahama
Saaka
University for Development Studies,
School of Medicine and Health
Sciences,Ghana
Email: mmsaaka@gmail.com
Corresponding

Keywords: Anaemia, Dietary diversity,

Pregnancy,
Haematological
Ghana

Haemoglobin,
status,
Northern

ABSTRACT
Introduction: Though nutrition is a key input to blood formation, little is
known about the extent maternal dietary quality contributes to the
haematological status of pregnant women in Northern Region of Ghana.
Objective: The aim of this study was to assess the independent
contribution of dietary diversity to haematological status of pregnant women
whilst controlling for potential confounding factors including malarial
infection. Methods: A cross-sectional study design was used on a sample
of 307 pregnant women in their third trimester. A structured questionnaire
was used to collect socio-demographic characteristics, obstetric and dietary
data related to anaemia. Overall dietary quality was assessed using the
dietary diversity score. Haemoglobin concentration (Hb) was measured
using portable HemoCueR Hb 301 system. Predictors of anaemia were
estimated using multiple linear regression analysis. Results: The mean Hb
was 10.81.4 g/dl and prevalence of anaemia (Hb<11.0 g/dl) was 46.3 %.
High dietary diversity score [Beta coefficient (), = 0.141 p < 0.001], multigravidity (=0.205) and high composite score for ANC content (= 0.201)
were associated with a decreased risk of anaemia in the third trimester of
pregnancy. Conclusion: The findings suggest the need to strengthen
interventions that focus on improving the consumption of diversified foods
particularly during pregnancy.

INTRODUCTION
In most developing countries maternal under nutrition
including micronutrient deficiencies is a leading cause of
[1]
maternal and child mortality and morbidity . Anaemia in
particular is one of the most prevalent public health
problems in Ghana. Anaemia is defined as a condition in
which the number and size of red blood cells or
haemoglobin concentration falls below an established cut
-off, consequently impairing the capacity of the blood to
[2]
transport oxygen around the body . According to recent
estimates, anaemia affects 60.0% pregnant women in
developing countries including Ghana and about 7.0 % of
[3,4]
cases are severe
.
The aetiological factors responsible for anaemia in
pregnancy are multiple and their relative contributions are
[5]
said to vary by geographical area and by season .
Admittedly, several predisposing factors contribute to
anaemia among pregnant women and these include sociodemographic, socio-economic status, multiparity, short
[6]
inter-pregnancy intervals and nutritional factors . The
relative importance of each of these varies from place to
place. In the Northern Region of Ghana, where anaemia is
of public health significance, very little is documented
regarding the role maternal dietary factors contribute to
haematological status. The role of diet on blood
biomarkers may be significant, but evidence of the
magnitude of this benefit is limited.
An understanding of association between dietary diversity
and haematological status may be complicated by other
factors including malarial infection and household socioeconomic status. This study sought to determine the

independent contribution of dietary diversity to


haematological status of pregnant women whilst
controlling for potential confounding factors. We
hypothesized that diversified diets during pregnancy would
be associated with better haematological status compared
to nutrient-poor diets.
MATERIAL AND METHODS
Study design: This study was analytical cross-sectional
design from January- March 2013.
Sample size: 307 was calculated using single population
proportion formula assuming the prevalence of all types of
anaemia among pregnant women in Northern Region was
[7]
estimated as 73.0 % , confidence interval 95%, margin
of error 5.0 %. Systematic random sampling procedure
was used to select the study participants. The attendance
list of the women who sought ante-natal care services
served as the sampling frame.
Ethical approval: The protocol for this study was
approved by the School of Medicine and Health Sciences,
University for Development Studies. Informed consent was
obtained from all study participants. Information about
objective of the study, procedures, potential risks, and
benefits was given to mothers before they were enrolled to
the study. Their full right to refuse participation was
explained. Written informed consent was obtained from
each mother/caregiver.
Inclusion criteria: The study population comprised
pregnant women who sought antenatal care at four major

749
Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

hospitals in Tamale Metropolis of the Northern region of


Ghana.
Data Collection; The study participants were recruited in
their third trimester (34-36 weeks gestation). Study
participants were then interviewed face-to-face by the
investigators. A pre-tested questionnaire was used to
collect information including haemoglobin concentration,
blood pressure, weight, maternal age, parity, gestational
age, level of education and occupation of the women,
history of malarial infection in the index pregnancy (selfreported fever or laboratory-tested), presence of any
chronic illnesses, and prophylactic medications received
during pregnancy. Standard procedures were followed for
the recording of blood pressure and weight.
Independent and dependent variables
The main outcome variable for this study was the
prevalence of anaemia (Hb less than 11g/dl). The
independent variables for this study were maternal, child
and household characteristics including antenatal care
(ANC) attendance, malarial infection, maternal dietary
intake.
A brief description of main independent and dependent
variables is as follows:
Diagnosis of anaemia : Haemoglobin concentration
levels were measured in late pregnancy (gestational age
34 weeks) using a portable haemoglobinometer made by
HemoCue Hb301. Capillary blood was collected from
participants using a finger prick method under sterile
conditions. The first drop of blood was wiped away using
alcohol sterile wipes, and the next drop was placed into
the Hemocue curvette for immediate testing of
haemoglobin. Women were classified as anaemic if they
had a haemoglobin concentration less than 11 g/dL.
Anaemia was further classified as mild (9.0-10.9 g/dL),
moderate (7.0-8.9 g/dL) or severe (<7.0 g/dL). Anaemia is
said to be a severe public health problem when its
prevalence is 40% or more in any group (all types of
anaemia) or when severe anaemia (haemoglobin < 7g/dL)
[8]
exceeds 2% .
Assessment of Maternal Height, Weight and
Gestational Weight Gain: Standard procedures were
followed to take anthropometric measurements of the
[9]
women
.Maternal height was measured on the
participants first visit to the antenatal clinic. Height was
measured to the nearest 0.1 cm. The Seca 767 digital
adult scale was used to weigh participants to the nearest
0.05 kg. Gestational weight gain was determined by the
difference in maternal weight in early pregnancy (5-10
weeks) gestation and late pregnancy (34-36 weeks).
Assessment of maternal dietary intake: The nutrient
adequacy of diet during pregnancy was assessed based
on dietary diversity. Maternal individual dietary diversity
score (IDDS) was derived on the basis of the number of
food groups consumed from a seven-day food frequency
questionnaire and included 11 food groups. The food
group frequency of consumption (past 7 days) was
measured for each food group by assigning a score of 0 if
not consumed during the previous week, 1 if consumed on
13 days, and 2 if consumed for at least 4 days. This
composite index of dietary diversity which took into
account the weekly food frequency varied from a minimum

of 0 to a maximum of 22. Eleven food groups flesh meats


(i.e. beef, pork, lamb, goat, poultry), fish, eggs, milk and
milk products, organ meat (e.g. liver, kidney), legumes,
cereals, roots & tubers, dark green leafy vegetables,
vitamin A rich fruits and fats & oils were selected based
on the dietary pattern of the study population.
The FAO validated 11-item food groups frequency
questionnaire (FFQ) was used to quantify maternal dietary
[10]
intake based on 7-day dietary diversity score .
Determination of Household Economic Status: A
household wealth index based on household assets and
housing quality was used as a proxy indicator for socioeconomic status (SES) of households. Principal
Component Analysis (PCA) was used to determine
household wealth index from information collected on
housing quality (floor, walls, and roof material), source of
drinking water, type of toilet facility, the presence of
electricity, type of cooking fuel, and ownership of modern
household durable goods and livestock (e.g. bicycle,
television, radio, motorcycle, sewing machine, telephone,
cars, refrigerator, mattress, bed, computer and mobile
[11-14]
phone)
.
These facilities or durable goods are often regarded as
modern goods that have been shown to reflect household
wealth. A household of zero index score for example
means that household had not a single modern good. The
scores were thus added up to give the proxy household
wealth index.
The main aim of creating the index was to categorize
households into SES groupings in order that we could
compare the difference in the prevalence of anaemia
between the groups of lowest and highest SES.
Content of ANC Services: Women were asked whether
specific services including taking of weight and height,
measurement of blood pressure, and taking blood or urine
samples were carried out for them. A composite index
comprising ten of these essential services received during
ANC was created by assigning a score of 1 for having
received a particular service and zero for not receiving the
service. The total score for each woman was then
categorized as low (< 7) or high (7).
Data Processing and Analysis: Data were analyzed
using SPSS version 20 statistical software. Both Bivarate
and multivarate analyses were carried out to identify risk
factors of anaemia. Association between anaemia and
some risk factors in pregnancy was tested using chisquare and multivariable analysis of risk factors. Variables
with p value less than 0.1 in bivariate analysis were
entered in to multivariable logistic regression model. P
value less than 0.05 were taken as statistically significant
and adjusted odds ratio with 95% confidence interval (CI)
was used to measure association. Multicollinearity was
investigated by using the variance inflation factor (VIF). A
VIF (the reciprocal of the tolerance statistics) of greater
than 5 is generally considered evidence of
multicollinearity.
RESULTS
Socio-demographic characteristics of the sample
A total of 307 pregnant women were approached and all of
them consented and accepted to participate in the study,
thus giving a response rate of 100%. The mean age of

750

Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

mothers was 27.24.0 years which ranged from 18 to 38


years. Majority (75.2%) of the respondents were Muslims.
Majority, 245 (79.8%), of the respondents were married
and (47.9 %) of the mothers had no formal education at
all. Petty trading was common among the mothers and
most of the participants (67.1%) were multigravida (Table
1).
Table 1: Sample Characteristics (N =307)
Frequency (n) Percentage (%)
Religion
Islam
231
75.2
Christianity
76
24.8
Classification of occupation
None
97
31.6
Petty trader
108
35.2
Farmer
72
23.5
Civil Servant
30
9.8
Tribe
Dagomba
180
58.6
Gonja
36
11.7
Mamprusi
34
11.1
Nanumba
28
9.1
Akan
12
3.9
Others
17
5.5
Education level of mother
None
147
47.9
Primary
41
13.4
JSS/Middle
50
16.3
Secondary
47
15.3
Tertiary
22
7.2
Marital status
Single
62
20.2
Married
245
79.8
Gravidity
Primigravida
32
10.4
Secundigravida
69
22.5
Multigravida
206
67.1
Magnitude of Anaemia: The mean hemoglobin level was
about 10.81.4g/dL which ranged from 7.3g/dL to
14.3g/dL. The prevalence of anaemia was 46.3%. In
terms of severity, mild anaemia was 34.9 %, moderate
anaemia was 11.4 % but there were no cases of severe
anaemia.
Factors Associated with Anemia: Bivariate analyses
were performed to assess association of sociodemographic and other maternal factors with child anemia
(Table 2). There was an inverse relationship between the
prevalence of anaemia and the level of education of the
women. This means the proportion of anaemic women
decreased with increased in the level of education.
Anaemia was significantly more common in women of
lower household wealth index. As maternal 7-day dietary
diversity increased, the prevalence of anaemia decreased.
As the number of sulfadoxine-pyrimethamine (SP) doses
increased the prevalence of malaria decreased.
Dietary Diversity and Food Group Frequency
Consumption
In late pregnancy, the minimum dietary diversity (that is,
proportion of women who receive foods from 5 or more
food groups in seven days was 85.5 %. The mean dietary
diversity score (DDS) from 11 food groups was 9.11.4.
The mean food group frequency of consumption (past 7
days) was 15.02.8. The minimum and maximum of the
food group frequency of consumption index scores were

6.0 and 22 respectively. More than half of the pregnant


women (52.8%) were on low diversified diet as measured
by DDS over a period of one week. A significant proportion
of the pregnant women rarely consumed dairy products
and eggs though over 80 % of consumed cereals and
roots & tubers on a daily basis (Table 3).
Table 2a: Bivariate Analysis of predictors of anaemia
among pregnant women
N
Anaemia
Characteris No n (%)
Test
tic
statistic
Yes n (%)
Maternal Education
None
147
78 (53.1)
Low
91
36 (39.6)
High
63
45 (71.4)
Religion of mother
Islam
227 110(48.5)
Christianity
74
49 (66.2)
Marital status
Single
60
23 (38.3)
Married
241
136(56.4 )
Malarial infection
None
45
1-2 times
223
3-4 times
33

30 (66.7)
121(54.3)
8 (24.2)
Maternal 7-day dietary diversity
Low

162

High

139

69(46.9)
55(60.4)
18(28.6)

=15.2
p= .001
2

117(51.5)
25(33.8)
37(61.7)
105(43.6)

= 7.1
p=.008

=
6.3
p=.012
2

15 (33.3)
102(45.7)
25 (75.8)

=14.5
p=0.001

91 (56.2)

=11.4
p=.001

71 (43.8)

88 (63.3)
51 (36.7)
Table 2b: Bivariate Analysis of predictors of anaemia
among pregnant women
N
Anaemia
Characteristic
No
n (%)

Test
statistic

Yes
n (%)

Household wealth index


Low

160

71 (44.4)

89 (55.6)

High

141

88 (62.4)

53 (37.6)

= 9.7
p
=
0.002

ANC visit
<4

146

58 (39.7)

88 (60.3)

155

101(65.2)

54 (34.8)

=
19.5
p<
0.001

Timing of first ANC


Late (After first
trimester)
Early
(First
trimester)

173

0-1

None

69 (39.9)

104 60.1)

90 (70.3)

38 (29.7)

=
27.3
p<
0.001

77

Parity
35 (45.5)

42 (54.5)

18

7 (38.9)

11 (61.1)

56 (58.9)
29 (37.7)

10.9
p=

128

=
8.9
2-3
194 114(58.8) 80 (41.2)
p=
At least 4
30
10 (33.3) 20 (66.7)
0.011
Doses of antimalarial prophylaxis (IPTp) with (SP)

1 dose
2 doses

95
77

39 (41.1)
48 (62.3)

751
Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

3 doses

111

65 (58.6)

46(41.4)

0.012

Table 3: Food groups consumption frequency in the past week (n= 307)
Frequency of foods consumption in the past week (% of women)
Type of food
Usually every day
4 to 6 times per week
1- 3 times per week
Meat
Poultry
Liver
Fish
Cereals
Roots & tubers
Legumes
Dairy products
Eggs
Fruits
Green leafy vegetables

58.0
2.3
14.3
18.6
97.1
84.7
58.0
2.0
4.2
22.5
37.5

34.2
19.2
43.0
30.6
2.3
11.7
34.9
22.8
16.3
30.6
44.6

7.2
50.8
53.8
41.7
0.7
1.3
7.1
45.0
39.4
36.2
14.3

Table 4: Determinants of Hb in the third trimester of pregnancy


Model
Standardized
Sig.
Coefficients
Beta ()
(Constant)
<0.001
Marital status of respondent
0.148
0.003
ANC initiated in the first trimester
0.214
0.001
Multi-gravidity
0.205
0.003
High Parity (4)
-0.193
0.007
High composite score for ANC
0.201
0.001
content
Maternal 7-day dietary diversity
0.239
<0.001
(FGFS > 7)
Relationship between Maternal Dietary Diversity and
Pregnancy Anaemia: In analysis of covariance
(ANCOVA) model, there was a significant difference in
adjusted mean Hb concentrations between women of low
and high diversified diets. The adjusted mean Hb in the
high diversified Group was 0.67 g/dl higher than in the
group that was on low diversified diets (95 % CI: 0.39 to
0.95, p < 0.001). Mean Hb in the third trimester was
adjusted for Hb in the first trimester, timing of first ANC
visit, parity, gravidity, and composite ANC content
received.
Determinants
of
third
trimester
hemoglobin
concentrations: Multiple regression analysis showed
significant positive associations between 7-day maternal
dietary diversity as measured by food groups consumption
frequency (FGFS) and a number of factors including parity
of the mother (Table 4). The set of independent variables
accounted for 32.0 % of the variance in the mean Hb
concentrations of pregnant women in the third trimester
2
(Adjusted R = 0.32).
Considering the beta coefficients (), women who initiated
ANC in the first trimester had mean Hb concentration
which was 0.214 standardized units significantly higher
than women who initiated ANC from the second trimester.
Mean Hb of multigravidae women was significantly higher
by 0.205 units. Women of higher dietary diversity (Food
Group Frequency Score) had higher Hb (Beta coefficient
= 0.141 p < 0.001). On the average, women of lower parity
(at least 4) had mean Hb which was 0.193 standardized
units lower, compared to women of lower parity (0-1).
Women who scored higher composite index of ANC
content had mean Hb which was 0.201 standard units

Never/rarely
0.7
27.7
6.8
9.1
0.0
2.3
0.0
30.2
40.1
10.7
3.6

95.0% Confidence Interval


for ()
Lower Bound Upper Bound
6.52
8.54
0.18
0.86
0.26
0.95
0.15
0.71
-0.80
-0.13

Collinearity
Statistics
Tolerance VIF
0.909
0.580
0.476
0.446

1.100
1.725
2.103
2.240

0.23

0.91

0.592

1.688

0.39

0.95

0.866

1.155

higher than those of lower score. Maternal 7-day dietary


diversity was the strongest determinant of mean Hb (Table
4).
DISCUSSION
This study sought to assess the independent contribution
of dietary diversity to haematological status of pregnant
women whilst controlling for potential confounding factors.
In the multivariable analysis, haemoglobin status of
women was positively associated with maternal DDS,
early initiation of ANC visits, and negatively associated
with parity.
In bivariate analysis, some variables including household
wealth index, malarial infection, antimalarial prophylaxis
(IPT) and maternal educational level showed a weak
association with anaemia but disappeared after adjusting
for confounders in multivariate analysis.
The aetiology of anaemia in pregnancy does not seem to
be the same in every geographical area and season.
Whereas in Malawi, iron deficiency was an important
contributor to anaemia in pregnancy 09, Mockenhaupt et
[15]
al.
reported that iron deficiency did not appear to be a
major risk factor for anaemia among pregnant women in
the Agogo district of Ghana.
Prevalence of anaemia: The prevalence of anaemia
among women in the third trimester of gestation was 46.3
% and this can be classified as a severe public health
[8]
problem according to WHO . The prevalence is lower
than the 51.959.6 % estimated prevalence of anaemia in
[16]
pregnancy in Africa
. The survey findings corroborate

752
Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

past research that showed a high prevalence of anaemia


[7,17,18]
among women in Northern Ghana
.
Most of the women in this study had anaemia of mild to
moderate severity with no case being severely anaemic.
These findings are similar to the findings from other
studies in which 47.5 % of women aged 15-49 years had
[17]
some form of anaemia .
Dietary diversity and haematological status: The
results of this study showed that high maternal dietary
diversity was associated with reduced risk of anaemia and
so nutritional factors may be important. This finding is
consistent with that of similar studies carried out
elsewhere in India, where low dietary intake of multiple
micronutrients, but higher intakes of nutrients that inhibit
iron absorption such as calcium and phosphorus, may
[19]
help explain high rates of maternal anaemia .
It has earlier been reported that some pregnant women do
restrict dietary intake in order to have smaller babies, and
[20,21]
therefore easier deliveries
. In Ethiopia, women with
restrictive dietary habits were reported of 39 % higher risk
of anaemia compared to those without restrictive dietary
[22]
behavior
and where maternal dietary diversity was
[23,24]
protective of pregnancy anaemia
. Studies conducted
in Pakistan and Turkey also reported that consumption of
fruit two or more times per week is associated with a
[25,26]
decreased risk of anemia
.
Diet is an important factor for anaemia, as some eating
patterns or habits may predispose individuals to a higher
risk for developing anaemia. For example, high fibre diets
can inhibit the absorption of iron; low fat diets can equally
inhibit iron absorption since fat is needed for iron
absorption, high tea and coffee consumption but without
vitamin C intake inhibits iron absorption. Poor dietary
diversity leads to deficiency of minerals and vitamins
which may increase bio-availability of iron then affects Iron
[27]
status .
Dietary diversity is considered to be a key indicator for
assessing the access, utilization, and quality of diet of
[28]
individuals or household
. Individual dietary diversity
scores have been shown to indicate adequate nutrient
intake through diet and it can be used as a proxy indicator
for measuring nutrient adequacy among pregnant females
[29]
.
A pregnant womans diet that lacks diversity is most likely
to be deficient in essential nutrients and as a result the
foetus will not be provided the nutrition it requires to have
[30]
a healthy growth
. Womens dietary behaviours and
intake during pregnancy are strongly influenced by
[31,32]
different cultural practices, myths and taboos
.
During pregnancy, dietary energy and nutrient
requirements are generally increased to support increased
maternal metabolism, blood volume and red cell mass
expansion, and the delivery of nutrients to the fetus. Key
nutrients including folate, iron, zinc, calcium, vitamin D,
and essential fatty acids function to promote red blood cell
production, enzyme activity, bone development, and brain
development. Poor maternal dietary quality may thus have
[33]
serious implications for anaemia during pregnancy .
Haematinics, particularly iron contributes to the rise in
serum erythropoietin which often decreases during
pregnancy. Deficiency of these essential haematinics
arising from increased requirements and inadequate

intake may have far reaching effects on both mother and


foetus.
Parity, gravidity and haematological status: On the
average, increased parity was associated with decreased
Hb concentration. It is generally believed that anaemia in
pregnancy increases with rising parity, due to repeated
[34]
drain on iron stores . However, the association between
high parity and anaemia in pregnancy is not unequivocal.
[35,36]
While some studies show high parity increases risk
,
[19]
others show no increased risk .
However, the prevalence of anaemia decreased with
gravidity, ranging from 75% among primigravidae to 43.7
% among multigravidae.
ANC attendance and anaemia: The content of ANC
services received and early initiation were found to be
associated with lower odds of having anaemia in the third
trimester. The percentage of women with anaemia was
lowest among those that booked for antenatal care in the
first trimester. This finding is in agreement with findings of
[4]
[37]
Komolafe et al.
and Bukar et al.
in Nigeria. The
positive contribution of early initiation of ANC attendance
to haematological status is probably due to the benefits
associated with ANC. For example, women who initiate
ANC visits early are more likely to benefit from
prophylactic measures against malarial infection, iron and
folic acid supplementation and that of nutrition and health
education. There is an increased foetal demand for
haematopoietic factors as pregnancy progresses and so
women who will not avail themselves to health services
early enough may suffer the consequences of increased
demand for nutrients. Such women are also more likely to
take advantage of accessing health services to treat any
underlying maternal diseases and untreated anaemia in
early pregnancy that are likely to worsen in the course of
pregnancy.
Limitation of the study: This study was hospital based
and as such may not be truly reflective of the situation in
the district due to selection bias. Pregnant women utilizing
the health institutions are also more likely to be educated,
of higher socioeconomic status than the typical pregnant
woman in the community.
Dietary diversity was assessed based on responses
obtained from participants (e.g. dietary recall) during the
pregnancy and this depended on memory and their ability
to recall accurately. Recall bias could not be ruled out
completely. However, methods used in assessing dietary
diversity are useful for ranking individuals but do not
necessarily permit exact assessments of absolute nutrient
intake.
The study also relied partly on secondary data about
participants recorded by health professionals during the
pregnancy. Therefore any error in measurements,
readings or recordings of these parameters and indices
will reflect in the results. However with the level of
professionalism of health workers in the institutions
involved in the study, this is expected to be minimal. The
cross-sectional study design used to collect data also
makes it difficult to demonstrate cause-and-effect
relationships.
CONCLUSION

753
Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

In the present study, there was statistically significant


association between maternal DDS and anaemia in
pregnancy. The content of ANC, as well as dietary
diversity of women had positive effect on Hb in the third
trimester and so women should be educated on the need
for improved quality diets as well as quality and content
of ANC services in the health facilities.
The study findings suggest the need to strengthen
interventions that focus on improving the consumption of
diversified
foods
particularly
during
pregnancy.
Additionally, anaemia was higher with increased parity
levels and among women who initiated ANC late. This
implies the need to target interventions to these vulnerable
groups of women.
ACKNOWLEDGMENT
The authors wish to express their profound gratitude to all
the study participants. We are also grateful to the
administrators and midwives of Tamale Teaching Hospital,
Tamale West Hospital, Tamale Central Hospital and SDA
Hospital for granting us permission to interview the
pregnant women admitted in their labour wards.
Conflict of Interest: Nil
REFERENCES
1.

Horton R. Maternal and child undernutrition: an


urgent opportunity. Lancet. 2008;371(9608):179.
2. DeMaeyer E, Adiels-Tegman M. The prevalence of
anemia in the world. World Health Stat Q
1985;38:302-16.
3. Omigbodun AO. Recent trends in the management of
anaemia in pregnancy Tropical Journal of Obstetrics
and Gynaecology. 2004;21 (1): 13.
4. Komolafe JO, Kuti O, Oni O, Egbewale BE.
Sociodemographic
characteristics
of
anaemic
gravidae at booking: a preliminary study at Llesha,
Western Nigeria
Nigerian Journal of Medicine.
2005;14 (2): 15154.
5. van den Broek NR, Letsky EA. Etiology of anemia in
pregnancy in south Malawi The American Journal of
Clinical Nutrition. 2000;72 (1): 24756.
6. Adinma JIB, Ikechebelu JI, Onyejimbe UN, Amilo G,
Adinma E. Influence of antenatal care on the
haematocrit Value of pregnant Nigerian Igbo Women
Tropical Journal of Obstetrics and Gynaecology.
2002;19 (2):68-70.
7. Ghana Statistical Service (GSS), Ghana Health
Service (GHS), ICF Macro. Ghana Demographic and
Health Survey (GDHS) 2008. Accra, Ghana: GSS,
GHS, and ICF Macro.;2009;
8. WHO. Worldwide Prevalence of Anemia: WHO Global
Database of Anaemia. Geneva: World Health
Organization;2008.
9. WHO. Physical status: the use and interpretation of
anthropometry. Report of a WHO Expert Committee.
Geneva: World Health Organization;1995.
10. Barker D. The malnourished baby and infant. Brit Med
Bull. 2001;60:69-88.

11. Vyas S, Kumaranayake L. Constructing socioeconomic status indices: how to use principal
components analysis. Health Policy Plan 2006;
21:45968.
12. Filmer D, Pritchett LH. Estimating wealth effects
without expenditure dataor tears: an application to
educational enrollments in states of India.
Demography 2001; 38:115-32.
13. Rutstein SO, Johnson K. DHS Comparative Reports
6: The DHS Wealth Index. Calverton, Maryland,
USA: ORC Macro, MEASURE DHS;2004; 6:4-10.
14. Howe LD, Hargreaves JR, Huttly SRA. Issues in the
construction of wealth indices for the measurement of
socio-economic position in low-income countries.
Emerging Themes in Epidemiology 2008; 5:3
15. Mockenhaupt FP, Rong B, Gunther M, et al. Anaemia
in pregnant Ghanaian women: importance of malaria,
iron
deficiency
and
haemoglobinopathies.
Transactions of the Royal Society of Tropical
Medicine and Hygiene. 2000;94:477-83.
16. McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist
B. Worldwide prevalence of anaemia, WHO vitamin
and mineral nutrition information system, 19932005.
Public Health Nutr 2009;12:444.
17. Ghana Statistical Service (GSS), Ghana Health
Service
(GHS),
ICF
International.
Ghana
Demographic and Health Survey. Accra, Ghana:
GSS, GHS, ICF International.;2015;6: 30-31
18. UNICEF. Multiple Indicator Cluster Survey (MICS)
Accra: UNICEF;2011.
19. Samuel TM, Thomas T, Finkelstein J, et al. Correlates
of anaemia in pregnant urban South Indian women: a
possible role of dietary intake of nutrients that inhibit
iron absorption. Public Health Nutr 2013;16(2):31624.
20. Galloway R, Dusch E, Elder L, et al. Womens
perception of iron deficiency and anaemia prevention
and control in eight developing countries Social
Science and Medicine 2002;55:52944.
21. Clerk CA. Efficacy of sulphadoxine-pyrimethamine
and amodiaquine alone or in combination as
intermittent preventive treatment in pregnancy in the
Kassena-Nankana district of Ghana: a randomized
controlled trial London, University of London; 2007;
PhD Thesis.
22. Kedir H, Berhane Y, Worku A. Khat Chewing and
Restrictive Dietary Behaviors Are Associated with
Anemia among Pregnant Women in High Prevalence
Rural Communities in Eastern Ethiopia. PLoS ONE
2013; 8(11):78601. .
23. Abriha A, Yesuf ME, Wassie MM. Prevalence and
associated factors of anemia among pregnant women
of Mekelle town: a cross sectional study BMC
Research Notes. 2014;7:888.
24. Gebremedhin S, Enquselassie F. Correlates of
anemia among women of reproductive age in
Ethiopia: evidence from Ethiopian DHS. Ethiopian J
Health Dev 2005; 25(1):2230.
25. Baig-Ansari N, Badruddin SH, Karmaliani R, et al.
Anemia prevalence and risk factors in pregnant
women in an urban area of Pakistan. Food Nutr Bull.
2008; 29(2):13239.

754
Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

26. Karaoglu L, Pehlivan E, Egri M, et al. The prevalence


of nutritional anemia in pregnancy in an east
Anatolian Province, Turkey. Health. 2010;10(1):329.
27. Jemal HNH, Urga K. Iron deficiency anemia in
pregnant and lactating mothers in rural Ethiopia. East
Afr Med J 1999; 76:61822.
28. FAO. Guidelines for measuring household and
individual dietary diversity. Rome, Italy: Food and
Agriculture Organization of the United Nations; 2011;
4: 1-31
29. Wen LM, Flood VM, Simpson JM, Rissel C, Baur LA.
Dietary behaviours during pregnancy: findings
from first -time mothers in southwest Sydney,
Australia. Int J Behav Nutr Phys Act 2010;7(13):1
7.
30. Neggers Y, Goldenberg RL. Some thoughts on
body mass index, micronutrient intakes and
pregnancy outcome. J Nutr. 2003;133(2):1737-40.
31. Patil R, Mittal A, Vedapriya D, Khan MI, Raghavia M.
Taboos and misconceptions about food during
pregnancy
among
rural
population
of
Pondicherry. Calicut Med J 2010;8(2):4.
32. Meena G. Associations
Between
Maternal
Nutritional Characteristics and the Anthropometric
Indices of Their Full -term and Pre-term Newborns.
Pak J Nutr 2012;4(11):34349.
33. Clerk CA, Bruce J, Greenwood B, Chandramohan D.
The epidemiology of malaria among pregnant women
attending antenatal clinics in an area with intense and
highly seasonal malaria transmission in northern
Ghana Tropical Medicine and International Health
2009; 14 ( 6): 68895.
34. Adinma JIB, Ikechebelu JI, Onyejimbe UN, Amilo G,
Adinma E. Influence of antenatal care on the
haematocrit Value of pregnant Nigerian Igbo Women.
Tropical Journal of Obstetrics and Gynaecology.
2002;19 (2): 6870.
35. Al-Farsi YM, Brooks DR, Werler MM, Cabral HJ, AlShafei MA, Wallenburg HC. Effect of high parity on
occurrence of anemia in pregnancy: a cohort study.
BMC Pregnancy Childbirth 2011; 11:7.
36. Uche-Nwachi EO, Odekunle A, Jacinto S, et al.
Anaemia in pregnancy: associations with parity,
abortions and child spacing in primary healthcare
clinic attendees in Trinidad and Tobago. Afr Health
Sci 2010; 10(1):66-70.
37. Bukar M, Audu BM, Sadauki HM, Elnafaty AU,
Mairiga AG. Prevalence of iron deficiency and
megaloblastic anaemia at booking in a secondary
Health facilty in North Eastern Nigeria. Nigerian
Journal of Medicine. 2009; 50 (2):3337.

755
Saaka et al.,

Int J Med Res Health Sci. 2015;4(4):749-755

DOI: 10.5958/2319-5886.2015.00147.2
Open Access

Available online at: www.ijmrhs.com


Research article

CLINICAL PATTERN AND EFFECT OF CO-MORBIDITIES IN THE ETIOPATHOGENESIS


OF INCISIONAL HERNIAS
*Murali U, Thakre N D

ARTICLE INFO
Received: 11th May 2015
Revised : 2nd Jun 2015
Accepted: 23rd Jul 2015
1,2

Department of
General Surgery, D Y Patil Medical
College, Mauritius
Authors

details:

author: Murali U
Department of General Surgery, D Y
Patil Medical College, Mauritius
Corresponding

Email: srimuralihospital2012@gmail.com

Incisional
hernia,
Complications, Co-morbidity, Obesity.
Keywords:

ABSTRACT
Background: Incisional hernia is a common iatrogenic complication of
abdominal surgery and is a cause of unwanted morbidity. The study was
reported for the first time from Republic of Mauritius. Aims & Objectives: The
objective of the study was to analyze the clinical pattern and effect of comorbidities on the clinical course of incisional hernias and repair. Methods: The
study is a cross sectional study conducted at a tertiary care hospital for over 22
months. 38 patients with incisional hernia were studied with special emphasis
laid on the predisposing factors and co-morbidities at the time of hernia repair.
Results: In this study the incidence of incisional hernia was prevalent in females
and occurrence was 3 times more than males. All hernias in females were the
result of a gynaecological operation. 68% (26 out of 38 patients studied) of
hernias were reported within 2 years of gynaecological operation. Majority of
patients presented with swelling and pain related to scar. Twenty two out of
thirty eight were operated and hernia repaired. Obesity was found to be the
most important factor when the effects of co-morbidities were studied. Fifteen
out of thirty eight (39.47%) patients came under the category of morbidly obese.
Conclusion: In patients with recurrent hernia control of obesity and other comorbidities before the attempt to repair hernia can be decisive.

INTRODUCTION
Incisional hernia is a problem of magnitude. It is also a
socioeconomic problem. For the individual patient
incisional hernia is an unexpected and hindering
complication, which can influence daily life in such a
manner that he or she could be consider disabled.
Repeated admissions and operations have a major impact
on the patient. When subsequent hernia repair does not
solve the problem, but results in recurrence or
complications, a patients quality of life may be seriously
affected.
Incisional hernia occurs in about 2-19% of patients after
[1, 2, 3, 4]
various incisions
. When the scar has a defect, the
abdominal contents may start protruding through it, due to
intra-abdominal pressure. Certain conditions like chronic
cough, chronic constipation, urinary obstruction, obesity,
pulmonary disease, repeated pregnancies and postoperative abdominal distension may further increase the
pressure unwantedly and increase the chance of incisional
[5, 6]
hernia
. Wound infection is probably an important risk
[7]
factor for the development of incisional hernia
and
[8, 1, 2]
wound dehiscence
. In spite of all precautions during
surgery and meticulous repairs to cure them, a number of
cases of incisional hernias are being reported with failures
of repairs leading to Recurrent incisional hernia.
Therefore, prevention of incisional hernia is warranted.
Our aim was to study the aetiopathogenesis and effects of
co-morbidities on the clinical course of incisional hernias
and repair.
MATERIALS & METHODS
Study design: It was a cross sectional, Descriptive study

Locus of study: The study carried out in patients of


Jawaharlal Nehru Hospital (JNH), Rose Belle, Mauritius
between December 2010 to September 2012.
Sample size: A total number of 38 cases were studied.
Inclusion criteria: All patients of both genders aged
above 25 years with incisional hernia who came to JNH
were included in this study.
Exclusion criteria: Patients with recurrent inguinal hernia
were excluded as they were categorized as primarily
hernias of different aetiopathology.
Ethics: The protocol and proforma for collection of data as
well for the study was approved by the ethical committee.
Methodology:
Detailed history pertaining to the surgery which later on
led to the incisional hernia was recorded; more stress was
laid on the predisposing factors and co-morbidities at the
time of operation. Thorough work up of all patients
included a complete physical examination, weight in
kilograms, height in meters, size of defect and
investigations like haemogram, X-ray chest, ECG, renal
profile and echocardiography.
Patients were evaluated for co-morbidities like asthma,
chronic obstructive pulmonary diseases (COPD), diabetes
mellitus (DM), morbid obesity, hypertension (HTN) and
malignancies at the time of first operation. Body mass
index (BMI) at the time of previous operation which led to
incisional hernia was also recorded.
Out of 38 patients in this study 22 patients were operated
and hernia repaired. These patients were studied for their
postoperative recovery and complications. Special
emphasis was laid on the date of the operation which led
to hernia formation and the actual date when the patient
detected hernia. These dates gave information about the

756
Murali et al.,

Int J Med Res Health Sci. 2015;4(4):756-759

exact time period between surgery and the hernia. In most


of the cases the information related to the type of previous
surgery and methods of closure adopted were also traced
from their earlier records.
Statistical analysis: Data was analyzed using descriptive
statistical principles (like mean, proportions and
percentages) with SPSS 19 Package analyzed and
different findings were compared with the available
literature and discussed.
RESULTS

for the hernia were infra umbilical midline (16) and supra
umbilical midline (13) (Table 1).
Lower segment caesarean section (LSCS) was the
commonest operation responsible for the incisional hernia
in 18 cases of this study followed by emergency
laparotomy (Table 1). The dimension of the defect was
studied in only 30 patients. The commonest defect size
was 12 sq. cm. observed in 7 followed by 8 sq.cm in 6 out
of 30 patients studied (Table 1). The time period
between the appearance of hernia and the operation
responsible for it showed that 26 out of 38 patients
reported about their hernia within 2 years of operation
(68.42%) (Table 2).
Morbid obesity was the commonest co-morbidity amongst
the patients (15) studied followed by hypertension in 14
patients (Table 3). Out of the 38 patients studied, 28
(73.68%) patients were obese (BMI over 25 kg/m2). Out of
these 28 patients, 15 came under the category of morbidly
obese with 3 in class III (BMI over 40 kg/m2), 4 in class II
(BMI over 35 kg/m2) and 8 in class I (BMI over 30 kg/m2).
Out of 38 patients, 22 were operated and repair of hernia
carried out. There was no recurrence or complications
observed in our study. There was no mortality.

Out of 38 patients in the study, 29 patients were female


while 9 were male. The age group of the patients varied
from 29 to 82 years. Incidence was highest in the age
group ranging from 50 to 70 years. Regarding the
occupation of patients, out of 29 females majority of them
(22) were house-wives.
Most of the patients (15) presented with swelling, followed
by pain and swelling in about 11 of them, pain alone in 9
cases and rest (3) with associated symptoms of
constipation. Only two out of 38 came with features
suggestive of intestinal obstruction. Incisional hernia was
more common after midline incision (76.31%). Out of the
38 patients studied the commonest incisions responsible,
Table 1: Operations and Incisions causing hernia with Defect sizes
Operation
No. of cases Incision
No. of cases Defect size No. of cases
LSCS
18
McBurney
2
2 sq.cm
3
Cholecystectomy
3
Kochers
2
2.25sq.cm
1
Hysterectomy
2
Infra umbilical transverse
2
4 sq.cm
4
Appendicectomy
2
Infra umbilical midline
16
6 sq.cm
5
Expl. Laparotomy
7
Supra umbilical midline
13
8 sq.cm
6
Laparotomy
1
Supra umbilical transverse
1
12 sq.cm
7
Umbilical hernia
4
Lumbar
1
15 sq.cm
2
Nephrolithotomy
1
Para median
1
24 sq.cm
2
[9]
Table 2: Onset of hernia
years. Ellis et al in their study observed a mean age of
49.4 years. The youngest patient in our study was 29
Time interval
Number of cases
years and the oldest was 82 years. The sex ratio of
0 to 6 months
9
incisional hernia among the cases studied was 1:3 (M: F),
6 months to 1 year
8
showing a female preponderance. This can be attributed
1 year to 2 year
9
to the laxity of abdominal muscles due to multiple
2 year to 3 year
1
pregnancies and an increased incidence of obesity in
3 year to 4 year
3
females. Most of the women were housewives which show
4 year to 5 year
3
that incisional hernias were more common in women.
5 years onwards
5
Thirty nine percent (39.4%) of patients presented with
Table 3: Types of Co-morbidities
abdominal swelling without any complaint of pain or
Co-morbidities
Number of Percentage
discomfort due to hernia. Two patients (5.26%) presented
cases
with complication, i.e. one with acute intestinal obstruction
Diabetes mellitus
7
18.42
which needed an exploratory laparotomy with resection
Hypertension
14
36.84
and anastomosis of small bowel for gangrene and repair
Morbid obesity
15
39.47
of hernia. The other was a sub-acute case of intestinal
Ischaemic heart disease
4
10.52
obstruction, treated conservatively and hernia repair done
[4]
Hyperthyroidism
1
2.63
later on. This can be compared with Mudge and Hughes
Bronchial asthma
4
10.52
series (14%).
Neurological disorder
2
5.36
In our study 42.1% of incisional hernia occurred in midline
Malignant disease
1
2.63
infra umbilical incisions. This may be because of following
features:
DISCUSSION
1. Intra-abdominal hydrostatic pressure is higher in
lower abdomen compared to upper abdomen, in erect
38 cases of incisional hernia admitted in JNH, Rose Belle,
position i.e. 20cm of water and 8cm of water
Mauritius for treatment were included in this study
respectively.
between December 2010 to September 2012. The mean
2. Absence of posterior rectus sheath below the arcuate
age of patients of incisional hernia in our study was 56.02
line.

757

Murali et al.,

Int J Med Res Health Sci. 2015;4(4):756-759

Midline infra umbilical incisions were used mainly in


females for LSCS and abdominal hysterectomy, which
have poor abdominal wall musculature. This can be
[10]
comparable with that of Goel and Dubey
studies
(44.6%).
Fifty two percent of cases (52%) occurred following
gynaecological procedures (abdominal hysterectomy and
[11]
LSCS). Suhas and Rigved
in their studies noted 68%
[10]
incidence and other studies
noted 28.76% incidence
following gynaecological procedures. Higher incidence in
[11]
our study similar to studies
may be because most of
these procedures were done through lower midline
incisions.
In our study 23.68% of patients developed incisional
hernia within 6 months of previous surgery. These early
hernias can be attributed to a possibly faulty technique of
repair. 21.05% of patients developed within 6-12 months.
23.68% of patients developed within 12-24 months.
31.57% of patients developed incisional hernia after 2
years of the previous surgery. All the hernias which were
reported by patients within 2 years come under the
category of early incisional hernia, the defect must have
started at the initial phase of healing but was detected little
later. Most studies showed incidence within a year of
[9]
follow-up of patients except for studies of Ellis et al
which showed an incidence of 5.8% for a follow-up period
of 2.5 5.5 years in 363 patients, similar to present study.
Considering the dimension of defect in 30 patients, 23.3%
of patients were found to have hernia defect of up to 12
sq. cm. While most others showed a defect size of 2sq.cm
[1]
to 8 sq. cm. Previous studies show that the size of the
fascial defect should dictate the selection of the most
appropriate method of hernia repair.
One patient with diabetes mellitus developed an
intractable infection which needed removal of the mesh. It
is one of the most dreaded complications, as it adds to the
morbidity and leads to recurrent hernia invariably. 11
patients (28.9%) in this study had history of multiple
[12]
attempts of repair. This can be compared with Ellis et al
series (25%). Co-morbidities which were encountered in
the patients were namely obesity (15) , hypertension (14),
diabetes mellitus (7), ischaemic heart disease , bronchial
asthma (4 each) and neurological disorder (2). One of the
patients had hyperthyroidism and one patient had colonic
malignancy. Out of all above conditions, morbid obesity
(39.47%) was the commonest co-morbidity in the patients
studied. This can be compared to the results reported by
[13]
Nikhil et al (40%) .
In our study Body mass index (BMI) of more than 30 was
considered as morbid obesity. 15 out of 38 patients were
morbidly obese with BMI of more than 30. In this study 11
patients with recurrent incisional hernia formed a major
group. Out of these 11 patients 6 (54%) were morbidly
obese with BMI of more than 40 (Morbid obesity class III).
Hernia repair was carried out in 22 cases. The types of
repair done were polypropylene mesh repair in 12 patients
and anatomical repair in 10 patients. Non-absorbable
suture material was used to close the fascial layer. In our
study no complications or recurrences were observed.
[14]
This can be compared to Usher
who reported zero
percent recurrence in 48 patients who were treated by
polypropylene mesh repair. Certain studies show

recurrence rates up to 43% after anatomical suture repair


[15]
and 24% after mesh repair
. Thus the recurrence rate
varies in different studies but all studies favor mesh repair
to decrease the rate of recurrence. The merit of our study
was that there was no mortality.
CONCLUSION
Thirty eight cases of Incisional hernias were studied with
respect to its clinical pattern aspects, effects of its comorbidities and efficacy of its repair. The following
conclusions were drawn: Obesity with deposition of fat in
the lower abdomen is an important factor in causation of
recurrent hernia. Operation for an incisional hernia should
be undertaken after reduction of body weight. The use of
midline incision should be restricted, to operations in
which unlimited access to abdominal cavity is necessarily
required. Non absorbable suture material should be used
for repair of facial layer. All co-morbidities should be
corrected before a planned operation.
ACKNOWLEDGEMENTS
We wish to express our thanks to Dr.R.K.Sharma, Dean,
Padmashree Dr. D. Y. Patil Medical College, Mauritius for
his support and encouragement. We are thankful to our
earlier HOD, Dr. Sanjay. M. Date for his contribution to
research article. We also thank Dr.S. L. Bodhankar for his
assistance in the preparation of manuscript.
Conflict of Interest: Nil
REFERENCES
1.
2.
3.

4.

5.

6.

7.

8.

9.

Santora TA, Roslyn JJ. Incisional hernia.Surgclin


north am 1993; 73(3): 557-70.
Eisner L, Harder F. Incisional hernia. Chirurg 1997;
68(4): 304-9.
Hodgson NC, Malthaner R A, Ostbye T. The search
for an ideal method of abdominal fascial closure: a
meta-analysis. Ann Surg 2000; 231(3): 436-42.
Mudge M, Hughes L E. Incisional hernia: a 10 year
prospective study of incidence and attitudes. Br J
Surg 1985; 72(1): 70-1.
Bucknall TE, Cox PJ, Ellis H. Burst abdomen and
incisional hernia: a prospective study of 1129 major
laparotomies. Br Med J (Clin Res Ed) 1982;
284(6320): 931-3.
Regnard JF, Hay JM, Rea S, et al. Ventral incisional
hernias: incidence, data of recurrence, localization
and risk factors. Ital J SurgSci 1988; 18(3): 259-65.
J.W.A.Burger. M.vantRiet, J. Jeekel . Abdominal
incisions:
Techniques
and
Postoperative
complications. Scandinavian journal of surgery,
December 2002; 91(4): 315-21.
Israelsson LA, Jonsson T. Incisional hernia after
midline laparotomy: a prospective study. Eur J Surg
1996: 162(2): 125-9.
Ellis H, Gajaraj H, George CD. Incisional hernias
when do they occur? Br J Surg 1983; 70(5): 290-91.

758
Murali et al.,

Int J Med Res Health Sci. 2015;4(4):756-759

10. Goel TC, Dubey PC. Abdominal incisional hernia


Anatomical technique of repair. India journal of
surgery 1981, 43: 324-27.
11. Suhas K, Rigved N. Incisional Hernia A Prospective
study of 50 cases for 1 year. Indian journal of Applied
Research 2014, 4 (5): 403-407.
12. Ellis H, Heddle R. Does the peritoneum need to be
closed at laparotomy? Br J Surg. 1977, 64(10): 733
736.
13. Nikhil N.B.A, Alok M, Robinson S.S. Incisional hernia
repair A clinical study of 30 patients. Int J Cur Res
Rev, 2013, 5(15): 35-41.
14. Usher FC, Ochsner J, Tuttle LL., Jr. Use of marlex
mesh in the repair of incisional hernias. Am Surg.
1958, 24(12): 969974.
15. Luijendijk R W, Hop WC, van den Tol MP, et al. A
comparison of suture repair with mesh repair for
incisional hernia. N Engl J Med 2000; 343(6): 392-8.

759
Murali et al.,

Int J Med Res Health Sci. 2015;4(4):756-759

DOI:10.5958/2319-5886.2015.00148.4

Available online at: www.ijmrhs.com

Research article

Open Access

IODINE STATUS OF FEMALE STUDENTS IN UNIVERSITY OF MAIDUGURI


BORNO STATE
1

*AH Musa , DS Mshelia , RM Gali , SK Adamu , A Ahmed

ARTICLE INFO

ABSTRACT

th

Received: 11 May 2015


th
Revised: 15 July 2015
th
Accepted: 9 Sep 2015
1

Authors details:
Department
Medical Laboratory Science, College
Medical
Sciences,
University
Maiduguri, Nigeria
2
Chemical
Pathology,
College
Medical Sciences, University of
Maiduguri, Nigeria

of
of
of
of

Corresponding author: AH Musa


1
Department of Medical Laboratory
Science, College of Medical Sciences,
University of Maiduguri, Nigeria
Email: alharu2u@yahoo.com
Keywords: Urinary iodine, Females

Background: Urinary iodine concentration is a sensitive marker of current


iodine intake and can reflect recent changes in iodine status. Although an
individual urinary iodine concentration varies daily, or even within the same
day, however, these variations tend to even out within populations and
provide a useful measure of the iodine status of populations. Objective: This
study intends to estimate the urinary iodine status of female students in this
environment as a pilot study. Methods: This study investigated the random
urinary iodine concentration of 158 female students in University of Maiduguri
between the ages of 20-41 years. The random urinary iodine concentration
was estimated using the Sandell-Kolthoff method. Results: The median
urinary concentration of this study is 95g/L and the Mean
Urinary Iodine Concentration of 101.42g/L 29.01 also the mean age of the
female students was 210.06. Following the WHO/UNICEF/ICCIDD
recommendations, this study revealed that 4.43% (7) had moderate iodine
deficiency, 46.84% (74) had mild iodine deficiency, and 48.73% (77) was in
iodine sufficient group. Conclusion: This study showed a median Urinary
Iodine Concentration that is mildly deficient, hence the need for more
awareness on the importance of consumption of iodine in this environment.
This is a pilot study, more research is necessary to establish the iodine status
of this environment.

INTRODUCTION
Iodine is an essential nutrient needed by the body in small
quantity but necessary for normal growth, development
[1-3]
and metabolism throughout a persons lifetime
. Iodine
is necessary for thyroid hormone synthesis. Thyroid
hormone influences general body metabolism, therefore,
iodine deficiency poses a threat throughout the lifecycle of
[4].
humans
Severe and mild iodine deficiency causes
harmful effects on brain and nervous system
dsevelopment in children and decrease ability to work and
[5,6]
think clearly in adults
. Iodine deficiency has been
associated with mental impairment, goiter, and some
complications in pregnancy, including stillbirth and
congenital anomalies. Inadequate iodine intake during
[4]
pregnancy may lead to irreversible fetal brain damage .
The recommended intake of iodide for adults is a
minuscule amount. Consuming seafood, vegetables
grown in iodine- rich soil and iodized salt easily meet the
[1,2, 6]
bodys need for iodine
. Urinary iodine (U.I) analysis
is the most common method for assessing population
wide iodine sufficiency and deficiency, because more than
90% of dietary iodine is excreted in the urine with normal
[7, 8]
renal function
. There is scarcity of information on
iodine status in this environment, since the Federal
Government campaign on iodized salt some years ago
hence the need for this pilot study.

Aim of the study: To determine the iodine status of nonpregnant females in the reproductive age group in this
environment.
MATERIALS AND METHOD
Study design: This study is a prospective case study.
Ethical approval: Ethical clearance was obtained from
the University of Maiduguri Ethical Committee. Personal
consent of the students were sought after explaining the
purpose of the research.
Sample size: The study Subjects comprised of 158
apparently healthy female students of University of
Maiduguri Borno State, Nigeria.
Inclusion criteria: Their ages ranged between 20-41
years and been resident in Maiduguri for at least seven
years. These groups of female students are in their
reproductive age and their iodine status may be of public
interest for better management. Female volunteers were
recruited within six (6) months.
Exclusion criteria: Those diagnosed with thyroid
disorders, obvious goiter, on medication with iodine
contain reasonable to influence patient iodine, on
antithyroid medications or on hormonal replacement
therapy, Females not in the reproductive age group,
Pregnant or breast feeding mothers
Methodology:

760
Musa et al.,

Int J Med Res Health Sci. 2015;4(4):760-762

Ten (10ml) of random urine sample was collected into


clean and sterile universal bottle from all the students who
were selected for the study. Their anthropometric
measurements were taken using standard methods such
as Digital scale (weight) and Height Ruler taped to the
wall (Height). Since the samples were not analyzed
0
immediately, it was stored frozen at -20 C until ready for
analysis.
Estimation of urine iodine levels: The standard method
of Sandell-Kolthoff reaction (the ammonium persulphate
[9]
technique), as described by Dunn et al
was used for
estimating the level of iodine in the urine. Urine is
digested with ammonium persulphate. Iodine present in
the urine acts like a catalyst in the reduction of ceric
ammonium sulphate (yellow) to cerous ammonium
sulphate (colourless). The degree of disappearance of the
yellow colour is a measure of iodine content in the urine.
The data obtained was analyzed using statistical package
for social science (SPSS) version 20.0 for descriptive
statistics and students t-test at the confidence interval of
95% and P<0.05.
RESULTS
This study investigated the random urinary iodine
concentration in female students of reproductive age in
the University of Maiduguri with the mean age of 210.06.
Table 1 shows the measured parameters in the study
population;
age,
Weight,57.5310.29Kg,
2
Height,1.620.006M , Mean Urinary Iodine 101.4229.01
g/L, a Median Urinary Iodine (MUI) of 95g/L and the
2
BMI, 21.93.74Kg/M . Table 2 shows the classification of
iodine nutrition of the studied population based on the
Epidemiological
Criteria for Assessing Iodine Nutrition using joint criteria
[10].
of WHO, UNICEF and ICCIDD
It shows no severe
Iodine Deficiency and no excess Iodine but 4.43% (7) had
moderate Iodine deficiency, 46.84% (74) had mild iodine
deficiency and 48.73% (77) are Iodine Sufficient.
Table 1: Measured parameters in the study population
PARAMETERS
MEAN SD
MEDIAN
Age (yrs)
21.10.06
23.0
Weight (kg)
57.5310.29
55.70
Height (m)
1.620.06
1.62
UI (g/l)
101.4229.01
*95
2
BMI (kg/m )
21.93.74
20.9
KEY: BMI= Body Mass Index, SD= Standard Deviation,
UI=Urinary Iodine, *Median Urinary Iodine
Table 2: Percentage distribution of Iodine Nutrition of
the Studied Population based on the Epidemiological
[10]
Criteria for Assessing Iodine Nutrition
Range (g/L)
% Distribution
Severe (<20)
Moderate (20-49)

0(0)
4.43(7)

Mild (50-99)

46.84(74)

Sufficient (100-199)

48.73(77)

Excess (>300)

0(0)

DISCUSSION
The potential impact of iodine deficiency on the
intellectual development of large segments of the
populations in underdeveloped countries is of particular
concern, especially when all of the adverse effects of
iodine deficiency can be prevented by long-term,
[10],[11]
sustainable iodine prophylaxis
. Universal salt
iodization has been extremely effective at reducing the
burden of iodine deficiency and represents a major global
public health success. Iodine deficiency can be prevented
by iodization of table salt with one part of sodium iodide to
[12]
every 100,000 parts of sodium chloride
. Urinary iodine
excretion has been reported as a good marker of th e
dietary intake of iodine, and used as an index for
evaluating the degree of iodine deficiency, correction and
[10],[11],[15]
toxicity
. Many countries including Nigeria have
adopted massive salt iodization as a means of correcting
iodine deficiency disorders (IDD) in countries where they
[13]
were prevalent
. The World Health Organization gave
an epidemiologic criteria for assessing iodine nutrition
based on median urinary iodine concentrations in different
target groups i.e. school-age children (6 years or older)
with Median urinary iodine (g/l) < 20 indicates insufficient
iodine intake (severe iodine deficiency), 20-49 indicates
insufficient iodine intake (moderate iodine deficiency), 5099 indicates insufficient iodine (mild iodine deficiency),
100-199 indicates adequate iodine intake (adequate
iodine nutrition) and 200-299 indicates above
requirements iodine intake that may pose a slight risk of
more than adequate iodine intake in these populations.
Median urinary iodine (g/l) 300 indicates excessive
iodine intake with risk of adverse health consequences
(iodine-induced) of hyperthyroidism, autoimmune thyroid
[4]
disease etc .The consequence of excess iodine is JobBasdow or even
hypothyroidism and may lead to
malignant changes particularly the follicular type of thyroid
carcinoma From this study, the median urinary iodine
excretion in the population studied was 95.0g/l (table1),
which is below the recommended value of (100-199 g/l)
by WHO. The results from this study indicate that none of
the students had severe iodine deficiency. However, that
there were still moderate (4.4%) and high percentage
(46.84%) of mild iodine deficiency suggests insufficient of
iodine intake in our study population (table 2), which is of
great public health concern. This finding is consistent with
[14]
the findings of Mu et al , who reported mild to moderate
iodine deficiency across the populations including school
children. This study shows higher percentage of mild
deficiency compared to the findings of Onyeaghala et al
[15]
[16]
and Cosmos et al
. Iodized salt is widely available
commercially in this environment but the percentage in
the salt need to be evaluated in further study. It is likely
that household salt may not contain the recommended
level of iodine. Our study showed none of the student had
excess urinary iodine (table 2). This finding contradicts
[17]
the report of Delange et al , who reported high
concentrations of urinary iodine in some African countries
few years after the introduction of massive iodization

761
Musa et al.,

Int J Med Res Health Sci. 2015;4(4):760-762

programme. Our study revealed that 77 (48.73%) have


sufficient iodine intake among the population studied
which is less than 50% of the study population, hence the
need to encourage and sensitize the public in this
environment about the importance of iodized salt.
[18]
Bellamy
reported that the success of the drive for
universal iodization of salt shows that the diets of children,
women and families worldwide can be changed in small
but very beneficial ways in just a
few years because of concerted global, national and local
action.

6.

CONCLUSION

9.

Study population are of reproductive age, hence any


preventive measure taken will go a long way to forestall
the effects of iodine deficiency disorders such as neonatal
hypothyroidism and mental retardation on the generations
yet unborn. In addition, more awareness campaign on
iodine deficiency disorders and the role of iodized salt
intake is necessary. Large community screening of
urinary iodine is not expensive and can be used to
establish the status of iodine consumption in this
environment.
ACKNOWLEDGEMENT
I wish to appreciate all the female students of the
University of Maiduguri that voluntarily avail them self for
the success of this research and Chemical Pathology
Department University of Maiduguri Teaching Hospital
Borno State Nigeria for allowing us used their Laboratory.

7.

8.

10.

11.

12.

13.

14.

15.
Conflict of Interest: Nil
REFERENCES
1.

2.

3.

4.

5.

Whitney, E.N. and Rolfes, S.R. Understanding


th
nutrition (6 ed.). Minneapolis: West publishing
company. 1998; 293-32
Author names, National Health and Medical
Research Council and New Zealand Ministry of
Health. Nutrient Reference Values for Australia and
New Zealand including Recommended Dietary
Intakes. Commonwealth of Australia. 2006; Available
online at http:// www. nhmrc. gov.au.
Centers for Disease Control and Prevention.
Ensuring
the
Quality
of
Urinary
Iodine
th
Procedures.2012. Retrieved on 20 April, 2014 from
http://www.cdc.gov
World
Health
Organization.
Urinary
iodine
concentration for determining iodine status deficiency
in populations. Vitamin and Mineral Nutrition
th
Information System. Geneva: 2013; Retrieved on 20
April,
2014
from
http://
www.
who.int/nutrition/ vmnis/ indicators/ urinary iodine
Berdenier, C.D. Advanced nutrition micronutrients.
Florida: CRC press.2000.

16.

17.

18.

National Institutes of Health office of dietary


th
supplements. Iodine Quickfacts.2011; Retrieved 20
April, 2014 from http://ods.od.nih.gov.
Amir A. M., Kathleen L. Caldwell. The U.S. CDCs
Ensuring the Quality of Urinary Iodine Procedures
(EQUIP) Program is 10years old.2011; Retrieved on
th
20 April, 2014 from http://www.cdc.gov
Augustine, A.O., Anetor, J.I., Nurudeen, A., and
Oyewole,O.E. Assessment of urinary iodine status of
primary school children in Saki, in south western
Nigeria. Bulletin of Environment, Pharmacology and
Life Sciences.2012; 1(5), 5-9.
Dunn JT, Semigran MJ, Delange F. Methods for
measuring Iodine in urine. ICCIDD,UNICEF, WHO.
The Netherlands, ICCIDD, 1993. 73-75.
WHO, UNICEF, ICCIDD. Assessment of the Iodine
Deficiency Disorders and monitoring their elimination.
Geneva: World Health Organization; 2001. WHO
Document WHO/NHD/01.1.
World Health Organization. Assessment of iodine
deficiency disorders and monitoring their elimination.
nd
A guide for programme managers.2001; 2 ed.1-124
Sembulingam, K., Sembulingam, P. Essentials of
th
medical physiology (5 ed.). India: Jaypee Brothers
Medical Publishers (P) ltd.2010.358-68
Daniel N.Lantum. Did universal salt iodization help
reduce the infant mortality rate in Nigeria? IDD
Newsletter, May 2009; (32), 24-26.
Mu Li, Gary Ma, Karmala Guttikonda , Steven C
Boyages ,Creswell J Eastman. Re-emergence of
iodine deficiency in Australia. Asia Pacific J. Clin.
Nutr.,2001; 10(3): 200-03.
Onyeaghala, AA, Anetor, JI, Nurudeen, A Oyewole
OE. High urinary iodine content (UIC) among primary
school children in Nigeria, a public health concern. J
of Toxicology and Environmental Health Science;
2010; 2(7), 93-96.
Ujowundu CO, Ukoha AI, Agha CN, Nwachukwu N,
Igwe, KO. Assessment of current iodine status of
pregnant women in a suburban areav of Imo State
Nigeria twelve years after universal salt iodization.
African journal of Biochemistry Research;2010; 4(1)
6-12
Delange F, de Benoist B, Alnwick D. Risks of iodineinduced hyperthyroidism after correction of iodine
deficiency by iodized salt. Thyroid Jun 1999; 9(6):
545-56.
Bellanmy, C. Micronutrient-iodine iron and vitamin A.
UNICEF.2008; Retrieved April 2014 from unicef.
Org/nutrition/index iodine. UNICEF/HQ98-0992

762
Musa et al.,

Int J Med Res Health Sci. 2015;4(4):760-762

DOI:10.5958/2319-5886.2015.00149.6
Open Access

Available online at: www.ijmrhs.com


Research article

ASSESSMENT OF INFANT AND YOUNG CHILD FEEDING PRACTICES AMONG


UNDER-3 YEARS CHILDREN IN URBAN SLUMS OF HUBBALLI CITY
1

Anjana P , Dattatreya D Bant

ABSTRACT

ARTICLE INFO
th

Received: 28 May 2015


th
Revised: 20 Jul 2015
th
Accepted: 29 Jul 2015
1

Postgraduate
Student, Department of Community
Medicine, Karnataka Institute of
Medical
Sciences,
Hubballi,
Karnataka
2
Professor
of
Department
of
Community Medicine & Director of
Karnataka Institute of Medical
Sciences, Hubballi, Karnataka
Authors

details:

Corresponding author: Anjana P

Postgraduate Student, Department


of Community Medicine, Karnataka
Institute of Medical Sciences,
Hubballi, Karnataka
Email: anjanagraju@gmail.com
Keywords: Exclusive breastfeeding,

Underweight, Urban slum, Dietary


diversity, Meal frequency

Background: Malnutrition is a serious public health problem affecting the


growth and development of children which have detrimental effect in later
adolescent and adult life. Although Malnutrition is multifaceted problem,
Infant and young child feeding practices by mothers is crucial for optimum
growth and development of the children Objectives: 1) To Assess the
Infant and Young child feeding practices followed by the Mothers. 2) To
study the influence of feeding practices on weight of Under 3 years
children. Methodology: Cross-sectional study conducted in an urban
slum of Hubli. 110 mother-child pairs recruited , where the child was
between 7 months to 3 years of age. Employed a pre-structured
questionnaire as tool and Childs Anthropometry done. Data presented as
percentages and proportions. Chi square test is applied to test association
between Feeding practices and underweight, P value less than 0.05
considered as significant. Results: 22.7 % mothers had Breast fed within
recommended time following delivery, prelacteal feeding practices
observed in 47.3 % and 37.3% followed Exclusively Breast Feeding.
However Timely Initiation of complementary foods was seen only in
34.5%. Breast feeding continued in 47.3 % beyond 6 months. 53.6 % &
86.4% didnt satisfy the Minimum meal frequency and dietary diversity
respectively. 50.9% of children were Normal, 49.09% were Underweight.
Conclusions: Nearly 50% of the children under this study were
underweight. Mothers who had not Exclusively Breast fed for 6 months,
not continued Breast feeding beyond 6 months and inadequate meal
frequency of the child were significantly associated with underweight of
the children.

INTRODUCTION
The nutritional status of children in the community is
alarming. Prevalence of stunting and wasting in children
aged less than 3 years is 44.9 % and 22.9 % respectively
[1]
. Nutritional status of children is an indicator of
nutritional profile of the entire community. Studies
conducted worldwide show that 150 million (26.6%) are
underweight, while 182 million (32.5%) are stunted all
over the world. More than half of the worlds
[2]
undernourished people live in India . Adequate Nutrition
is critical to child and its development .The period from
birth to two years of age is particularly important because
of the rapid growth and brain development that occurs
during this time. This period is often marked by growth
faltering, micronutrient deficiencies, and common
childhood illnesses such as diarrhoea, as transition of
diet of children from exclusive breastfeeding to solid
[3]
foods in addition to breast milk .The urban population is
rapidly expanding because of large scale migration to
cities for a possible better life. As a result, urban poverty
and hunger are increasing in many developing countries.
It is projected that more than half of the Indian population
will live in urban areas by 2020 and nearly one third of
this urban population will be of slum dwellers. The
ongoing process of rapid urbanization has deleterious

repercussions on health and nutrition especially for


[4]
children . Infant and young child feeding practices are
an important determinant of nutritional status. Infant and
young child feeding practices is a set of well known and
common recommendations for appropriate feeding of
[5]
newborn and children less than 2 years of age .
As a global health policy for both developing and
developed countries, WHO recommends exclusive
breastfeeding for six months, followed by a combination
of continued breastfeeding and safe, appropriate and
[6]
adequate feeding with other foods . Adequate nutrition
during infancy and early childhood is critical to the
[7]
development of childrens full human potential
According to the NFHS 3 report of Karnataka, 33% of the
[8]
under three children are underweight . Malnutrition is a
threat to the Childs survival and development as well as
social, economic development of family state and Nation
at large. Although malnutrition is a multifaceted problem,
Infant and Child feeding Practices hold a crucial place in
the childs growth and development. The World Health
Organization and UNICEF have developed the Global
Strategy for Infant and Young Child Feeding which
recognizes appropriate infant feeding practices to be
crucial for improving nutrition status and decreasing

763
Anjana et al.,

Int J Med Res Health Sci. 2015;4(4):763-767

infant morbidity and mortality in all countries. The diets


and nutritional status of Urban Slum children in India is
far from satisfactory, being worse among all urban groups
[4]
and is even poorer than rural average .Therefore this
study was undertaken to assess IYCF Practices followed
by mothers and its influence on the weight of the children
in Urban slums of Hubli with the objectives of Assessing
the Infant and Young child feeding practices followed by
the Mothers and influence of feeding practices on weight
of Under 3 years children.

e)

Age appropriate complementary feeding for children


6-23 months, while continuing breastfeeding.
Children should receive foods from 4 or More food
groups.
Grams, roots and tubers, legumes and nuts, Dairy
products, Flesh foods ( Meat, Fish, Poultry), Eggs,
Vit A rich fruits and vegetables, Other fruits and
vegetables and fed for minimum number of times ( 2
times for Breast fed Infants 6-8 months,3 times for
breast fed children 9-23 months,4 times for non
breast fed children 6-23 months.
[5]
Active Feeding for children during and after illness

MATERIALS AND METHODOLOGY

f)

Study design: It was a Cross-sectional community


based study.
Place of research: Study was conducted in an Urban
Field Practice Area of Department of Community
Medicine KIMS Hubballi which is an urban slum.
Ethical approval: Clearance obtained for the study from
Instituitional Ethics committee KIMS Hubballi. An
Informed consent was taken from mothers who were
willing to participate in this study.
Study period: Conducted between August to September
2014.
Inclusion criteria: Children between the age group of 7
months to 3 years with their mothers residing in Urban
Slum of Old Hubballi were selected.
Exclusion criteria: The children with congenital
anomalies or metabolic diseases affecting growth were
excluded and those mothers of children who did not
consent to participate in the study and who were not
available for interviewing after attempting twice to meet
them were not included in the study.
Sample size: Considering the Prevalence of Under 3
children in Karnataka as 33 % according to NFHS 3, and
taking 9% as margin of error at 95% confidence interval,
the sample size calculated by using the formula n= 4pq /
2
l ,works out to be 109.18 approximated to 110. Out of 4
wards coming under Urban Health Training Center, ward
No 42 was randomly selected. The total population of
children between 6 months to 3 years residing in this
area covered by 3 Anganwadis of Ward no.42 is 239. 34,
41, 35 children were proportionately selected from each
Anganwadi list and mother and child visited at their
homes.
Methodology
A Pre structured questionnaire was used to interview the
mothers regarding the socio-demographic and Child
feeding practices.
IYCF include following optimal IYCF Practices,
a) Early Initiation of Breast feeding , immediately after
birth, preferably within one hour.
b) Exclusive Breast Feeding for first 6 months of life
i.e., 180 days ( no other foods or fluids ,not even
water ,but allows infant to receive ORS, drops,
syrups of vitamins, minerals and medicines when
required.
c) Timely Introduction of complementary foods (Solid,
Semisolid or soft foods) after the age of Six months
i.e., 180 days.
d) Continued Breastfeeding for 2 years or beyond

The children were weighed using the salter harris


weighing scales available at Anganwadi nearest to 0.5
kg. Before weighing the child it was ensured that there
was minimal and light clothing of the child.
The
Underweight is expressed in standard deviation units (Z
scores) calculated Using WHO Anthro software v 3.2.2
[9]
2011
. Underweight (mixed acute and chronic
malnutrition) is defined as weight for age Z-score (WAZ)
of <2SD. Severe underweight is considered if WAZ is
[10]
<3SD .
Statistical analysis: The data was analysed using MSExcel 2007 and SPSS version 20. Chi square test was
used to assess the association between the feeding
practices and underweight of the children. Results with P
value < 0.05 was considered as Significant
RESULTS
The Mean Age of the children was 18 + 7.5 months.
Among the selected children, 42.7% were males and
57.3 % were females. The distribution of population
according to Standard of living Index is that 69%
belonged to moderate and 27% are belonged to Low
category. The Literacy status among Mothers of the
children enrolled for the study was 68.2%.The Z scores
calculated for Weight for Age for overall sample showed
49.1% as underweight. In this, 31.81% belonged to
moderately underweight and 17.27% were severely
underweight. Age wise distribution showed 11.81 % were
moderately and 7.27 % were severely underweight
respectively between 7 -12 months and 10.9 % and 5.45
% were moderately and severely underweight between
13 -24 months. In the age group of 25 -36 months, 9.09
% and 4.54 % were moderately and severely
Underweight respectively. Exclusively Breast Feeding for
6 months was seen only in 37.3% of the study sample, in
which 45 % were females and 55% were males. The
history of illness in the past 1 month was found in 69.1%,
out of which ARI accounted for 40.9% and diarrhoea
constituted 27.3%. The children who were not exclusively
breast fed for 6 months, discontinuation of Breast feeding
beyond 6 months and inadequate meal frequency of the
child were found statistically significant with the
underweight of the children.

764
Anjana et al.,

Int J Med Res Health Sci. 2015;4(4):763-767

Table: 1.
Subjects

Socio-Demographic

profile

Socio-Demographic profile
Variable
Frequency
(N = 110 )
Sex
Male
7
Female
63
Religion
Hindu
43
Muslim
67
SES
Class 2
1
Class 3
33
Class 4
55
Class 5
21
Mothers
Illiterate
35
Education
Literate
75
Type
of Nuclear
27
Family
Joint
66
3 generation
17

of

Study

(%)

Nutritional
Status

42.7
57.3
39.1
60.9
0.9
30.0
50.0
19.1
31.8
68.2
24.5
60.0
15.5

25 (22.7 )

Normal
Underweight

85( 77.3)

52 (47.3 ) 58 ( 52.7)
41 (37.3 ) 69 ( 62.7)
38 (34.5)

72 ( 65.5)

Is Breast Feeding continued


52 (47.3) 58 (52.7)
for Child beyond 6 months
Adequate Meal Frequency of
51 ( 46.4) 59 ( 53.6)
child in past 24 hours
Adequate Dietary Diversity of
15 ( 13.6) 95 ( 86.4)
the Child
*Numbers in the parentheses indicates percentages

Distribution of IYCF Practices


Initiation of breast
feeding within 1 hour

34.5

62.7
65.5

Breastfeeding
Continuation after 6

52.7
47.3

Adequate Meal
Frequency Followed

53.6
46.4

Adequate Dietary
Diversity Followed

No

13.6

Pre-lacteal Feeds given after birth


Yes
No
Normal
27
29
Underweight
25
29
Exclusive Breast Feeding of the child
for 6 months
Yes
No
Normal
28
28
Underweight
13
41
Timely Initiation of
Feeding
Yes
Normal
24
Underweight
14

0.136

0.840

0.0049*

complementary
No
32
40

Breast Feeding continuation after 6


Months
Yes
No
Normal
32
4
Underweight
20
34
Meal Frequency of the child in past 24
hours
Adequate Inadequate
Normal
31
25
Underweight
20
3
Dietary diversity of the child
Normal
Adequate Inadequate
Underweight
9
47
6
48

0.06

0.034*

0.05*

0.44

DISCUSSION

37.3

Timely Initiation of
Complementary feeding

40
45

*p value < 0.05 is considered significant

52.7
47.3

Exclusive Breast Feeding


of the child

16
09

No

77.3

22.7

Prelacteal Feeds given

Initiation of BF within 1
hour of Birth
Yes

Table 2: showing the percentage of practices of age


appropriate feeding by mothers in their children
Age appropriate child feeding practices
Practices
Yes
No
Breast Feeding within 1 hour
of Birth
Prelacteal Feeds given after
Birth
Exclusive Breast Feeding of
child for 6 months
Timely Initiation of
Complementary Feeding

Table: 3. showing association of feeding practices


with underweight of children
Association of feeding practices with P value *
underweight of children

86.4

Yes

Fig 1: Depicting the distribution of Infant & young


child feeding Practices in percentages followed by
mothers for their children

In the present study, the administration of prelacteal


feeds was 47.3% which was slightly less than the study
[7]
done by Shravanan Udhyar et al , where it was 60.3%.
Similarly the Practice of Exclusive Breast feeding was
seen only in 36.3% of the mothers in this study which is
similar to that seen in Shravanan Udhyar study, which is
[11]
30 % . However in A.Khokhar et al study
, only 20%
were exclusively breastfed. According to Amir Maroof
[12]
Khan et al.,study
, 37.2% of the children were put to
breast within 1 hour of birth , whereas in our study it was
only 22.7%, which is even lesser than data from NFHS 3
report of Karnataka, where 35.6% had initiated
[8]
breastfeeding within 1 hour .77.3 % of the mothers did
not initiate Breast feeding within 1 hour of birth which is
[13]
higher than that observed in a study by Das N et al
which was 65.8% . The Minimum meal frequency was

765
Anjana et al.,

Int J Med Res Health Sci. 2015;4(4):763-767

adequately followed in only 48.6% in a study by Amir


[12]
Maroof Khan et al
which is almost similar to that found
in our study accounting to 46.4 % . In the same study by
[12]
Amir Maroof Khan et al ,67.4% were not adequately
following dietary diversity which is lower than our study
where in 86.4% failed to follow adequate Dietary
[8]
diversity. NFHS-3
finds that only 44% of breastfed
children are fed at least the minimum number of times
recommended and only half of them also consume food
from three or more food groups. In the present study also
36.5% are Exclusively Breastfed and more than half did
not consume adequate number of food groups which is
recommended. Likewise continued Breast feeding in
children beyond 1 year was seen in 72.1% in Amir
[12]
Maroof Khan et al ., study whereas in our study it was
only 47.3%. Child undernutrition is internationally
recognized as an important public health indicator, for
monitoring nutritional status and health in populations
[14].
The prevalence of Underweight in our study was
49.1% which is slightly higher than the prevalence
according to NFHS 3 Karnataka data which is 40%.In a
[15]
study conducted by Mukhopadhyay et al
43.7%
households belong to Medium SLI category whereas in
our study Medium SLI amounted to 62.7% higher than
Low and High SLI category. In our study, Children who
were not exclusively breast Fed, Discontinued
Breastfeeding beyond 6 months were found significantly
associated with underweight of the children which is
[16]
similar to the study by Muchina EN and PM Waithaka
where children who had not been Exclusively Breatfed for
6 months were more than twice as likely to be
underweight than those who did Exclusively Breast fed
and significant association was seen between continuing
Breast feeding and underweight. There has been no
significant association seen between the exclusively
Breastfeeding and occurrence of acute respiratory tract
infections and diarrhoea which is in contrast to study by
[17]
Seema Mihrshahi et al
in Chittagong, Bangladesh,
where in partially breastfed infants had a higher incidence
of acute respiratory infection and diarrheal infection when
compared to exclusively breastfed infants and that
difference was found to be statistically significant.

the study. I thank the Anganwadi workers for their help


and the mothers of the children who actively participated
and co-operated with us.
Conflicts of Interest: Nil
REFERENCES
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
CONCLUSION
The Infant and Young child feeding practices in this study
area were not satisfactory. Nearly half of the children
were underweight which can be attributed to the poor
IYCF practices. Although there have been numerous
efforts to improve the Mother and Child health by the
state as well as central through plenty of national
programs, yet persists the problem of malnutrition and
inadequate child feeding practices.
As the present study was cross-sectional, temporal
association cannot be found out. Hence there is a need
for large community based prospective study in this area
to determine the benefits of adequate IYCF practices and
health and nutrition education measures in improving the
nutritional status of children.
Acknowledgement: I extend my gratitude to all the staff
of Community medicine Department, KIMS Hubballi for
helping and supporting me in one or the way throughout

11.

12.

13.

Sreedhara MS and CR Banapurmath. A study of


nutritional status of infants in relation to their feeding
practices. Curr Pediatr Res 2013;18(1): 39-41
Mittal A, Singh J, Ahluwalia SK. Effect of maternal
Factors on nutritional status of 1-5 year old children
in urban slum population. Indian J Community Med
2007;32:264-7
Mukuria AG, Kothari MT, Abderrahim N. Infant and
Young Child Feeding Updates. Calverton, Maryland,
USA:ORCMacro;2006.
Available
from:
http://www.measuredhs.com/pubs/pdf/NUT1/NUT1.p
th
df. Last accessed on 25 April 2015.
Ghosh S , Shah D. Nutritional problems in urban
slums children. Indian Paediatrics 2004;41(7): 68296
Government of India . Guidelines for Enhancing
optimal infant and young child feeding practices.
Ministry of Health and Family welfare: 2013, p. 1-70.
WHO/PAHO .Guiding principles for complementary
feeding of the breastfed child. Washington, DC: Pan
American Health organisation ; 2003.p.1-37
Dr.Shravanan Udayar C, Dr. Angadi M , Dr. Rekha
Udgiri, Dr. Santhosh Patil D. A community based
study of Infant and Young child feeding practices in
a rural area of Karnataka. Journal of Evolution of
Medical and dental sciences 2012;1(3): 231-6
National Family Health Survey (NFHS-3), 2005-2006
: India: Vol.1.Mumbai : International Institute for
Population Sciences (IIPS) and Macro International ;
2007.
WHO Anthro for personal computers version
3.2.2,2011: software for assessing growth and
development
of
the
worlds
children,WHO2010(http://www.whowho.int/child
growth/software/en.
Sudarsan Mandal , Ram Prabhakar V , Jayita Pal, R
Parthasarathi , Rahul Biswas. An assessment of
nutritional status of children aged 0-14 years in a
slum area of Kolkata. Int J Med Public Health
2014;4:159-62
A Khokhar , S Singh , R Talwar ,SK Rasania, SR
Badhan, M Mehra.A study of malnutrition among
children aged 6 months to 2 years from a
resettlement colony of Delhi. Indian J Med Sci
2003;57(7):286-9
Amit Maroof Khan, Pricilla Kayina , Paras agarwal ,
Anita Gupta,Anjali Tupil Kannan. A study on Infant
and young child feeding practices among Infant and
young Child feeding practices among mothers
attending an urban Health center in East Delhi.
Indian J Public Health 2012;56(4):301-4
Das N ,Chattopadhyay D, Chakraborty S , Dasgupta
A. Infant and young child feeding perceptions and
practices among mothers in a rural area of West
Bengal. Ann Med Health Sci Res 2013;3(3):370-5

766
Anjana et al.,

Int J Med Res Health Sci. 2015;4(4):763-767

14. Anjali B Dhone , Uday B Chitnis , Jitendra S


Bhaawlkar , Sudhir L Jadhav . Epidemiological study
of undernutrition among under five years children in
an urban slum. Med J DY Patil Univ 2012;5(2):110-3
15. Dipta K Mukhopadhyay , Apurba Sinhababu,Asit B
Saren , Akhil B Biswas.Association of Child feeding
practices with Nutritional status of Under two slum
dwelling children-A community based study from
West Bengal, India. Indian J Public Health
2013;57(3):169-172
16. Muchina EN and PM Waithaka.Relationship between
Breastfeeding practices and nutritional status of
children aged 0-24 months in Nairobi Kenya. African
Journal of Food, agriculture nutrition and
developmemt 2010;10:2358-2378
17. Mihrshahi s, Ichikawa N , Shuaib M, Oddy W,
Ampon R , Dibley MJ , Kabir AK , Peat JK.
Prevalence of Exclusive Breast Feeding in
Bangladesh and its association with diarrhoea and
acute respiratory infection. Results of the Multiple
Indicator Cluster Survey 2003 J Health Popul
Nutr.2007; 25(2)195-204

767
Anjana et al.,

Int J Med Res Health Sci. 2015;4(4):763-767

DOI: 10.5958/2319-5886.2015.00150.2

Available online at: www.ijmrhs.com

Research article

Open Access

EFFECTS OF PROTEIN ENERGY MALNUTRITION ON PERIPHERAL NERVE


CONDUCTION IN CHILDREN
1

Rubha S , Vinodha R

ARTICLE INFO
Received: 2nd Jun 2015
Revised: 21st Jul 2015
Accepted: 5th Aug 2015
Authors details: 1Postgraduate student
in
Physiology,
Department
of
Physiology, Thanjavur Medical College,
Thanjavur, Tamilnadu, India
2
Professor & HOD, Department of
Physiology, Thanjavur Medical College,
Thanjavur, Tamilnadu, India
Corresponding author: Rubha S,
Department of Physiology, Thanjavur
Medical College, Thanjavur, Tamil Nadu,
India
Email: rubhasethuraman@yahoo.com
Keywords: Malnutrition, Children, Nerve
conduction velocity, Motor & Sensory
nerve conduction velocity

ABSTRACT
Background: Peripheral nerve conduction changes caused by malnutrition
can be shown clinically and electrophysiologically. They are produced
mainly due to deficiency of micro and macronutrients like vitamins,
minerals, protein, fat & Carbohydrate Aim : Protein energy malnutrition
(PEM) affects the myelination and growth of the nervous system. The
aim of this study was to assess the effects of PEM on peripheral
nerve conduction in children. Materials & Methods: Study group includes
40 malnourished children of 5 10 years of age from Raja Mirasudar
Hospital, Thanjavur based on Indian Academy of Paediatrics & WHO
classification for malnutrition. Control group consists of 40 normal
children of same age group. Nerve conduction study for median nerve
was performed using eight channel digital polygraph. Nerve conduction
velocity was evaluated. Results were analysed statistically using
unpaired student t test. Results : Nerve conduction study (NCS) showed
reduced motor and sensory nerve conduction velocity ( p < 0.05 ) in
children with Grade III malnutrition. Children with Grade I, II malnutrition
showed reduced sensory nerve conduction velocity ( p < 0.05 ).
Conclusion: The present study shows significant reduction in nerve
conducion velocity in children with malnutrition which may be due to
nutritional deficiency affecting myelination of peripheral nerves which
depends on duration and severity of malnutrition. So nerve conduction
study can be used to detect malnutrition at its early stage.

INTRODUCTION
WHO defines protein energy malnutrition as a range of
pathological conditions arising from coincidental lack in
varying proportions of proteins and calories, frequently
occurring in infants and young children usually
associated with infection. About 60 70% of children
have mild to moderate malnutrition and the remaining
[1]
are severely malnourished.
Protein energy malnutrition is known to be a major
[2]
health and nutrition problem in India.
Children
having birth order greater than or equal to 3 and
those not immunized had higher prevalence of
[3,4]
protein energy malnutrition.
A marginally adequate
diet, as weaning diets in developing countries does not
meet these increased needs. Protein energy malnutrition
is observed even in industrialized countries, associated
with the presence of clinical conditions that decrease
food intake or absorption of food. Dietary proteins are
the source of brain enzymes and neurotransmitters. The
quality of dietary proteins determines the quantity of
cerebral proteins and neurotransmitters. Thus the amino
acid profile of cerebral extracellular milieu is a function of
[5,6]
dietary proteins.
Malnutrition does not only risk the
population for anemia and repeated infection, but it
affects the developmental milestones and intellectual
development. This persistent influence will lead to
devastating effects in future. This burden continues in
generations, as
malnourished young girls become

Rubha et al.,

[7]

mother, deliver a malnourished young offspring.


Undernutrition can cause developmental delays among
the children and adolescents, leads to poor school
[8]
performance and cause school dropouts. Iron
deficiency alters myelination,
Hippocampal energy
metabolism during neonatal period. Zinc deficiency
alters
autonomic
nervous
system
regulation,
Hippocampal & Cerebellar development. Long chain
fatty acids are essential for synaptogenesis, membrane
[9]
function and myelination.
Malnutrition causes
structural and functional pathology of brain. Effect of
chronic protein energy malnutrition causes stunting and
wasting in children. It can also affect higher cognitive
[10]
processes during childhood (> 5 yrs of age) . Kinds of
behaviours & cognitive functions are impaired by
malnutrition which is related to altered emotional
[11]
response to a stressful events.
Measuring Nerve
Conduction Velocity is a method of evaluation of status
of peripheral nerves. Nerve conduction studies examines
Peripheral motor & sensory nerve function by recording
the evoked potential in nerve or muscle in response to
[12,13].
electrical stimulation of a peripheral nerve
Kumar et
al observed delayed motor nerve conduction velocities in
children with protein energy malnutrition. Delayed nerve
conduction velocity in malnutrition is due to slowing or
arrest of myelination that results from deprivation of
[14]
nutrition . Hence with the help of electrophysiological

768
Int J Med Res Health Sci. 2015;4(4):768-770

study we can find the peripheral nerve conduction


alterations in children with malnutrition.
MATERIALS AND METHODS:
Study design: Case control study
Place of research: This study was conducted in
Research Laboratory , Department of Physiology,
Thanjavur Medical College & Hospital, Thanjavur.
Study period: August 2013 to July 2014.
Ethics approval: Ethical committee approval was
obtained from
Institution before
commencing the
study. The aim, nature of the study was explained to the
subjects & Parents / Guardians. An informed written
consent was obtained from the Parent / Guardian of
the child prior to the test.
Inclusion criteria: Study group consists of 40
malnourished
children. Out of 40, 20 children (13
males, 7 females) had Grade III (Severe) malnutrition
[15]
according to IAP & WHO classification
for
malnutrition. They had Weight for age, 51 - 60% of
expected weight & Height for age < 85% of expected
height. Remaining 20 children ( 10 males, 10 females)
had Grade I & II ( mild to moderate) malnutrition as
they had weight of 61 80 % of expected weight
with normal height appropriate for their age. Control
group consists of 40 normal children ( 20 males , 20
females ) with weight > 80 % of expected with normal
height for their age. Malnourished children with the
age group of
5 10 years according to IAP
classification & WHO Classification for malnutrition were
included in this study.
Exclusion criteria: Children with genetic & endocrine
causes for short stature were excluded from the study.
Sample size: Eighty
Procedure:
Nerve conduction study (NCS) was
performed using eight channel digital polygraph, model IT 173SB ( Neuro perfectplus)
Motor nerve conduction velocity (MNCV) was recorded
by placing active electrode over muscle belly (Abductor
pollicis brevis ) & reference electrode at 3cm distal to
st
active electrode at 1 metacarpophalangeal
joint.
Ground electrode was placed between stimulating &
recording electrodes Median nerve was stimulated at
wrist ( 3cm proximal to the distal wrist crease) & at
elbow (near the volar crease of brachial pulse).
Distance between the wrist & the elbow point of
stimulation was measured in mm & conduction velocity
(m / sec) was calculated by dividing the distance (mm)
with latency difference. Sensory nerve conduction study
was performed by placing ring electrodes at the index
finger with the help of conducting gel. Ground electrode
was placed over the forearm.
Median nerve was
stimulated at wrist. Sensory nerve action potential was
recorded using antidromic conduction. The distance
between the recording electrode & the stimulation site
was measured. Sensory nerve conduction velocity
(SNCV) was measured
by dividing the distance by
[16]
onset of latency.

Rubha et al.,

RESULTS
Statistical analysis was done by using SPSS version
20.The results were analysed using unpaired student
t test. Values were expressed as mean with standard
deviation. The control group was compared with
grade III & grade I,II malnourished group. p value <
0.05 was considered as statistically significant.
Table 1: Anthropometric measurements of case &
control group
Height for
age (cm)

Group
GradeI&II

123.0 9.67

Weight for
age (kg)

Age (years)
Mean SD

21.513.76

8.451.82
Grade III
103.4 7.56
15.322.96
Control
124.1 1.58
26.754.50
7.571.74
Table 2: Nerve conduction study results in study
group
Parameter
Control
Study group Study group
(m/sec)
group
(Grade III)
(Grade I& II)
MNCV
46.58 17 33.8117.9*
40.6620.0
SNCV
46.78
30.75 9.3*
38.9617.5*
12.1
*p < 0.05 Significant, MNCV= Motor nerve conduction
velocity, SNCV = Sensory nerve conduction velocity
DISCUSSION
Malnutrition is widely prevalent in all developing
countries and children are the worst sufferers. Early
development of malnutrition during the critical period of
brain development has devasating effect on brain
growth. This period extends from prenatal to early
postnatal life. Active synthesis of myelin occurs in this
period. Myelin is composed of protein & phospholipid
derived from cell membrane of oligodendrocytes in
central nervous system and from Schwann cells in
peripheral nervous system. Malnutrition in this period
results in physical, chemical, & functional changes in
brain. All changes occurring in this period are likely to be
irreversible that has a long lasting effect mainly due to
delay in myelination. Malnutrition results in poor
learning abilities, impaired cognitive functions and
[17]
school dropouts .
This study has shown significant reduction in nerve
conduction velocity in children with malnutrition. Motor &
sensory nerve conduction velocity is significantly
reduced in children with Grade III Malnutrition. Sensory
nerve conduction velocity is significantly reduced in
Grade I & II group.Sensory nerve conduction studies are
more sensitive than motor nerve conduction study in
[18] .
detecting early or mild demyelinating diseases
[19]
Shanthi ghosh et al
conducted nerve conduction
study in 67 children to assess the effect of malnutrition
on peripheral nervous system. Significant reduction in
nerve conduction velocity was observed in children with
severe protein energy malnutrition and ongoing longterm
malnutrition .They found that undernutrition produces
permanent molecular errors in brain membrane
composition and affects biochemical maturity of

769
Int J Med Res Health Sci. 2015;4(4):768-770

brain. This result is consistent with the present study


result.
[14]
Kumar et al
measured nerve conduction velocity in
children with protein calorie malnutrition. 38 marasmus,
13 kwashiorkor children were studied. They found that
conduction velocity were reduced in each type of
malnutrition suggested that PEM when it occurs during
the development of nervous system affects myelination
of peripheral nerves. Result of the present study agreed
with this result.
The present study results agreed with results of Nimet
[20]
kabakus et al
. They did peripheral nerve conduction
study in children with iron deficiency anemia. Children
with iron deficiency anemia were tested against healthy
children . Median motor & sensory nerve conduction
velocity were significantly lower than control group .
The result of present study is similar with research
[21]
done by Jagjit S.Chopra
. Reduction in nerve
conduction velocity was observed in children with protein
calorie malnutrition.
CONCLUSION
This study shows significant reduction in nerve
conduction velocity which may be due to nutritional
deficiency affecting myelination of peripheral nerves .
Severe and chronic malnutrition affects motor &
sensory nerve conduction velocity. Mild to moderate
malnutrition alters sensory nerve conduction velocity
which is more sensitive than motor nerve conduction
study in detecting early or mild demyelinating diseases.
Thus there is strong association between duration
and severity of malnutrition with NCS . So this
electrophysiological tests can be used for early
detection of malnutrition. But whether these changes
are
reversible
or
irreversible after
nutritional
rehabilitation needs to be evaluated.
Limitation of the study: This study doesnot eveluate
the effect of nutritional supplementation on nerve
conduction velocity in malnourished children.
Acknowledgment: I would like to thank the Dean,
Thanjavur Medical College, Thanjavur for granting me
permission to conduct this study.
Conflict of Intrest : No conflict of interest

5.
6.

7.
8.

9.

10.

11.

12.

13.

14.

15.

16.
17.

18.

REFERENCES
1.

2.

3.

4.

Swarna Rekha Bhat. Achars Textbook of


Paediatrics. In: Nutrition:Normal nutrition and
th
Malnutrition,Universities Press;2009;4 Edition. 4553
Parthasarathy A, MKC Nair, PSN Menon, Raju C
Shah, Nitin K Shah, HPS Sachdev etal., IAP
Textbook of Pediatrics.In:Meenakshi N Mehta. Child
rd
nutrition,Jaypee;2006; 3 Edition:120-139
Sen PM, Gupta VM, Singh TB. PEM among rural
preschool children of eastern U.P Indian Journal of
Maternal & child health.1996;7(4):95-98
Santhosh kumar A. Sunil kumar D, Ashok NC,
Ragavendrasamy Koppad. PEM & its Association
with immunisation status among 1-5 aged children in

Rubha et al.,

19.

20.

21.

southern part of India, Mysore. IJCRR. 2013;


5(2):105-110
Agarwal KN. Textbook of Paediatrics. In: Nutrition,
st
Ane Books Pvt.Ltd; 2010: 1 Edition.49- 81.
Mohammad Ramadan Hassaan. Ashgan Abd Alla
Abdel-aal Alghobashy, Hadeel Mohammed AbdelRahman. Auditory neural efficiency in protein energy
malnourished toddlers with and without iron
deficiency
anemia.
Egyptian
journal
of
Ear.Nose,Throat & allied Sciences. 2011;12:105-14
Aziz Abdul Rehman Jiwani. ISRA Medical
journal.2011;3(3):82-83
Bruno de Benoist, Erin McLean, Ines Egli and Mary
Cogswell.WHO global database on anemiaWorld
prevalence of anaemia 1993-2005:1-13.
Michel K Georgieff. Nutrition & the developing brain:
Nutrient priorities & measurement. The American
journal of nutrition 2007; 85:614s-20s
Bhoomika R Kar, Shobini L Rao, Chandremouli BA.
Cognitive development in children with chronic PEM.
Behavioral & Brain function 2008,4,31:1-12
David A.Levitsky, Barbara J. Strupp. Malnutrition
and the brain: Changing concepts, changing
concerns. J.Nutr.1995;125:2212S-20S
Mallik, A.I weir. Nerve conduction studies:
Essentials & pitfalls in practice. J neurol Neurosurg
Psychiatry 2005 ;76(S II ): ii23-ii31
Randolph W. Evans. Diagnostic testing in
Neurology. In: Daniel M. Feinberg, David C Preston.
rd
Mononeuropathies, Saunders;3 edition: 284-85
Kumar, Ghai OP, Singh N. Delayed nerve
conduction velocity in children with PEM. J
Paediatrics. 1997;90(1):149-53
Ghai OP, Piyush gupta, Paul VK. Ghai Essential
paediatrics. In: Piyush Gupta, Dheeraj shah.
Nutrition & Macronutrient disorders: Protein energy
malnutrition, CBS Publications & Distributors;
th
2005;6 edition:101- 104.
th
Jain AK. Manual of Practical Physiology.2012;4
edition:297-301
Stoch MB, Smythe PM..Does undernutrition during
infancy inhibit growth and subsequent intellectual
development? Archs Dis Children.1963;38:546-552
Shanthi
Ghosh,
Kumkumvaid
Manmohan,
Maheshwari. Effect of degree & duration of PEM on
Peripheral nerves in children .J neurology,
Neurosurgery &Psychiatry, 1979, 42: 760-763.
Michel J Aminoff. Electrodiagnosis in clinical
neurology. In.Jasper R. Daube. Nerve conduction
th
studies, Elsevier;2005;5 edition: 285-308
Nimet Kabakus, Ahmet Ayar Tahir Kurtulus Yoldas.
Reversal of Iron Deficiency Anemiainduced
Peripheral Neuropathy by Iron Treatment in Children
with Iron Deficiency Anemia. Journal of tropical
paediatrics.2002;48(4):204-209.
Jagjit S Chopra, Upinder K Dhand, Saroj
Mehta,Vilakshna Bakshi,Satyavathi Rana, Jagjivan
Mehta. Effect of protein calorie malnutrition on
peripheral nerves, A clinical, Electrophysiological &
Histopathological
study.
Oxford
J
of
Neurology.1986;109(2):307-23

770
Int J Med Res Health Sci. 2015;4(4):768-770

DOI: 10.5958/2319-5886.2015.00151.4

Available online at: www.ijmrhs.com

Research article

Open Access

EVALUATION OF BRAINSTEM AUDITORY EVOKED POTENTIAL IN MIGRAINE


PATIENT
1

Sowmiya R , Vinodha R

ARTICLE INFO
nd

Received: 2 Jun 2015


th
Revised: 4 Aug 2015
th
Accepted: 12 Aug 2015
1

Authors details: Postgraduate


2
student, Professor & HOD,
Department of Physiology, Thanjavur
Medical College, Thanjavur, Tamil
Nadu, India
Corresponding author: Sowmiya R
Postgraduate student, Department of
Physiology,
Thanjavur
Medical
College, Thanjavur, Tamil Nadu, India
Email: sowmimbbs87@gmail.com
Keywords: Migraine, Aura, Brainstem
auditory evoked potential, Wave
Latency, Interpeak Latency

ABSTRACT
Background: Migraine is worldwide common, chronic, Neurovascular
disorder, characterized by attacks of severe headache and an Aura
involving neurologic symptoms. Its pathogenesis was incompletely
understood whether of cortical or brainstem origin.
Aim: The present
study was undertaken to investigate brainstem auditory functions in
Migraine patients. Materials and Methods: The subjects were recruited
based on International Headache Society classification for Migraine.
Subjects with episodes of headache for at least 2yrs, 2 attacks per month in
last quarter year were included in the study. Forty subjects (16 Migraine
with Aura & 24 cases Migraine without aura) & forty age / sex matched
controls were selected. Brainstem auditory evoked potential was recorded
using 4-Channel polygraph (Neuro perfect plus). Electrodes were placed
according to 10 20 electrode placement system. Auditory stimulus in the
form of click sound is delivered through the headphones. Clicks were
delivered at a rate of 8-10 /sec. The intensity of the stimulus is set at 30db.
About 100 averages were recorded. BAEP waveforms - Wave I, III & V
latencies and the interpeak latencies were measured. The results were
analysed statistically using studentt test. Results: BAEP recording shows
significant prolongation in latencies of Wave I, III & V and the Interpeak
latency (IPL) I-III, III-V & I-V in Migraine with aura. In Migraine without aura,
there was significant prolongation of Wave I, III & V and III-V & I-VIPL
(P<0.05). Conclusion: Prolongation suggests that there is involvement of
brainstem structures in Migraine, thus BAEP can be used as an effective
tool in evaluation of Migraine.

INTRODUCTION
Headache is one of the most frequently encountered
[1]
Neurological symptom. Headache is caused by irritation
of pain sensitive Intracranial structures like Dural sinuses,
intracranial portions of Trigeminal , Glossopharyngeal,
Vagus and upper Cervical nerves ;large arteries and
venous sinuses. The structures which are insensitive to
pain are Brain parenchyma, Ependymal lining of
.[2]
ventricles and the Choroid plexus
Painful stimuli arising from the brain tissue above the
Tentorium cerebelli are transmitted via Trigeminal nerve
whereas impulses from posterior fossa are conveyed by
Glossopharyngeal, vagus and upper two cervical
[2]
nerves. Headache disorders can be classified into
Primary Headache disorder and Headache secondary to
structural brain disease.
Primary Headaches are disorders in which headache
and associated features occur in the absence of
exogenous cause. Migraine, Tension type headache and
Cluster headache are most common Primary headache
[3]
syndromes.
Migraine is the disorder of the brain characterized by
[4]
complex sensory dysfunction.
It is an Episodic
headache disorder and second most common type of
[2,3]
primary headache.
Migraine occurs at any age either
at childhood, adolescent or adult life , more common in

Sowmiya et al.,

Females than Males in the ratio of 3:1. 60% of patients


[5]
have positive Family history.
Migraine has a great impact on mental, physical,
[6]
functional and socioeconomic aspects of patients life.
Migrainous have higher lifetime risk of Depressive
disorder, Panic disorder, Generalized Anxiety disorder,
phobias
and
Suicide attempts than the normal
[7]
subjects.
The Diagnosis of Migraine was based on headache
characteristics and associated symptoms, which is
[2]
subjective.
Routine Clinical Examination also appears
to
be
normal
in
Migraine
patients.
So,
Electrophysiological and Psychophysical tests have been
[6]
carried out in Migraine patients.
Migraine attacks originate due to abnormal Nociceptive
Neuromodulator centers especially the Monoaminergic
sensory control systems located in the Brainstem. Neurootological symptoms like vertigo, phonophobia, tinnitus,
and unsteadiness and hearing loss are also common in
Migraine. There is a mild bilateral and reversible auditory
& vestibular hypofunction during Migraine attack. So,
Brainstem auditory evoked potential (BAEP) can be done
to assess the function of Brainstem structures traversed
by auditory pathways.
BAEPs are the potentials recorded from the Ear and
scalp in response to brief auditory stimuli that assess the

771
Int J Med Res Health Sci. 2015;4(4):771-774

conduction through the auditory pathway from the


[8]
auditory nerve up to Midbrain. Transduction of acoustic
stimulus by the hair cells create an electrical signal that
appear as evoked potential and is carried through the
auditory pathway to the brainstem and from there to the
[9]
cerebral cortex.
BAEPs are recorded within 10ms after the acoustic
stimulus. Stimulus is delivered to one ear via headphones
while the contralateral ear is masked with continuous
[10]
white noise.
The stimulus is usually a square wave
pulse. If the electrical square pulse causes the diaphragm
of the earphone to move toward the patients ear then
condensation click is produced. Reversing the polarity
produces rarefaction click. The amplitude of the
[11]
waveforms is affected by the type of the stimulus.
Five waveforms are recorded within 10ms of auditory
stimulus. Wave I originates from the peripheral portion
of the eighth cranial nerve, Wave II arises from cochlear
nucleus, Wave III from superior olivary nucleus, Wave
IV originates from the lateral lemniscus and Wave V
[9]
from inferior colliculi. The interpeak latencies measured
are I-III, III- V & I- V. They are measured as the distance
between the peaks of both waves.I-III IPL represents
conduction from the eighth nerve into the core of the
lower pons. III - V IPL represents conduction from the
lower pons to the midbrain. I- V IPL measures conduction
th
from the proximal part of 8 cranial nerve upto the
[10]
Midbrain.
Hence, Brainstem Auditory Evoked Potential was done in
Migraine patients to better understand the pathogenesis
of Migraine and to utilize this test for Diagnosis and
Effective management of Migraine.
MATERIALS AND METHODS
Study design: This study, a case control study
Place of research: The study was conducted in the
Research laboratory, Department of Physiology,
Thanjavur Medical College & Hospital, Thanjavur.
Duration of study: The study period extended from
August 2013 to June 2014.
Ethical approval: Ethical Committee approval was
obtained from the institution before commencing the
study. The nature of the study was explained to the
subjects, an informed written consent was obtained from
the subjects prior to the study.
Inclusion criteria: The subjects were recruited from the
Out-patient clinic of Department of Neuromedicine.
Grouping: The study group : comprises of 40 Migraine
patients who were selected according to International
[3]
Headache Society Diagnostic Criteria and subdivided
into 16 patients Migraine with Aura and 24 patients
Migraine without Aura (4 males and 36 females).
Out of 40 controls, 6 males and 34 females of age group
19 to 55yrs with no history of headache, healthy controls
were selected for the study.
Patients in the age group of 19 to 52 yrs diagnosed as
Migraine with episodes of headache for at least 2yrs
and at least 2 attacks per month in the last quarter year
were included in the study.

Exclusion criteria: Subjects with Neurological diseases,


ENT, Systemic diseases and auditory deficits were
excluded.
Methodology: A detailed history of Headache duration,
frequency and history suggestive of aura and history to
rule out other types of headache were noted.
Methods: Brainstem auditory evoked potential was
recorded using 4-Channel polygraph (Neuro perfect
plus). Electrodes were placed according to 10 20
electrode placement system. Channel 1 is placed at Cz Ai (ipsilateral ear ) and Channel 2 is placed at Cz - Ac (
contralateral ear ). Ground electrode is placed about 20%
from the Nasion Fz position. Auditory stimulus in the
form of click sound is delivered through the headphones.
Clicks were delivered at a rate of 8-10 /sec. The intensity
of the stimulus is set at 30db. About 100 averages were
recorded. BAEP waveforms - Wave I, III & V latencies
and the interpeak latencies were measured.
Statistical analysis: the statistical analysis was done by
using Statistical package SPSS version 20. The statistical
analysis was done using unpaired studentt test. Values
were expressed as mean with standard deviation. P
value less than 0.05 was considered as statistically
significant.
RESULTS
Table 1: Comparison of Brainstem Auditory Evoked
Potential Mean values in cases (Migraine with aura )
&Control group
Migraine
with Aura

Control

Wave I

Mean SD
1.2720.293

Mean SD
1.12220.23

0.044

Wave III

3.9381 0.62

3.43230.64

0.009

Wave V
I III IPL

6.34441.40
2.66250.58

5.65100.92
2.27970.58

0.033
0.028

III V IPL

2.59060.57

2.24200.46

0.020

Parameters
(msec)

P value

I V IPL
5.25561.05
4.48880.82 0.005
BAEP study results showed significant prolongation in
latencies of Wave I, III & V with P value <0.05 in Migraine
patients when compared with controls. Also, the
interpeak latencies I- III, III- V & I- V were significantly
prolonged in study group, Migraine with aura than the
controls (Table 1). In Migraine without Aura III- V & I- V
IPL were significantly prolonged. (Table 2)
Table:2. Comparison of Brainstem Auditory Evoked
Potential Mean values in cases ( Migraine without
aura ) &Control group
Parameters

(msec)
Wave I
Wave III
Wave V
I III IPL
III V IPL
I V IPL

Migraine
without Aura

Control

Mean SD

Mean SD

1.390.359
3.79 0.56
6.33 0.82
2.39 0.42
2.56 0.52
4.950.67

1.12220.23
3.43230.64
5.65100.92
2.27970.57
2.24200.46
4.48880.82

P
value
0.000
0.029
0.004
0.411
0.014
0.022

772
Sowmiya et al.,

Int J Med Res Health Sci. 2015;4(4):771-774

DISCUSSION
In the present study, Brainstem auditory Evoked Potential
parameters were evaluated in Migraine patients with and
without Aura and in control group. Migraine can best be
explained as a Brain state in which the cellular and
vascular functional changes occur at the same time due
to dysfunction of subcortical structures, brainstem and
diencephalic nuclei that modulate sensory inputs. These
nuclei act as a Migraine Mediator whose dysfunction will
lead to abnormal perception and activation of Trigeminal
Vascular System(TVS) which then activate the central
structures.
Thus, Migraine is mainly due to TVS activation generated
within the brain without a peripheral sensory input.
Migraine is the central sensory processing disorder,there
is dysfunction of descending brainstem pain modulatory
system. The hyperexcitability of the nociceptive circuitry
downstream is responsible for this central sensitization in
[12]
Migraine patients.
BAEP study reports showed significant prolongation of
Latencies and Interpeak latencies in Migraine when
compared with controls.
[13]
D Kaushal, S Sanjay Munjal, M Modi, N Panda
Evaluated BAEP in 25 Migraine patients. They reported
prolongation inwave I, III & V latencies and I-III & I- V
interpeak latencies and revealed that prolongation was
due to involvement of Brainstem structures as well as
activation of brainstem in Migraine patients. These results
were in accordance with our present study.
[14]
Anil K Dash et al ., Studied audiovestibular functions in
Migraine patients with and without vertigo. BAEP results
revealed that there was significant prolongation in
latencies of wave I, III & V and interpeak latencies I-III ,
III-V & I-V. This study concluded that BAEP abnormalities
are the earliest indicator of impending auditory
involvement in patients with Migraine. These results were
consistent with our present study.
[7]
Laila EL Mosly et al., Evaluated the effect of Migraine on
quality of life in females and associated changes in
evoked potentials. They measured BAEP in 30 Migraine
patients and reported
that there was prolongation of
wave III& wave V latency and I- III & I- V interpeak
latency due to hyperexcitability of the cerebral cortex but
no significant change in III V interpeak latency both
during an attack and in the interictal phase. These
results were similar with our present study.
[15]
Firat Y et al ., Measured auditory brainstem responses
in pediatric population during the period of an attack and
asymptomatic period of Migraine. There was prolongation
of wave V and I V Interpeak latency in Migraineurs.
These changes were due to transient impairment of
auditory brainstem function in Migraine patients. These
results were in accordance with our present study.Drake
[16]
ME et al., Measured BAEP in 50 common Migraine
cases. They found that there was significant prolongation
of I V and III- V interpeak latency in Migraine patients.
This study suggests that prolongation was due to
dysfunction of brainstem centers and possibly related to
endorphin or serotonin neurotransmission.
[17]
Sherifa A Hamed ,Amal Mohammed Elatter Evaluated
vestibular function in 58 Migraine patients(with and

without aura) and reported prolongation in wave III


latency and I-III, III -V& I - V interpeak latencies. This
study suggests that in Migraine, there is permanent
vestibular damage either peripheral or central vestibular
pathways. Similar results were observed in our
[18]
study.Yang Y ,Li P , Ye HC
Explored personality test
and BAEPs in 30 Migraine patients. They reported that
the latencies of wave I , III & V and the Interpeak
latencies of III- V were prolonged and related this
prolongation to brainstem dysfunction. Similar results
were observed in our study.
[19]
ZgorzalewiczM et al .,
This study evaluated BAEP in
children and adolescents with primary headaches. They
reported significant prolongation in latencies of wave III in
Migraine children when compared with TTH. This study
suggests
that
brainstem
contributes
to
the
[20]
pathophysiology of Migraine. Bayazit Y et al ., Studied
BAEP in 20 Migraine patients , they reported abnormal
BAEP findings in seven patients with increased latency
of waves I , III & V and the interpeak latency III-V. They
concluded that cochlear vestibular symptoms can be
seen in Migraine patients. Thus there is dysfunction of
neuronal excitability in Migraine, due to defective
neurotransmitter signaling and cerebral bioelectrical
dysrhythmia.
CONCLUSION
The present study results show that there is involvement
of the Brainstem in Migraine patients. Thus, Auditory
brainstem evoked responses can be considered as
useful, non-invasive, reliable & diagnostic technique and
earliest indicator of impending auditory involvement in
migraine patients.
Limitations: This study does not compare the duration of
the disease with the changes in the Brainstem auditory
evoked potential study and the role of Neuromodulatory
centers in the brainstem in pathophysiology of Migraine.
Acknowledgement: Special thanks to The Dean ,
Thanjavur Medical College
Conflict of interest: No conflicts of Interest
REFERENCES
1. Nicholas A.Boon, Nicki R.Colledge, Brian R. Walker,
John A.A. Hunter., Davidsons Principles & Practice
of Medicine.In. C.M.C.Allen, C.J.Lueck, M.Dennis.
th
Neurological disease. Elsevier 2006; 20 edition
:1160-1163.
2. Andreoli and Carpenter s Cecil Essentials of
Medicine., Charles C.J.Carpenter , Robert C.Griggs,
Ivor
J.
Benjamin.In.Timothy
J.Counihan.
Headache,Neckpain and other painful disorders.
th
Saunders Elsevier 2007;7 edition: 1069- 1073.
3. Dan L.Longo , Antony S. Fauci , Dennis L. Kasper,
J.Larry Jameson , Stephen L. Hauser, Joseph
Loscalzo., Harrison s Principles of Internal Medicine.
In. Peter J. Goadsby, Neil H.Raskin. Headache.
th
McGraw Hill Medical 2012;18 edition Vol 1:114120.
4. Till
Sprenger
and
Peter
J
Goadsby
Minireview..Migraine pathogenesis and state of

773
Sowmiya et al.,

Int J Med Res Health Sci. 2015;4(4):771-774

5.
6.

7.

8.

9.

10.
11.

12.

13.

14.

15.

16.

17.

18.

19.

pharmacological treatment options. BMC Medicine


2009; 7(71): 1- 5
Chugh S N, Ashimachugh Textbook of Medicine.
Delhi Arya publications 2010: 596 599.
Nofal MKhalil, Nigel J Legg, Duncan J Anderson
Long term decline of P100 amplitude in Migraine with
Aura. J NeurolNeurosurg Psychiatry 2000;69 : 507
511.
Laila El Mosly, AzzaBayoumy, HodaMassoud ,
Mahmoud Abdel Moty, Manal Hafez, Taghreed
Elshafie and Rasha El Bialy Impact of Migraine
Headache on Quality of Life in a group of Female
patients using Neurophysiological Assessment.
AAMJ 2012; 10 (2): 245-267
Misra UK, Kalita Clinical Neurophysiology-Brainstem
rd
auditory evoked potentials. 2014; 3 edition:301314.
Pal GK, Pravati Pal Textbook of Practical
Physiology.Brainstem auditory evoked potentials.
rd
2010;3 edition : 298 303.
Jain AK. Manual of Practical Physiology. Brainstem
th
auditory evoked potentials. 2012; 4 edition : 305-9.
Michael J.Aminoff Electrodiagnosis in Clinical
Neurology. In: Alan D. Legatt Brainstem Auditory
Evoked Potentials :Methology, Interpretation and
th
Clinical Application, Elsevier 2005;5 edition: 490519.
EricA.M oulten , Rami Burstein , Shannon Tully ,
Richard
Hargreaves
,Lino
Becerra,
David
BorsookInterictal dysfunction of a brainstem
descending modulatory center in Migraine patients.
PLoSONE 2008 : 3(11):e3799.
Kaushal D, Sanjay Munjal S , Modi M , Panda N.
Auditory brainstem evoked responses in Migraine
patients. The Internet Journal of Neurology 2008;
12(1).
Anil KD, Naresh Panda, Gaurav Khandelwal,
VivekLal, Sherbaj S. Mann. Migraine and
audiovestibular dysfunction: is there a correlation?
American Journal of Otolaryngology head and
Neck Medicine and surgery. 2008; 29:295 299.
Firat Y, Ozturan O, Bicak U, Yakinci C, Akarcay M
Auditory brainstem response in pediatric Migraine :
during the attack and asymptomatic period.
International journal of Pediatric Otorhinolaryngology
2006; 70 (8) : 1431-1438.
Drake ME, PakalnisA, Hietter SA , Padamadan H.
Visual and Auditory evoked potentials in Migraine .
ElectromyogrClinNeurophysiol 1990 Feb Mar ; 30
(2) :77 81
Sherifa A. Hamed ,AmalMohamadElattar Peripheral
and central vestibular function in patients with
Migraine . JurnalofNeurology andNeuroscienceVol
3, No.1 2012.
Yang Y, Li P, Ye HC Brainstem auditory evoked
potentials and assessment of personality test in
patients with Migraine. Hunan medical university
2000; 25 ( 1) :63 64.
Zgorzalewicz M The study of Early auditory evoked
potentials in primary headaches in children and
adolescents
and
their
pathogenetic
implications.Neurologia 2005; 39 (4s1):s17 25.

20. Bayazit Y, Yilmaz M, Mumbuc S, Kanlikama M.


Assessment of Migraine -related cochleovestibular
symptoms. Rev Laryngol Otol Rhinol ( Bord). 2001
;122 (2) :85-8.

774
Sowmiya et al.,

Int J Med Res Health Sci. 2015;4(4):771-774

DOI: 10.5958/2319-5886.2015.00152.6
Open Access

Available online at: www.ijmrhs.com


Research article

ADVERSE MATERNAL AND PERINATAL OUTCOMES IN GESTATIONAL


DIABETES MELLITUS
1

2 *

Ambarisha Bhandiwad , Divyasree B , Surakshith L Gowda

ARTICLE INFO
th

Received: 5 Jun 2015


th
Revised: 24 Jul 2015
th
Accepted: 5 Sep 2015
1

Authors details:
Professor and
2,3
Head, Junior Resident Department
of OBGY, JSS Medical College, JSS
University, Mysore, India
Corresponding author: Surakshith L
Gowda
Junior Resident Department of OBGY,
JSS Medical College, JSS University,
Mysore, India
Email: surakshithlgowda@gmail.com
Keywords: Gestational Diabetes
Mellitus, Maternal and Fetal
complications, Macrosomia,
Preeclampsia

ABSTRACT
Introduction: Women with Gestational Diabetes Mellitus (GDM) are at
increased risk for many other health concerns with short and long-term
implications for both mother and child. They are at higher risk for glucosemediated macrosomia, hypertension, birth trauma, respiratory distress,
hypoglycemia, hyperbilirubinemia with increased neonatal intensive care
unit (NICU) admissions. Postpartum complications include obesity and
impaired glucose tolerance in the offspring and diabetes and cardiovascular
disease in the mothers. Objectives: To study the incidence of maternal
and fetal co-morbidities associated with GDM. Materials and Methods:
This is a retrospective observational study where cases with GDM were
analyzed for maternal and fetal complications. Results: 189 cases were
detected to be Gestational Diabetes Mellitus, out of which 63.49% cases
developed co-morbidities with GDM. 11.11% cases developed
preeclampsia, 9.52% had polyhydramnios, 5.8% patients went into preterm
labour, 3 cases had Antepartum Haemorrhage and one case had
Postpartum Haemorrhage. 19.57% cases developed macrosomia,
hypoglycemia was seen in 7.40% babies and hyperbilirubinemia in 3.70%
babies. 6 Intra Uterine Deaths and 2 still borns were documented.
Conclusion: GDM is a condition which is worth monitoring and treating,
since it has been demonstrated that good metabolic control maintained
throughout gestation can reduce maternal and fetal complications.

INTRODUCTION
Gestational Diabetes Mellitus (GDM) is commonly
defined as carbohydrate intolerance that first becomes
[1]
apparent during pregnancy. Women with GDM are at
increased risk for many other health concerns with short
and long-term implications for both mother and child.
Women with GDM are at higher risk for glucosemediated macrosomia, hypertension, adverse pregnancy
outcomes (stillbirth, birth trauma, cesarean section, preeclampsia,
eclampsia,
respiratory
distress,
hypoglycemia,
hyperbilirubinemia,
polycythemia,
hypocalcemia, increased neonatal intensive care unit
admissions) and neonatal adiposity with its long-term
[2, 3]
sequelae including childhood obesity and diabetes.
Postpartum complications include obesity and impaired
glucose tolerance in the offspring and diabetes and
[3]
cardiovascular disease in the mothers. Women who
have GDM are at higher risk of developing T2DM in the
future.This risk has been shown to be as high as 50% for
[4]
future T2DM risk.
The ADA recommends that all
women with GDM be screened at six to 12 weeks after
delivery for persistent diabetes and then every three
[5]
years thereafter
where as the DIPSI recommends to
screen women with GDM at 6 weeks, 6 months and then
yearly thereafter for persistent diabetes. This condition is
worth monitoring and treating, since it has been
demonstrated that good metabolic control maintained
throughout gestation can reduce maternal and fetal
[1]
complications.

Ambarisha et al.,

MATERIALS AND METHODS


Study design: This is a retrospective observational
study
Study period and location: The study was done
between January 2013 to December 2014, at JSS
Hospital, Mysore
Ethics approval: The study was approved by the
Institutional Ethics committee
Inclusion criteria: All antenatal patients who were
diagnosed as GDM and who delivered during the study
period available from the record section
Exclusion Criteria: Patients with oral glucose challenge
test value of <140 mg/dl, incomplete data of the patient
How GDM was diagnosed ?: All pregnant women were
screened and diagnosed with Diabetes In Pregnancy
[6]
Study group India (DIPSI) criteria i.e. irrespective of the
timing of the last meal, as and when the pregnant
women entered the antenatal clinic, she was given 75gm
oral glucose. Then two hours later, plasma glucose was
estimated by Glucose oxidase - peroxidase method. 2hr
post plasma glucose value of 140 mg/dl was diagnostic
of GDM and those patients were included in the study.
All women were screened between 24-28 weeks of
gestation and women with high risk factors such as age
>30 yrs, obesity, family history of diabetes, previous bad
obstetric history, history of GDM in previous pregnancy
were screened earlier at 12 16 weeks of gestation and
those diagnosed with GDM were included in the study,

775
Int J Med Res Health Sci. 2015;4(4):775-777

but in a normally glucose tolerant women the test was


repeated again at 32 34 weeks.
Methodology:
The incidence of maternal (i..e, Preeclampsia,
Polyhydramnios,
Preterm
labour,
Antepartum
Haemorrhage, Postpartum Haemorrhage) and fetal
complications ( i.e., Macrosomia, ICU admissions,
Hypoglycemia, Hyperbilubinemia, Intra Uterine Death,
Still born) which developed in those GDM patients were
retrospectively analyzed from the medical records and
the data was presented as percentage of complications.
RESULTS
A total of 2070 cases delivered during the study period in
which 189 cases were detected to be Gestational
Diabetes Mellitus, out of which 120 (63.49%) cases
developed co-morbidities with GDM.
Maternal complications: 21 cases (11.11%) developed
preeclampsia, 18 cases (9.52%) had polyhydramnios, 11
patients went into preterm labour i.e. 5.8%, 3 cases had
APH (1.58%) and one case had PPH.
Fetal complications: 37 cases developed macrosomia,
i.e. 19.57% (birth weight for Indian standards was taken
as >3500 gms), 22 babies were admitted to NICU and 14
developed hypoglycemia (7.40%) and 7 babies had
hyperbilirubinemia (3.70%). 6 Intra Uterine Deaths
(3.17%) and 2 still borns (1.05%) were documented.
Table 1: Maternal & Fetal Complications with GDM
Maternal complications
Fetal complications
N (%)
Preeclampsia
21(11.1)
Macrosomia
37 (19.6)
Polyhydramnios 18 (9.5)
NICU
22 (11.6)
admissions
Preterm labour 11 (5.8) Hypoglycemia 14 (7.40)
Antepartum
3 (1.58)
Hyperbilirubin 7 (3.70)
Haemorrhage
emia
Postpartum
1 (0.52)
IUD
6 (3.17)
Haemorrhage
Still borns
2 (1.5)
DISCUSSION
The incidence of GDM in the present study was found to
be 9.13 %. In India the prevalence of GDM varied from
[6]
3.8 to 21% across the different regions and 63.49% of
GDM cases developed complications. Macrosomia in
this study was found to be 19.57% which is similar to a
[7]
study in which the incidence of macrosomia was 18%.
Currently, it is not known whether the overlap in GDM
and hypertensive disorders reflects a common causal
pathway. Both GDM and hypertensive disorders are
associated with factors such as insulin resistance,
[8]
inflammation, and maternal fat deposition patterns . In
a randomized MiG trial, which only included GDM
women, about 5.0% of women had gestational
[9]
hypertension and 6.3% had pre-eclampsia. However,
[10]
the randomized ACHOIS trial reported that 15% of its
GDM population had pre-eclampsia, and in the present
study Pre eclampsia was associated with GDM in
11.11% of patients.

Ambarisha et al.,

In 1987, Cousins reviewed the literature published in


English from 1965 to 1985 on the impact of diabetes on
the frequency and severity of obstetric complications.
[11]
Hydramnios was found to be 5.3%
where as it was
9.52% in the present study
Preterm delivery is usually defined as delivery <37
weeks gestation. While acknowledged as a risk of GDM,
spontaneous preterm delivery is less common compared
[3]
with other adverse outcomes. . In the present study the
incidence of preterm delivery was 5.3%. In the HAPO
study, approximately 1608 of the 23,316 participants
(6.9%) experienced preterm delivery (both induced and
spontaneous), compared with 9.6% of infants who were
LGA and 8.0% of infants who underwent intensive
[12]
neonatal care admission.
The association between
GDM and preterm delivery may be partially explained by
the coexistence of other conditions with GDM that may
lead to indicated or induced preterm delivery. Such
conditions include pre-eclampsia and hypertensiveassociated conditions, such as intrauterine growth
restriction
and
placental
abruption.
However,
spontaneous preterm birth, or birth in the absence of
conditions prompting medical intervention, accounts for
approximately three-quarters of preterm births and is not
[12, 13]
associated with GDM.
. In the present study 3 cases
had antepartum haemorrhage and one patient had post
partum haemorrhage following a cesarean section where
the neonatal birth weight was 3.9 kgs. In this study 22
babies had NICU admission and 14 babies were
admitted for neonatal hypoglycemia. The reasons for
neonatal hypoglycemia include physiologic fluctuations in
glucose seen in GDM women, apart from treatment.
Maternal hyperglycemia is thought to lead to excess fetal
glucose exposure and fetal hyperinsulinemia. In turn,
fetal hyperinsulinemia is thought to lead to hyperplasia of
fat tissue, skeletal muscle, and subsequent neonatal
[14]
hypoglycemia.
In ACHOIS, the prevalence of clinical
hypoglycemia was 7% in GDM receiving intervention and
[10]
5% in GDM not receiving intervention,
which was
similar to 7.4% in the present study.
Hyperbilirubinemia is more common among women with
GDM than in women without GDM. Maternal
hyperglycemia and the subsequent induction of fetal
hyperinsulinemia and reduced oxygenation are
hypothesized to lead to increased fetal oxygen uptake,
fetal
erythropoiesis,
and
subsequent
[15]
[12]
hyperbilirubinemia.
In the HAPO study
8.3% of the
babies were affected with hyperbilirubinemia in
comparison with 3.7% in this study. In more recent years
and in industrialized nations, stillbirth is an uncommon
outcome, even among women with glucose intolerance.
Reduced stillbirth rates have been attributed to initiation
of insulin therapy combined with closer monitoring and
[16]
subsequent induction of labor as necessary. In a study
population consisting primarily of women with GDM, the
[17]
stillbirth rate was approximately 1.4 per 1000 births. .
3.17% fetal death an 1.05% neonatal death were
documented in this study. In HAPO, only 130 women
(0.56%) of the 23,316 deliveries experienced a perinatal
death, 89 of which were fetal and 41 of which were
[12]
neonatal.

776
Int J Med Res Health Sci. 2015;4(4):775-777

The effects of GDM upon fetal health may still be


conceptualized through the framework of the Pederson
[18]
hypothesis,
which postulated that intrauterine
exposure could lead to permanent changes in fetal
metabolism. During the GDM pregnancy, the fetus may
be imprinted or programmed, resulting in excess fetal
growth, decreased insulin sensitivity, and impaired
insulin secretion. In the short term, elevated infant birth
weight confers perinatal risks, such as shoulder dystocia
and infant hypoglycemia. In the longer term, altered fetal
metabolism may be associated with impaired glucose
[19]
tolerance during early youth and adolescence.
The
reduced beta-cell reserve in GDM women can manifest
[20]
in the decade after delivery. Even among women who
have a normal postpartum glucose tolerance test, the
risk of future diabetes may be up to seven-fold higher
[21]
than in women without histories of GDM.
As many as
one-third of women with diabetes may have been
[22]
affected by prior GDM.
In turn, the increased risk of
diabetes
is
associated
with
future
maternal
[23]
cardiovascular disease.
CONCLUSION
The prevalence of GDM will continue to increase as
obesity rates rises. There are sufficient evidences to
show the association between hyperglycemia and
adverse maternal and perinatal outcomes in the mother
and offspring. A close attention to the fetal growth along
with maternal glucose and weight monitoring during
pregnancy and also in the postpartum period will
minimize adverse outcomes. GDM is a condition which is
worth monitoring and treating, since it has been
demonstrated that good metabolic control maintained
throughout gestation can reduce maternal and fetal
complications.
Conflict of Interest: None
REFERENCES
1. Metzger BE, Coustan DR (Eds.): Proceedings of the
Fourth International Workshop- Conference on
Gestational Diabetes Mellitus. Diabetes Care
1998;21(suppl. 2):B1-B167.
2. Langer O. Management of gestational diabetes:
pharmacologic treatment options and glycemic
control. Endocrinol Metab Clin North Am.
2006;35(1):53-78.
3. Gestational diabetes: risks, management, and
treatment options, Int J Womens Health. 2010; 2:
339351
4. Metzger BE. Long-term outcomes in mothers
diagnosed with gestational diabetes mellitus and
their offspring. Clin Obstet Gynecol.2007;50:972-79.
5. ADA Clinical Practice Guidelines 2011. Diabetes
Care. 2011;34(suppl 1):S4-S5.
6. Seshaiah V, Sahay BK, Das AK, Shah S, Banerjee
S, Rao PV et al. Gestational diabetes mellitus-Indian guidelines. J Indian Med Assoc. 2009
Nov;107(11):799-802, 804-806.
7. Vedavathi KJ , Swamy Rm , Kanavi Roop
Shekharappa , Venkatesh G , Veerananna HB
Influence of Gestational Diabetes Mellitus on Fetal

Ambarisha et al.,

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

growth parameters. Int J Biol Med Res. 2011; 2(3):


832-834
Seely E, Solomon C. Insulin resistance and its
potential role in pregnancy-induced hypertension. J
Clin Endocrinol Metab. 2003;88(6):23932398.
Rowan J, Hague W, Gao W, Battin M, Moore M.
MiG Trial Investigators. Metformin versus insulin for
the treatment of gestational diabetes. N Engl J Med.
2008;358(19):20032015.
Crowther C, Hiller J, Moss J, et al. Effect of
treatment of gestational diabetes mellitus on
pregnancy
outcomes.
N
Engl
J
Med.
2005;352(24):24772486.
Cousins L: Pregnancy complications among diabetic
women: review 1965-1985. Obstet Gynecol Surv ,
1987;42:140-49
HAPO Study Cooperative Research Group.
Hyperglycemia and adverse pregnancy outcomes. N
Engl J Med. 2008;358(19):19912002.
ACOG Committee on Practice Bulletins Obstetrics.
ACOG practice bulletin. Management of preterm
labor. Int J Gynaecol Obstet. 2003;82(1):127135.
HAPO Study Cooperative Research Group.
Hormonal and metabolic factors associated with
variations in insulin sensitivity in human pregnancy.
Diabetes Care. 2010;33(2):356360.
Ferrara A, Weiss N, Hedderson M, et al. Pregnancy
plasma glucose levels exceeding the American
Diabetes Association thresholds, but below the
National Diabetes Data Group thresholds for
gestational diabetes mellitus, are related to the risk
of neonatal macrosomia, hypoglycaemia, and
hyperbilirubinaemia. Diabetologia. 2007;50(2):298
306.
ACOG Practice Bulletin. Clinical management
guidelines for obstetrician-gynecologists. Obstet
Gynecol. 2001;98(3):525538.
Girz B, Divon M, Merkatz I. Sudden fetal death in
women with well-controlled intensively monitored
gestational diabetes. J Perinatol. 1992;12(3):22933
Pedersen J. Weight and length at birth in infants of
diabetic mothers. Acta Endocrinol. 1954;16(4):330
42
Catalano P, Kirwan J, Haugel-de Mouzon S, King J.
Gestational diabetes and insulin resistance: Role in
short- and long-term implications for mother and
fetus. J Nutr. 2003;133(5 Suppl 2):S1674S1683.
Kim C, Newton K, Knopp R. Gestational diabetes
and incidence of Type 2 diabetes mellitus: A
systematic
review.
Diabetes
Care.
2002;25(10):186268.
Bellamy L, Casas J, Hingorani A, Williams D. Type
2 diabetes mellitus after gestational diabetes: A
systematic review and meta-analysis. Lancet.
2009;373(9677):177379.
Cheung N, Byth K. Population health significance of
gestational
diabetes.
Diabetes
Care.
2003;26(7):200509.
Carr D, Utzschneider K, Hull R. Gestational diabetes
mellitus increases the risk of cardiovascular disease
in women with a family history of Type 2 diabetes.
Diabetes Care. 2006;29(9):207883.

777
Int J Med Res Health Sci. 2015;4(4):775-777

DOI: 10.5958/2319-5886.2015.00153.8

Available online at: www.ijmrhs.com

Research article

Open Access

MORBIDITY PROFILE, HEALTH SEEKING BEHAVIOUR AND HOME


ENVIRONMENT SURVEY FOR ADAPTIVE MEASURES IN GERIATRIC
POPULATION - URBAN COMMUNITY STUDY
1

*Warbhe Priya A , Warbhe Rupesh

ARTICLE INFO
Received: 10th June 2015
Revised: 24th August 2015
Accepted: 20th September 2015
Authors details: 1Assistant Professor,
Department of Community Medicine,
Grant Government Medical College,
Mumbai, Maharashtra, India. 2Research
Officer, NIRRH, Mumbai.
Corresponding author: Warbhe Priya A
Assistant Professor, Department of
Community Medicine, Grant Government
Medical College, Mumbai, Maharashtra,
India
Email: priyawarbhe@gmail.com
Keywords: Geriatric, Morbidity profile,
Adaptive measures, Health seeking
behaviour, Home environment survey

ABSTRACT
Background: Population ageing is a significant product of demographic transition.
Declining fertility and improved health and longevity have generated rising
proportions of the older population. Double burden of communicable and noncommunicable diseases affects the geriatric segment of the population with
variable health seeking behaviour. Objectives: To assess morbidity profile,
health seeking behaviour and home environmental survey for adaptive measures
in geriatric population from an urban community. Material and Methods: Crosssectional study stratified systematic random sampling was applied. Research tool
was interviewer based closed ended questionnaire. Adaptive measures as part of
environment survey were assessed. Proportions and Pearsons chi-square test
were calculated. Results: 64.1% participants were from 60-69 years age
category, 9.1% current smokers. 94.1% had 1-3 morbidities, 4.1% had 4-6
morbidities .37.3% gave a history of fall and 31.4% history of fracture. 13.6%
cataract operation, 16.8% procedure for fracture.10% had dental procedure.
54.2% went to UHC and GOVT/BMC hospitals for treatment and 78.6% received
both allopathic and ayurvedic treatment. History of fall was not associated with
adaptive measures in the house (p=0.952). Conclusions: Majority of the
participants suffered from old age related morbidities, hypertension emerged as a
major morbidity. Most of the participants relied on government hospitals for
treatment. Adaptive measures were lacking in most of the houses.

INTRODUCTION
The worlds population is ageing at an uncontrolled rate.
Population ageing is a major demographic trend
worldwide. Declining fertility and improved health and
longevity resulted in rising older population. Older
population has also increased because of improvement in
health services; educational status and economic
development. Ageing is a reward of recent years which is
due to improved public health, sanitation and
development. The global population aged 65 and over
was estimated to be 506 million as of midyear 2008, about
7 percent of the worlds population. (ranging from 13
percent to 21 percent) By 2040, the world is projected to
have 1.3 billion older people- accounting for 14 percent of
the total. The fastest growing portion of the older
population in many nations is the oldest- old, those aged
.[3,11,15]
80 years and above
India is also in a phase of demographic transition. As per
the 1991 census, the population of elderly in India was 57
million as compared to 20 million in 1951. There has been a
sharp increase in the number of elderly persons between
1991 and 2001 and it has been projected that the numbers
of elderly in India will increase to 100 million in 2013 and to
198 million in 2030.By the year 2050, the number of elderly
people would raise to about 324 million. India has thus
acquired the label of an ageing nation with 7.7% of its
population being more than 60 years old. India as the
second most populous country has 76.6 million people at or
[7]
over the age of sixty years.
According to recent WHO projection, over three-quarters of
death occurring in the developing world by the year 2020

will be due to non- communicable diseases. Communicable


diseases and injuries will contribute to the rest 25% of
deaths. Thus there will be double burden in developing
countries. This scenario of double burden also affects this
older segment of the population. Many diseases have
iceberg phenomenon so that submerged aspects are not
revealed to the health system unless they are actively
searched for. These problems have their effect on the
quality of life of the old person. Mental health, social health
and financial position of the person gets disturbed due to
these problems, which further increases the financial
[11]
burden on the country for their treatment.
Disease burden: - Major causes of morbidity among elderly
[10]
according to ICMR are as follows
Table 1: Major causes of morbidity among elderly
according to ICMR
Diseases
Percentages

Priya et al.,

Int J Med Res Health Sci. 2015;4(4):778-782

Visual impairment

88

Locomotor disabilities

40

Neurological diseases

18.7

Cardiovascular diseases
Respiratory diseases

17.4
16.1

Skin diseases

13.3

Falls are due to the complex interaction between a


variably impaired patient and an environmental challenge.
With age, balance becomes impaired and sway increases.
The resulting vulnerability predisposes the older person to

778

fall. Most falls occur in or around the home due to


environmental obstacles. Adequacy of illumination (older
people needs twice as much as younger people); absence
of glare and shadows; accessible switches at room
entrances; night light in bedroom, hall, bathroom are
modification in home environment for elderly. Most falls
occurs in or around the home due to environmental
obstacles. Floors, stairs, kitchen, bathroom, yard and
entrances need adaptive measures as modification in
[9]
environment for elderly to avoid falls .
Studies done earlier on this topic were hospital based and
had a rehabilitation approach. Current study has
community approach which assesses morbidities in
geriatric population. Study also assesses health seeking
behavior. Falls and fracture is a common consequence of
poor adaptive measures in houses which usually affect the
eldery population so a survey of household environment
for adaptive measures was carried out.
MATERIALS AND METHODS
This study was carried out at a residential colony in an
urban community. The health problems of population from
this residential colony is catered by Urban Health Centre
which is a part of a tertiary care teaching institute, located
in same area. January 2008 September 2009
Study design: Descriptive Cross sectional study
Inclusion criteria: participants who are willing to
participate after taking their written informed consent with
age - 60 years and above.
Sample size: Prevalence of 60+ population is 7.3 and
applying sample size calculation formula n = 170 Sampling
method: Stratified systematic random sampling method was
used as a sampling technique. Sample size as calculated is
170. 5%, 20%, 35% and 40% of participants out of 170
were recruited from class I to IV respectively for
representational purposes. These percentages are as per
the record maintained at the urban health centre. A total of
173 households were visited with a response rate of 98%.
From some households all geriatric participants fitting the
inclusion criteria were included from single house. Hence
finally 14, 44, 74 and 88 participants were enrolled for the
study from class I to IV respectively. This amounts to a final
[1]
sample size of 220.
Ethical approval and Consent: -The study was initiated
after written approval from the institutional ethics committee
of the parent institution. Informed, valid and written consent
was collected from every geriatric participant included in the
study.
Pilot study and questionnaire testing: Pilot study was
conducted to test the feasibility and accuracy of the
proforma. 50 participants more than 60 years of age were
interviewed at random. The participants included in the pilot
study were not included in the actual study.
Research instrument: - Face to face interview was
conducted by the investigator with the questionnaire which
is research instrument. It includes socio-demographic data,
personal history and past history record of physician
diagnosed morbidities and procedure done. It also included
questions related to home environment for survey of
household lighting and adaptive measures. Age 60 years
and above is considered as geriatric age group they are
further classified into young-old (60-69 years), old-old (70-

[5]

79 years) and oldest-old (80 years and above).


Statistical analysis: Pearsons chi-square test was applied
to test the relationship of categorized independent and
dependent variables. If expected number in the cell was
below 5 in a table, Fischers Exact test (Exact Two sided)
was used. A p value (significance) of<0.05 is deemed
statistically significant. Stata SE 10.1 was used to analyse
data.
RESULTS
220 participants were enrolled in the study. 64.1%
participants were from young-old (60-69 years) category,
27.7% were from old-old (70-79 years) and 8.2% from
oldest-old (>=80 years) category. 61.4% participants were
female and 38.6% were males. 29.5% were illiterate, 23.6%
received primary education, 30.5% received secondary
education, 14.1% received higher secondary education and
2.3% participants were graduates.73.6% were married,
25.9% were widow/widower, one participant was divorced.
70% participants did not receive any pension and 79.5%
were economically dependent on other family members
(Table 2).
Table 2: Socio-demographic status
Variable
Frequency (n) %
Age groups (Years)
60-69
141
64.1
70-79
61
27.7
>= 80
18
8.2
Gender
Males
85
38.6
Females
135
61.4
Education
Illiterate
65
29.5
Primary
52
23.6
Secondary
67
30.5
Higher Secondary
31
14.1
Graduation
05
2.3
Marital status
Married
162
73.6
Widow/Widower
57
25.9
Divorced/Separated
01
0.5
Pension
Yes
66
30
No
154
70
83.2% of participants lacked moderate physical activity.
58.6% did not participate in any leisure activity, 25% spend
leisure time in reading/writing, and 16.4% had group activity
as leisure time spending activity. (Table 3)
Table 3: Physical and leisure time activity status
Variable
Frequency(n) %
Moderate physical activity
Yes
37
16.8
No
183
83.2
Leisure time activity
Reading/writing
55
25.0
Crossword/ Puzzle games 00
0.0
Group activity
36
16.4
Others
00
0.0
None
129
58.6

779
Priya et al.,

Int J Med Res Health Sci. 2015;4(4):778-782

9.1% of participants were current smokers. 0.9% currently


addicted to alcohol. 10% were currently addicted to
tobacco and 10% were currently addicted to betel-nut.
(Table 4)
Table 4: Addiction status
Variable
Frequency (n) %
Smoking History
Non-smoker
171
77.7
Ex-smoker
29
13.2
Current
20
9.1
Alcohol consumption
Never
168
76.4
Occasional
21
9.5
Ex-drinker
29
13.2
Current
02
0.9
Tobacco addiction
Never
176
80.0
Ex-addict
22
10.0
Current
22
10.0
Betel nut addiction
Never
184
83.6
Ex-addict
14
6.4
Current
22
10
Morbidity profile:
19.5% participants suffered from
hypertension and O.A., 8.3% suffered from Diabetes
mellitus, 7.7% from only hypertension, 6.4% from
hypertension and cataract, 5.5% from IHD, 37.7% suffered
from other combination of diseases, 4 participants did not
suffer from any diseases. 13.6% participants had cataract
operation, 16.8% had procedure for fracture, 10% had
dental procedure and 26.8% had history of operations for
other conditions (Table 5).
Table 5: Morbidity profile
Variable
Freque
%
ncy (n)
Type of morbidities
Hypertension and O.A.
43
19.5
D.M.
18
8.3
Hypertension
17
7.7
Hypertension and cataract
14
6.4
IHD
12
5.5
Anemia, Hypertension, and 11
5.0
O.A.
O.A. and asthma
10
4.5
Hypertension and D.M.
08
3.6
None
04
1.8
Other combination of diseases
83
37.7
History of procedure/operation
Cataract
30
13.6
Dental
22
10.0
Fracture
37
16.8
Others
59
26.8
Combination
21
9.5
None
51
23.3
1.8% participants had no morbidities, 94.1% had 1-3
morbidities, 4.1% had 4-6 morbidities and none of the
participants had 7-9 morbidities. (Table 6)

Table 6: No. of Morbidities


Variable
Frequency (n)
%
No .of morbidities
0
04
1.8
1-3
207
94.1
4-6
09
4.1
7-9
00
0.0
37.3% participants gave a history of fall and 31.4% gave
history of fracture (Table 7)
Table 7: Fall and Fracture
Variable
Frequency (n)
%
Fall history
Yes
82
37.3
No
138
62.7
Fracture history
Yes
69
31.4
No
151
68.6
Treatment seeking behaviour: 54.2% participants went to
UHC and Govt/BMC hospital for treatment and 78.6%
received allopathic and ayurvedic treatments (Table 8).
Table 8: Treatment seeking and treatment received
Variable
Frequency n
(%)
Treatment seeking
UHC
08
3.6
Govt/BMC hospitals
05
2.3
Private hospitals
21
9.5
UHC and Govt/BMC hospitals
119
54.2
UHC and Private hospitals
19
8.6
Govt/BMC hospitals and private 19
8.6
hospitals
UHC, Govt/BMC and private 29
13.2
hospitals
Type of treatment received
Frequency %
Allopathy
25
11.4
Ayurvedic
00
0.0
Homeopathy
00
0.0
Allopathy and Ayurvedic
173
78.6
Allopathy and Homeopathy
04
1.8
Allopathy,
Ayurvedic
and 18
8.2
Homeopathy
Adaptive measures assessment: 12.3 % participants had
inadequate lighting in their house. 82.7% participants did
not have adaptive measures in house to avoid fall (Table
9).
Table 9: Adaptive measures assessment
Variable
Frequency n (%)
Household lighting
Proper
193
87.7
Improper
27
12.3
Adaptive measures
Yes
38
17.3
No
182
82.7
The association between fall history and household lighting
was not statistically significant. (Table 10)

Priya et al.,

Int J Med Res Health Sci. 2015;4(4):778-782

780

Table 10: Association between fall


household lighting
Fall history Household lighting
Proper
Inadequate
Yes
76(92.68)
6(7.32)
No
117(84.78) 21(15.22)
Total
193(87.73) 27(12.27)

history

and

[14]

Socio-demographic data from 220 geriatric participants


reveals majority of the participants are from young-old
category i.e 64.1% were from young-old category
remaining 27.7% were from old-old and 8.2% from oldestold category. Similarly a study carried out in urban area of
Kashmir valley shows 66.6% participants were from 65-74
years age group, 26.8% and 6.6% from 75-84 and more
than 85 years age group respectively. Gaash B. et al.
[6] .
(2008)
Also a study carried out among elderly people in
Northern India had 68% participants from 61-72 age
group, 23 % participants from 73-84 age group and 9%
[12]
from 85+ age group. Kumar R. et al (2003)
. As age
advances population faces mortality which results in
majority as young old population and diminishing oldestold population. But recent trend shows that the fastest
growing portion of the older population in many nations is
the oldest- old, those aged 80 years and above due to
improvement in health services, sanitation and overall
development. In this study 61.4% were female geriatric
participants. Similarly study on elderly in Karnataka shows
61.9% and 80.1% males and females respectively in age
[13]
group 60-69 years. Leena A. et al. (2009)
.Females
have more life expectancy hence they tend to outnumber
the male geriatric participants. In this study 70% of
participants did not receive any pension. 60 years and
above reflects retired population in India. Loss of work
brings economic dependence also most of the participants
did not receive any pension which adds to their
[9]
dependency on other family members . Also study on
elderly from an urban slum shows 58.42% participants
were economically dependent on their children. Gurav R.
[8]
et. al. (2002) . In this study 83.2% lacked moderate
physical activity. Similarly study of health profile of aged
persons in urban field practice areas of medical college
Amritsar shows 32.97% of urban aged persons were going

for morning or evening walk. Padda A. et al. (1998) . In


the current study 58.6% participants did not participate in
any leisure activity, 25% in reading and writing, 16.4% in
group activity. Study of health profile of aged persons in
urban field practice areas of medical college Amritsar
shows 33.69% of urban aged were reading newspaper or
[14]
books. Padda A. et al. (1998) .
History regarding addiction revealed 9.1% were currently
smokers. 0.9% currently addicted to alcohol. 10% were
currently addicted to tobacco. Study among geriatric
population in Udaipur by Choudhary S. et al (2004) had
62.66% non-smokers, 22% current smokers and 10.66%
[4]
ex-smokers. 4.6% were addicted to tobacco chewing .
History regarding past history of physician diagnosed
diseases conditions and verification of drug prescription by
the investigator revealed that 19.5% participants suffered
from hypertension and O.A., 8.3% suffered from Diabetes
mellitus, 7.7% from only hypertension, 6.4% from
hypertension and cataract, 5.5% from IHD which shows
hypertension as the major emerging mortality among the
geriatric population. Similar result is seen in a study by
Leena A. et al. (2009) on elderly in Karnataka which
showed 59.1% had hypertension, 10.3% had diabetes,
[12]
41.3% had osteoarthritis
. Also study by Bhatia S. et al.
(2007) among elderly in Chandigarh showed main health
problems among aged were those of the circulatory system
51.2%,
with about two-fifth 41.6% suffering from
hypertension, followed by those of musculoskeletal system
and connective tissue disorders 45.7%, cataract was seen
[2]
in 18.6% .
History regarding past history of operation/ procedure done
which is verified by medical documents by investigator
revealed that 13.6% participants had cataract operation,
16.8% had procedure for fracture, 10% had dental
procedure. Study by Kumar R et al. (20003) carried out
among elderly in Northern India shows 27% had undergone
[12]
a cataract surgery .
A count of morbidities in geriatric participants showed 1.8%
participants had no morbidities, 94.1% had 1-3 morbidities,
4.1% had 4-6 morbidities and none of the participants had
7-9 morbidities. Study by Gaash B. et al. (2008) carried out
in urban area of Kashmir valley shows 88.9% of the study
population was suffering from at least one ailment while
69.9%, 47.3% and 16.9% of population, respectively, had
.[6]
two, three and four or more ailments Study by Kumar R et
al. (2003) among elderly people in Northern India shows
majority of subjects i.e 42.5% were diagnosed as having 46 morbidities, 23% had 7-9, 1-5% had a maximum of 13
.[12]
and only 0.5% had no morbidities
History regarding fall and fracture revealed 37.3%
participants had history of fall and 31.4% had history of
fracture. History of fall and fracture is common in old age
due to gait and balance impairment. Study carried out by
Kumar R et al. (2003) among elderly in Northern India
showed 51.5% subjects gave a history of fall and fracture
[12]
was reported from 21.3%
Treatment seeking behaviour among the geriatric
participants showed 54.2% participants went to UHC and
Govt/BMC hospital for treatment and 78.6% received
allopathic and ayurvedic treatments. Study carried out
among elderly people in Northern India by Kumar R. et al
(2003) showed that 43.5% participants were seeking

Priya et al.,

Int J Med Res Health Sci. 2015;4(4):778-782

Total
82
138
220(100)

Pearsons chi square= 2.98, df=1,p=0.084(NS*)


Figures in parenthesis indicates percentages
NS- Not Significant
The association between fall history and adaptive
measures in house was not statistically significant. (Table
11)
Table 11: Association between fall history and
adaptive measures in house
Fall
Adaptive measures
Total
history
Yes
No
Yes
14(17.07) 68(82.93)
82
No
24(17.39) 114(82.61) 138
Total
38(17.27) 182(82.73) 220(100)
Pearsons chi square= 0.0036, df=1, p=0.952(NS).
Figures in parenthesis indicates percentages
DISCUSSION

781

treatment. Of the participants seeking treatment, 35.5%


were on allopathic treatment, 2.5% were receiving
[12].
ayurvedic treatment and 0.5% were using homeopathy
Current study revealed 12.3 % participants had inadequate
lighting in their house. 82.7% participants did not have
adaptive measures in house to avoid fall. Though the
association between fall history and household lighting was
not statistically significant (p=0.084), also the association
between fall history and adaptive measures in house was
not statistically significant (p=0.952). Limitation of studySample size of 220 participants, association of adaptive
measures and fall/ fracture with a larger sample size needs
to be further studied.

8.

9.
10.

11.

12.

CONCLUSION
13.
Double burden of communicable and non-communicable
diseases affects older section of the population also which
is again emphasized in this study and supported by various
other studies. Also the fastest growing portion of the older
population is the oldest- old, those aged 80 years. Female
geriatric participants outnumber the male geriatric
participants. Hypertension emerged as major morbidity.
Majority of this population suffer from one or more of
morbidities, which are potentially preventable This increase
in life expectancy coupled with morbidities is just adding
years to life. Emphasis should be on adding life to years.
Community based health assessment programme with
home environment survey coupled with educating the
families and caretakers the importance of adaptive
measures in house to prevent fall and fracture can prevent
functional dependency of these elderly and improve quality
of life thus adding years to life.

14.

15.

Gurav R. et al. Problems of geriatric population in an


urban area. Bombay Hospital Journal. 2002: Jan
44(1):12-16.
Harrisons Principle of Internal Medicine. 16th edition.
USA. Mcgraw-Hill Medical Publishing division. 2005.
J. Kishore. National Health Programs of India. National
Policies and Legislations Related to Health. 8th edition.
New Delhi: Century publications; 2009. 720-22.
Kinsella, Kevin and Wan He. An Ageing World .
Washington, DC: U.S. Government printing office;
2009; 38-56
Kumar R et al. Morbidity profile and its relationship with
disability and psychological distress among elderly
people in Northern India. International Journal of
Epidemiology. 2003; 32:978-98.
Leena A. et al. Health and social problems of the
elderly: A cross sectional study in Udipi taluk,
Karnataka. Indian Journal of Community Medicine.
2009; 34: 131-34.
Padda A.S. et al. Health profile of aged persons in
urban and rural field practice areas of medical college
Amritsar. Indian Journal of Community Medicine. 1998;
23: 72-76.
Sharma O.P. Geriatric care in India, Geriatric and
rd
Gerontology a textbook. 3 edition. New Delhi: ANB
publishers; 1999. 12-30.

ACKNOWLEDGMENT
A sincere thank to all the faculty members and the
participants of the study who made this study possible.
Conflict of Interest: Nil
REFERENCES
1.

2.

3.
4.

5.
6.

7.

Abramson J.H. et al. Survey methods in community


medicine. 5th edition. USA: Churchill Livingstone
publication; 1999;45-64.
Bhatia S. et al. A study of health problems and
loneliness among the elderly in Chandigarh. Indian
Journal of Community Medicine. 2007; 32(4): 76-82.
Cassel et al. Geriatric Medicine evidence based
approach. 4th edition. New York: Springer; 2003; 45-70
Choudhary S et al. A study of morbidity pattern among
geriatric population in an urban area of Udaipur,
Rajasthan. Indian Journal of Community Medicine.
2004;29: 35-40.
Detels R et al. Oxford Textbook of Public Health. 4th
edition. USA: Oxford University Press; 2002; 55- 85
Gaash B. et al. Morbidity profile of geriatric population
in Kashmir. Indian Journal of Practising Doctor.
2008;4(6); 92-96.
Government of India. Sample registration system
statistical report. Report no. 4. 2008. 25-40.

782
Priya et al.,

Int J Med Res Health Sci. 2015;4(4):778-782

DOI: 10.5958/2319-5886.2015.00154.X

Available online at: www.ijmrhs.com

Research article

Open Access

MODULATION OF SYMPATHOVAGAL BALANCE AFTER CHANDRANADI


PRANAYAMA IN HEALTHY VOLUNTEERS
1

Chintala Kiran Kumar CH , Bandi Hari Krishna , Mallikarjuna Reddy N

ARTICLE INFO
Received: 10th June 2015
Revised: 14th Aug 2015
Accepted: 9th Sep 2015
1
Authors
details:
Department
of
Physiology, Narayana Medical College,
Nellore,
Andhra
Pradesh,
India,
2
Department
of
Physiology,
Sri
Venkateswara Medical College, Tirupati,
Andhra Pradesh, India

Corresponding author: Chintala Kiran


Kumar CH
Narayana Medical College, Nellore,
Andhra Pradesh, India,
Email: dr.chkirank@gmail.com
Keywords:
Heart
rate
variability,
Autonomic function, Pranayama, Blood
pressure.

ABSTRACT
Background and objectives: Regardless of prevailing advances in yoga
research, the immediate benefit of chandranadi pranayama (CNP) on heart rate
variability was not explored. Therefore, in this study, we planned to study the
immediate effect of CNP on heart rate, blood pressure and HRV. Methods: One
hundred and ten medical students were randomly divided into two groups;
control group (n=55) and CNP group (n=55). CNP group participants were
individually trained to perform CNP by an experienced yoga instructor with a
regularity of 6 breaths/min for five minutes. CG volunteers didnt undergo CNP,
Pre and post intervention HR, BP measurements and spectral analysis of HRV
was done in both the groups. The paired students t test was used to determine
significant differences. Results: There was a significant decrease in HR
(p<0.01), BP (p<0.05), LFnu (p<0.05), LF/HF (p<0.001) and increase in HFnu
(p<0.01) followed by five minutes of CNP in CNP group. Further, HR, SBP, DBP
was reduced by 9.10%, 4.80%, 7.75 % respectively. HRV results showed 7.59%
reduction in LFnu, 17.8% reduction in LF/HF and HF was increased by 12.37%.
There were no significant changes in CG. Conclusion: It is concluded that CNP
is beneficial in reducing HR, BP and to improve Sympathovagal balance. We
advise that this effective method be included with the management protocol of
hypertension and utilized when immediate reduction of blood pressure is
required in day-to-day as well as clinical situations.

INTRODUCTION
Yoga is mind-body practice which consists of relaxation,
meditation together with a group of physical exercises
carried out in sync with breathing. Being holistic, it will
be ideal means for achieving physical, mental, social
and spiritual well being of the practitioners. This may
be attained by methodical and well organized practice
of ashtanga (eight-limbed) yoga described by sage
Patanjali. The first two limbs of ashtanga yoga are
yama and niyama which are ethical code and
personal discipline for the development of our moral,
rd
th
spiritual and social aspects. 3 and 4 limbs are asana
and pranayama which help in our physical development
th
th
and improvement of physiological functions. 5 and 6
limbs are pratyahar and dharna for controlling our senses
[1]
and making our mind one-pointed, calm and alert .
Prana means breath, wind, life, energy, and vitality.
Ayama means length, stretching, restraint or expansion
It is the science of breath. There are many techniques of
pranayama. In humans, the left and right nostril will not
work at the same time. One of the nostrils is usually more
congested as compared to the other no matter if the nasal
passages are clean and unobstructed by mucus. This
congestion alternates between the right and left nostril
[2]
through the day and night .The influence of CNP on
cardio respiratory as well as autonomic function
[3,4,5]
parameters were investigated only these days
. with
exceptionally conflicting outcomes; the authors describing
increase, decline and no alterations in Respiratory rate
(RR), Heart rate (HR), and Galvanic skin response (GSR).
Furthermore, to the best of our understanding, the
immediate effect of chandranadi pranayama (CNP)

Sympathovagal modulation measured by spectral


analysis of heart rate variability (HRV) was not explored.
Therefore, the present study was planned to investigate
the immediate effects CNP on HR, SBP, DBP and HRV.

Chintala et al.,

Int J Med Res Health Sci. 2015;4(4):783-785

MATERIALS AND METHODS


Study design: This was Experimental randomized
controlled trial.
Ethical approval: The procedure was explained to the
volunteers and informed written consent obtained. The
study was approved by the institute ethics committee
Inclusion criteria: The present study was conducted on
110 apparently healthy medical students, aged from 19
22 yrs. The participants were of the same socio economic and nutritional status.
Exclusion criteria: The participants suffering free from
any cardio - respiratory diseases and were using any
drugs which affect autonomic nervous system.
Sample size: 110
Grouping: Divided into two groups Group 1: control
group (CG) (n=55), Group 2: CNP group (n=55) and
Their age, height, weight and food habits were recorded.
The Control group participants didnt receive any
intervention; chandranadi pranayama group participants
underwent the following procedure.
Pranayama procedure: The CNP was done with
subjects in lying down posture and it was ensured that
there was no nasal obstruction. The participants were
individually taught to perform CNP by a qualified and

783

experienced yoga therapist. An overview of the practice


was given to the subjects. They were asked to keep their
eyes closed. The subjects were instructed to perform
nasika mudra with their right hand, by touching the tip of
their index finger to the base of their thumb. The right
thumb was then used to close their right nostril with gentle
pressure. The CNP was then performed through the left
nostril in a calm and regular manner with a conscious
effort to use low, mid and upper parts of the lungs in a
sequential manner for both inspiration and expiration.
Subjects were instructed to breathe in and out for an
equal count of 5 that was given by the yoga therapist
throughout the period. A regularity of counts at the rate of
6 breaths/min (BPM) was maintained by the yoga
therapist for the entire duration of nearly 5min taken to
complete 27 rounds of CNP. HRV was recorded before,
during, and immediately after CNP.
Methodology:
Laboratory conditions and assessment of Sympathovagal
balance: All experiments were carried out in the cardiac
autonomic function research laboratory. Sympathovagal
balance was assessed by using spectral analysis of heart
rate variability (HRV). Recording of Short-term HRV
was carried out at 8.00 AM following ten minutes of
supine relaxation. The volunteers were instructed to stay
away from extreme physical exercise for one day and
from drinking of alcohol and caffeinated beverages for
twelve hours before to the recording. The laboratory
o
o
temperature was maintained as 25 C - 28 C and lights
subdued. The volunteers were instructed to void urine
before the recording and asked to sit in the lab to adjust to
the lab environment. First, HR and ascultatory BP were
recorded after the volunteer had been sitting calmly for
ten minutes. The mean of 3 successive recordings with an
optimum difference of 4 mm Hg of both SBP and DBP
[6]
was taken . Then with eyes closed at supine rest and
relaxed posture, lead II ECG was recorded at 200
samples/second
for
ten
minutes
with
12-18
breaths/minute using an ECG machine (Cardiowin
system, PC based 12 channel simultaneous digital ECG,
Genesis Media System Pvt. Ltd, India). The task force
[7]
recommendations on HRV were followed
; an RR
interval collection was acquired from ECG with optimum
amplitude and sharpness of the peaks for R wave
identification. After exclusion of artifacts and ectopics, a
stationary 256s RR interval collection was selected and
analyzed with Kubios HRV Version 2.0 software for
HRV (Bio-signal analysis Group, Finland). The RR
series was resampled at 4Hz, its mean and trend
removed, a Hann window applied and the 1024 data-point
series was transformed by Fast Fourier Transformation
(FFT). Frequency domain indices such as total power
(TP), normalized LF power (LFnu), normalized HF power
[8]
(HFnu) and LF-HF ratio were calculated .
Statistical analysis: Statistical analysis was performed
by using SPSS 16. All data passed normality testing by
Kolmogorov-Smirnov test and hence was analyzed using
Students t test for paired data. P values less than 0.05
were accepted as indicating significant differences
between pre and post intervention data.

RESULTS

Chintala et al.,

Int J Med Res Health Sci. 2015;4(4):783-785

The baseline characteristics of the subjects were given in


Table 1. There were no significant differences in baseline
parameters. Results of the pre and post CNP
comparisons are given in Table 2 and Fig 2-7. All values
are given as mean SD. No significant differences were
found in CG Table 2. Five minutes of CNP produced an
immediate decrease in all the measured cardiovascular
parameters with the decrease in HR (p<0.01), SBP
(p<0.05), DBP (p<0.05). Spectral analysis of HRV showed
significant reduction in LFnu (p<0.05), LF/HF (p<0.001)
and significant increase in HFnu (p<0.01). HR, SBP, DBP
was reduced by 9.10%, 4.80%, 7.75 % respectively. HRV
results showed 7.59% reduction in LFnu, 17.8% reduction
in LF/HF and HF was increased by 12.37%.
Table 1: Baseline physiological characteristics of
participants.
Parameter

CNP group (n=55)

Control group
(n=55)
19.48 + 3.21

Age (year)
20.23 2.45
Gender
42/13
39/16
(male/female)
Height (cms)
172.56 34.45
171.67 31.23
Weight (kg)
67.51 12.45
65.44 11.19
2
BMI (kg/m )
22.7 6.24
22.21 5.92
2
BSA (m )
1.83 0.34
1.77 0.29
Data expressed as mean + SD
Table 2: Values of HR, SBP, DBP and HRV parameters
in Control group (Baseline and after 5mins),
Immediate effect of chandranadi pranayama.
Para
meter

HR
(bpm)
SBP
(mmhg)
DBP
(mmhg)
LFnu
HFnu
TP
(ms2)
LF-HF

Group1 Control group

Group II
( Interventional group CNP)
Parameter Baseline
Before
After CNP %
CNP
change
78.7+ 7.36 77.45 + 7.12 79.45 + 8.46 72.22+8.1** 9.10
119.4+ 12.6 118.43+11.2 118.24+13.5 112.6+12.3* 4.80
76.45+11.12 78.34+ 12.8 78.44+10.25 72.4+ 11.5*

7.75

61.0+ 13.18 63.0 + 7.42 62.0 + 12.08 57.3+ 8.45* 7.59


39.0+ 13.18 37.0 + 7.42 38.0 + 12.08 42.7+ 8.45** -12.37
190+ 79.56 191+ 55.46 185 + 88.34 177 + 65.45 4.3
1.61+ 0.29

1.7 + 0.55

1.63 + 0.34

1.3+ 0.25*** 17.8

P<0.05; P<0.01; P<0.001.


HR: Heart rate; SBP: Systolic blood pressure; DBP:
Diastolic blood pressure; LFnu: Normalized units of low
frequency component of HRV; HFnu: Normalized units of
high frequency component of HRV; TP: Total power; LFHF: Low frequency to high frequency ratio.
DISCUSSION
In the present study, following five minutes of CNP, there
was a decrease in HR, SBP, DBP, LFnu, LF/HF and
increase in the HFnu (Table 2). The low frequency band
(0.05-0.15Hz) of the heart rate variability spectrum is
thought to correspond to sympathetic modulation,
especially when expressed as normalized as opposed to
[7]
absolute units . The representation of low frequency and

784

high frequency energy values in normalized units


expresses the degree of control exerted and the relative
balance of the two branches of the autonomic nervous
system. The efferent vagal activity is a major contributor
to the high frequency band (0.15-0.50Hz). The low
frequency/high frequency ratio is correlated with the
[9]
sympathovagal balance .
The immediate reduction in HR, SBP, DBP, LFnu and
LF/HF followed by five minutes CNP in our participants
can be explained by changes in the autonomic balance as
it has been previously reported that sympathetic activity is
[5]
lower during left nostril breathing . It has also been
reported that exclusive left nostril breathing, repeated 4
[3]
times a day for a month reduced sympathetic activity .
Our findings are in agreement with those of a previous
[10]
report that left UFNB at the rate of 6 BPM lowers HR .
Another study done on normal volunteers reported a
[11]
significant decrease in blood pressure .
In this study, the reduced LFnu and increased HFnu
indicates the decreased sympathetic activity and
increased parasympathetic activity of heart, further the
reduce LF/HF indicates the shift towards parasympathetic
dominance. Limitations: The HRV tool used to assess
sympathetic activity is not adequate. Therefore, potential
investigations should include precise approaches to
assess the sympathetic activity by using of plasma
catecholamines or metabolites of catecholamines in urine
like vanillylmandelic acid (VMA), metanephrine, and
normetanephrine.
CONCLUSION

4.

Khanam AA, Sachdeva U, Guleria R, Deepak KK.


Study of pulmonary and autonomic functions of
asthma patients after yoga training. Indian J Physiol
Pharmacol. 1996;40(4):31824.
5. Mohan SM. Svara (nostril dominance) and bilateral
volar GSR. Indian J Physiol Pharmacol. 1996
;40(1):5864.
6. Chobanian AV, Bakris GL, Black HR, Cushman WC,
Green LA, Izzo JL, et al. Seventh report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.
Hypertension. 2003;42(6):120652.
7. Heart rate variability: standards of measurement,
physiological interpretation and clinical use. Task
Force of the European Society of Cardiology and the
North
American
Society
of
Pacing
and
Electrophysiology. Circulation. 1996;93(5):104365.
8. Krishna BH, Pal P, Pal G K, Balachander J,
Jayasettiaseelon E, Sreekanth Y, et al. Effect of yoga
therapy on heart rate, blood pressure and cardiac
autonomic function in heart failure. J Clin Diagn Res.
2014;8(1):146.
9. Malliani A, Pagani M, Lombardi F, Cerutti S.
Cardiovascular neural regulation explored in the
frequency domain. Circulation. 1991;84(2):48292.
10. Shannahoff-Khalsa DS, Kennedy B. The effects of
unilateral forced nostril breathing on the heart. Int J
Neurosci. 1993;73(1-2):4760.
11. Raghuraj P, Telles S. Immediate effect of specific
nostril manipulating yoga breathing practices on
autonomic
and
respiratory
variables.
Appl
Psychophysiol Biofeedback. 2008;33(2):6575.

It is concluded that CNP is effective in reducing HR, SBP


and DBP. This may be due to a normalization of
autonomic cardiovascular rhythms with increased vagal
modulation and/or decreased sympathetic activity along
with improvement in baroreflex sensitivity. Further studies
are required to enable a deeper understanding of the
mechanisms involved as well as determine how long such
a BP lowering effect persists. We suggest that this simple
and cost effective method be added to the regular
management protocol of hypertension and utilized when
immediate reduction of blood pressure is required in dayto-day as well as clinical situations.
Conflicts of Interest: Nil.

REFERENCES
1.

2.

3.

Effect Of Yogic Practices On Different Systems OF


HUMAN BODY.doc - yogresearchMMT.pdf [Internet].
[cited
2014
Nov
2].
Available
from:
http://icyer.com/documents/yogresearchMMT.pdf
Jain N, Srivastava RD, Singhal A. The effects of right
and left nostril breathing on cardiorespiratory and
autonomic parameters. Indian J Physiol Pharmacol.
2005 ;49(4):46974.
Telles S, Nagarathna R, Nagendra HR. Breathing
through a particular nostril can alter metabolism and
autonomic activities. Indian J Physiol Pharmacol.
1994 ;38(2):1337.

785
Chintala et al.,

Int J Med Res Health Sci. 2015;4(4):783-785

DOI: 10.5958/2319-5886.2015.00155.1

Available online at: www.ijmrhs.com

Research article

Open Access

OXIDATIVE STRESS AND ANTI OXIDANTS STATUS IN PELLAGRA


1

*Desireddy Neelima , Bandi Hari Krishna , Masthan saheb , Natham Mallikarjuna Reddy .

ARTICLE INFO
th

Received: 11 Jun 2015


Revised: 18th Sep 2015
Accepted: 25th Sep 2015
Authors details: 1Department of
Dermatology Velammal Medical College,
Madurai, Tamilnadu, India.
2
Department
of
Physiology,
Sri
Venkateswara
Medical
College,
Tirupathi, Andhra Pradesh, India
3
Department
of
Dermatology,
Shanthiram Medical College, Nandyal,
Andhra Pradesh, India.
4
Department of Physiology, Narayana
Medical College, Nellore, Andhra
Pradesh, India
Corresponding author:
Desireddy
Neelima,
Department of Dermatology, Velammal
Medical College, Madurai, Tamilnadu,
India.
Email: neelimadermatlogist@gmail.com

ABSTRACT
Background and objectives: Pellagra was vanished from most parts of
the world where it was formerly present due to its dietary modification.
However, it is still encountered among the jowar eating populations of India.
The information about the role of oxidative stress in pellagra was not
established. Therefore, in this study we assessed the oxidative stress
status by using malondialdehyde (MDA), total anti oxidant status (TAOS)
and redox ratio (RER) in clinically diagnosed pellagra patients. Materials
and methods: Clinically diagnosed pellagra patients aged between 18 to
40 years, both male and females were recruited (n=78) from department of
Dermatology. Age and gender matched controls (n=78) were recruited from
the student and residents of the hospital. Malondialdehyde (MDA) is a
marker of lipid peroxidation, Total Anti Oxidant Status (TAOS) and Redox
Ratio (RER) markers were assessed by using commercially available kits.
Results: There were no significant differences in the anthropometric
parameters. However, the oxidative stress markers MDA (p<0.05), RER
(p<0.001) were significantly high and TAOS was low (P<0.001) in pellagra
patients in comparison with age and gender matched controls. Conclusion:
The results of this study showed the increased MDA, RER levels and
decreased TAOS levels. Estimation of these markers at early stage will help
to take measures to prevent the progression of disease and develop
antioxidant strategies.

Keywords: Total anti oxidant status,


Malondialdehyde, Redox ratio, Pellagra.

INTRODUCTION
Pellagra is derived from the Italian Pelle means skin
and Agra signifying rough, in reference to its thickened
rough skin. Pellagra has long been known to be a
nutritional disorder caused by cellular deficiency of niacin,
resulting from inadequate dietary supply of niacin and
[1]
tryptopan .
Pellagra has been reported from most parts of the world
where maize is consumed as a staple diet. Since the
Second World War, pellagra was vanished from most
parts of the world where it was formerly present due to its
dietary modification. However, it is still encountered
[2]
among the jowar eating populations of India .
Oxidative stress is defined as a state in which oxidation
exceeds the antioxidant systems in the body secondary
[3]
to a loss of the balance between them . It not only
causes hazardous events such as lipid peroxidation and
oxidative DNA damage, but also physiologic adaptation
phenomena and regulation of intracellular signal
transduction. Oxidative stress plays a pathological role in
the development of various diseases including diabetes,
atherosclerosis, or cancer. Systemic oxidative stress
results from an imbalance between oxidants derivatives
production and antioxidants defenses. Reactive oxygen
species (ROS) are generally considered to be detrimental
for health. However, evidences have been provided that
they can act as second messengers in adaptative

responses to stress. Obesity represents a major risk


factor for deleterious associated pathologies such as type
2 diabetes, liver, and coronary heart diseases. Many
evidences regarding obesity-induced oxidative stress
accumulated over the past few years based on
established correlations of biomarkers or end-products of
free-radical-mediated oxidative stress with body mass
index. The hypothesis that oxidative stress plays a
significant role in the development of metabolic disorders,
especially insulin-resistance state, is supported by
several studies where treatments reducing ROS
production reverse metabolic alterations, notably through
improvement of insulin sensitivity, hyperlipidemia, or
[4]
hepatic steatosis .
However, the information about the role of oxidative
stress in pellagra was not established. Therefore, in this
study we assessed the oxidative stress status by using
malondialdehyde (MDA), total anti oxidant status (TAOS)
and redox ratio (RER) in clinically diagnosed pellagra
patients.
MATERIALS AND METHODS
Study design: Analytical study

786
Neelima et al.,

Int J Med res Health Sci. 2015;4(4):786-788

Ethics approval: This study was approved by Institute


Ethics Committee, written inform consent was obtained
from all the participants.
Inclusion criteria: Clinically diagnosed pellagra patients
aged between 18 to 40 years, both male and females
were recruited (n=78) from department of Dermatology.
Age and gender matched controls (n=78) were recruited
from the student and residents of the hospital.
Exclusion criteria: Patients suffering from chronic
hypertension, diabetes mellitus, coronary artery diseases
and other diseases were excluded. Age and gender
matched controls were recruited among residents and
staff of our hospital.
Sample size: one hundred fifty six.
Grouping: Group 1: Pellagra patients (n=78), Group 2:
Control (n=78).
Methodology: Age, gender, height, weight were
recorded for all the participants. The medical chart was
reviewed
for
clinical
characteristics, such as
hypertension, diabetes, coronary artery disease etc., 5ml
of blood was collected under aseptic conditions by
venipuncture, allowed to clot and centrifuged at 3,000
o
RPM at 4 C for 10 min and the serum was separated and
o
stored in a frozen state at - 20 C for analysis.
Malondialdehyde (MDA) is a marker of lipid peroxidation,
Total Anti Oxidant Status (TAOS) and Redox Ratio (RER)
[5]
markers were assessed by using commercially
available kits.
Statistical Analysis: Statistical analyses were performed
using Statistical Package for Social Sciences 16. Data
expressed as mean SD. Independent students paired
t test was applied to compare various parameters
between groups. The null hypothesis was rejected at
p<0.05.
RESULTS
As shown in Table. 1, there were no significant
differences in baseline characteristics like age, gender
and other anthropometric parameters like height and
weight. Table 2, depicts the information about the
markers of inflammation like MDA, TAOS and RER. The
markers of oxidative stress (MDA, RER) were
significantly high (p<0.001) and TAOS was low (p<0.001)
in patients suffering from pellagra, when compared to age
and gender matched controls.
Table: 1 Physiological characteristics of study
participants.
Parameter
Age (Years)

Pellagra patients
37.34 7.58

Controls
38.32 6.4

Men/Women,

42/36

47/31

Height (cm)

163.44 + 5.24

161.98 + 6.4

Weight (Kg)

66.23 + 7.48

67.18 + 3.48

Table: 2. Difference of Oxidative stress markers.


Parameter
Pellagra
patients
Controls
TAOS (mM)
MDA (uM)

0.40 + 0.14
11.41 + 9.72

0.99 + 0.33***
9.08 + 9.08**

RER

28.52 + 15.12

9.17 + 3.9***

* p<0.05, *** p<0.001. TAOS: Total Anti Oxidant Status,


MDA: Malondialdehyde, RER: Redox ratio.
DISCUSSION
Oxidative stress occurs if the production of free radicals
and active intermediates in a system exceeds the
[6]
systems capability to neutralize and eliminate them .
The recent concept of oxidative stress should also
include the pathways related to the nitrosative stress
and, for their implication in cellular and extracellular
metabolic events, to the metabolic stress. Reactive
oxygen intermediate (ROI) and reactive nitrogen
intermediate (RNI) are constantly produced under
[7] [8]
physiological conditions
, is the crucial event in living
organisms. At the moment, the concept of oxidative
stress confined to ROI such as hydroxyl and superoxide
radicals, and hydrogen peroxide and singlet oxygen has
been extended onto RNI such as nitric oxide (NO),
[8]
peroxynitrite and, recently, to S-nitrosothiols . Thus, ROI
and RNI react with proteins, carbohydrates and lipids,
with consequent alteration both in the intracellular and
intercellular homeostasis, leading to possible cell death
[9]
and regeneration . To cope with the oxidative stress
elicited by aerobic metabolism, animal and human cells
have developed a ubiquitous antioxidant defense system,
which consists of superoxide dismutase (SOD), catalase
(CAT), glutathione peroxidase (GPx) and glutathione
reductase together with a number of low molecularweight antioxidants such as ascorbate, -tocopherol and
glutathione, cysteine, thioredoxin, vitamins, etc. However,
this antioxidant defense system may be overwhelmed by
various pathological or environmental factors so that a
fraction of ROS may escape destruction and form the far
more reactive hydroxyl radicals (10)(11). An increase in
ROS elicited oxidative damage to DNA and other
biomolecules may impair normal functions of tissue cells
[12] [13]
and lead to human aging and disease
.
In this study, the reduced TAOS, increased MDA and
RER indicate that, there was a high level of oxidative
stress in pellagra patients.
CONCLUSION
In conclusion, the results of this study showed the
increased MDA, RER levels and decreased TAOS levels.
Estimation of these markers at early stage will help to
take measures to prevent the progression of disease and
develop antioxidant strategies.
Limitations: Future studies should include more sample
size and more precise oxidative stress markers of
pellagra.
Acknowledgements: We sincerely acknowledge all
participants of the study. We extend our sincere thanks to
dean, director and other staff who provided the laboratory
facilities to estimate the inflammatory markers.
REFERENCES
1.

Stratigos JD, Katsambas A. Pellagra: a still existing


disease. Br J Dermatol. 1977;96(1):99106.

787
Neelima et al.,

Int J Med res Health Sci. 2015;4(4):786-788

2.
3.
4.

5.

6.

7.

8.
9.

10.

11.

12.

13.

Gopalan C. The changing nutrition scenario. Indian J


Med Res. 2013;138(3):3927.
Betteridge DJ. What is oxidative stress? Metabolism.
2000;49(2 Suppl 1):38.
Le Lay S, Simard G, Martinez MC, Andriantsitohaina
R. Oxidative Stress and Metabolic Pathologies:
From an Adipocentric Point of View. Oxid Med Cell
Longev [Internet]. 2014 [cited 2015 Jun 9];2014.
Available
from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC41310
99/
K rishna BH, Pal P, Pal G K, S ridhar M G, B
alachander J, J ayasettiaseelon E, S reekanth Y, G
aur G S. Yoga Training In Heart Failure Reduces
Oxidative Stress And Inflammation. Journal of
Exercise Physiology online 20 1 4; 17 ( 1 ):1 0 - 18 .
Sies H, Cadenas E. Oxidative stress: damage to
intact cells and organs. Philos Trans R Soc Lond B
Biol Sci. 1985;311(1152):61731.
Nathan C. Specificity of a third kind: reactive oxygen
and nitrogen intermediates in cell signaling. J Clin
Invest. 2003;111(6):76978.
Krncke K-D. Nitrosative stress and transcription.
Biol Chem. 2003;384(10-11):136577.
Garrido N, Meseguer M, Simon C, Pellicer A,
Remohi J. Pro-oxidative and anti-oxidative
imbalance in human semen and its relation with
male fertility. Asian J Androl. 2004;6(1):5965.
Fridovich I. Superoxide anion radical (O2-.),
superoxide dismutases, and related matters. J Biol
Chem. 1997;272(30):185157.
Bender DA. Pellagra. In: Sadler MJ, Strain JJ,
Caballero B, eds. Encyclopedia of Human Nutrition.
San Diego, CA: Academic Press;1999:1298-1302.
In.
Beckman KB, Ames BN. Endogenous oxidative
damage of mtDNA. Mutat Res Mol Mech Mutagen.
1999;424(1):518.
Wei YH, Lu CY, Wei CY, Ma YS, Lee HC. Oxidative
stress in human aging and mitochondrial diseaseconsequences of defective mitochondrial respiration
and impaired antioxidant enzyme system. Chin J
Physiol. 2001;44(1):111.

788
Neelima et al.,

Int J Med res Health Sci. 2015;4(4):786-788

DOI: 10.5958/2319-5886.2015.00156.3
Open Access

Available online at: www.ijmrhs.com


Research article

LIVED EXPERIENCES OF HEALTH PROBLEMS OF ELDERLY RESIDING IN


URBAN AREAS, KATHMANDU: PILOT STUDY
*Bista Archana1, Joshi Sarala2
ARTICLE INFO
th
Received: 4 June 2015
th
Revised: 14 July 2015
th
Accepted: 29 July 2015
1

Authors details: PhD Scholar in


2
Nursing,
Professor, Head of
Department, Research & Educational
Science,
Tribhuvan
University,
Institute
of
Medicine,
Nursing
Campus, Maharajgunj, Kathmandu
Nepal
Corresponding author: Bista Archana
1
2
PhD Scholar in Nursing, Professor,
Head of Department, Research &
Educational
Science,
Tribhuvan
University, Institute of Medicine,
Nursing
Campus,
Maharajgunj,
Kathmandu Nepal
Email: archanabista67@yahoo.com
Keywords: Elderly,
Health
Problems,
Phenomenology

Experiences,
Hermeneutic

ABSTRACT
Introduction: Globally, number of old age population is increasing with
advancement of biomedical technology. Old age is the time associated with
biological, psychological and social changes which situate elderly to acquire
different health related problems. Objectives: To find out lived experiences
of elderly regarding their health problems residing in homes of Kathmandu
city. Methods: Qualitative hermeneutic phenomenology approach was
adopted. Researcher selected purposively four elderly residing in an urban
area of Kathmandu Valley as the study participants. In-depth interview was
conducted by using in-depth interview guideline, as well as medical records,
field notes and observation clues were recorded. Interview was conducted in
Nepali Language and was audio taped. The recording was transcribed by the
researcher herself, and the data were analyzed thematically. Finally, different
sources of data were triangulated. Results: The four main themes identified
were physical health problems, impaired functional abilities, psychological
and social problems. Experienced physical health problems were joint pain,
hearing and vision deficit, chronic obstructive pulmonary disease, diabetes,
gastritis and fall injury. Impaired Functional abilities in performing activities of
daily living was commonly experienced problems. Loneliness and decreased
recent memory power were the psychological problems. Being neglected by
family members, financial constraints for treatment and improper care during
illness were the discerned social problems. Conclusion: Elderly are suffering
from different physical health problems, impaired functional abilities, as well
as various psycho-social problems. Thus, health promotional activities need
to be promoted for decreasing morbidity of elderly. Family members need to
be focused in the care of elderly through national policy.

INTRODUCTION
Globally, old age population is increasing at an
[1].
unprecedented rate
At present, 12 % of total population
is of old age. It is projected that the proportion of the world
[2]
population will be doubled by the year 2050 . Further,
[3]
this pace of ageing is faster in developing countries . In
Nepal, the ageing population above 60 years has been
double from 4.6 % in the year 2001 to 9.1 % in the year
[4]
2011 . Thus concern over the health of elderly is
increasing in Nepal with this unprecedented growth rate of
ageing population.
Old age is associated with increases in physical and
[5-7
mental health problems
]. Studies revealed that non
communicable diseases like cardiovascular diseases,
chronic
respiratory
diseases,
diabetes
and
musculoskeletal problems and cancer are common in old
[8age people adding burden related to disease conditions
10].
With advancing age elderly usually faces decline in
functional ability as a result of limited mobility, frailty or
[8]
other health related problems . Studies assessing
functional disability among elderly revealed that elderly
usually losses mobility in performing activities of daily
living. Mostly advanced aged elderly losses their abilities
of performing instrumental activities causing them
[11, 12]
dependent to others
.

Along with these physical health problems varying


psychiatric morbidity have been identified among elderly.
Studies demonstrated that depression and cognitive
impairment are more common among elderly. Around
14% -20% of elderly living in home settings of developing
[13-15] ..
countries had symptoms related to depression
Cognitive impairment is also a common psychological
problem among advanced age group negatively affecting
their quality of life but very few related studies were
[16,17,18]
available in developing countries like in Nepal
.
Along with these health conditions many elderly people
have to faces social problems like isolation, negligence,
physical and psychological abuse which further may
deteriorate their health conditions and they are allowed to
[19]
remain depressed and alone
. Some studies indicated
that elder abuse is social problems which are mostly in
hidden form affecting both the physical and mental health
[19, 29, 30]
of the elderly
. Thus, this study was carried out to
explore the lived experiences of elderly regarding their
health problems.
MATERIALS AND METHODS

789
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

This is a pilot study report of a proposed mixed method


research entitled "Health Problems and Lived Experiences
of Elderly Living in Urban Areas of Lalitpur City". In this
report
qualitative
hermeneutic
phenomenological
approach was applied to gain deep understanding about
lived experience of elderly about their health problems and
to interpret this phenomena in real life situation. Four
female elderly of three different age groups (young age,
very old and oldest old), living in their homes (ward no 4,
Kalanki, Kathmandu, an urban city of Nepal) were
selected as a study participants, purposively by the
researcher. Elderly who were medically diagnosed with
mental illnesses, and who have verbal impairment were
excluded from the study.
Data Collection: Before data collection ethical approval
was obtained from Institutional Review Board of Institute
of Medicine, Tribhuvan University. Data were collected
over a period of four months from June 2013 to
September 2013. Before data collection, all the
participants were informed about the process of research
and ensure their voluntarily participation in the study.
Before the day of interview, interview was scheduled in
the mutual convenient time of the participants and
researcher. First author conducted interview that were
audio taped. Three to four interview sessions were
conducted with each participant lasting from 40 to 60
minutes. As interview was conducted in home setting,
privacy was maintained by interviewing in a separate
room. Each interview was started with grand tour
[32]
questions followed by probe questions
such as: Could
you tell me about your overall health as getting old? Could
you tell me your daily activity level? Would you tell me
what that means to you? "Can you give me some
examples of that what you said about this? In all cases,
last open ended question asked was: Would you like to
provide any additional information to explain these
experiences? Participants were encouraged to provide
detailed descriptions of their experiences through active
listening, using probing questions, homing and sometimes
repeating the last word of the participants. Before
subsequent interviews, memory call was given to the
participants and interview was stopped when data
saturation was achieved by the interviewer. Similarly, data
was also collected from different sources such as
reviewed medical records, field notes and observation
clues. To make the findings more credible and valid
researcher gathered supportive information from key
informants mainly with daughter in law and son.
The recorded information was downloaded to a password
protected personnel computer that had only access to the
researcher To enhance the credibility of the findings
information obtained from different sources were
triangulated. Data were thematically analyzed by using
Gibson's qualitative data analysis method in five stages
[22]
. Initially, in first stage researcher read and read
transcribed data to identify meaning. In second stage,
researcher again read it several times then identified the
codes by using key words. Thirdly, the codes were
analyzed, compiled & compare to the context. In fourth
stage codes were grouped to the context to develop super
code (concept). Effort was made to get collective meaning

from those super codes. Fifth stage: Further analysis was


done by combining related super code (concepts) to
develop supra code (theme).
RESULTS
Results are illustrated in three parts. Socio-demography
profile of the participants, experiences of health problems
including theme development process.
(1) Socio demography characteristics are illustrated in
(Table: 1).

Table 1: Profile of Elderly Residing at Home


*N
o
1

Age Gender Ethnicity


Yrs
74 Female Chhetri

Religi Marital
on
Status

Living
With

Hindu Widow

Son's
Family
Son's
family
Grands
on's
Family
Son's
Family

86

Female

Newar

Hindu Widow

91

Female

Brahmin

Hindu Widow

94

Female

Newar

Hindu Widow

*Number used to protect the identity of participants.


Table 1 shows that participants were from three different
group young old (74yrs), very old (86yrs) and oldest old
(91yrs & 94 years). All of them were female and were from
homogenous religion. Regarding their marital status all
were widow and among them three were living with their
son's family and one with grandsons family.
(2) Experiences of Health Problems
1. Physical Health Problems
It is obtained that physical health problems increases with
old age. In this study participants were experiencing
different form of physical health problems such as
musculoskeletal problems, vision problems, hearing
problem, endocrine, respiratory problem, & accidental
injury. And most of the participants were suffering from
impaired functional activities in their daily living.
1.1. Musculoskeletal problems
Joint pain: Among the study group majority of the elderly
(3/4 participants) were experiencing symptoms related to
joint pain caused by increase of uric acid levels in the
blood serum. For lessening the problem two of them were
taking medicine & restricted diet also.
One Participant of (91 yrs) said that, my affected knee
(left) gets swollen occasionally & I feel pain over there. I
have to take rest at that time. I am taking medicine to treat
uric acid problem for last few years. I am taking prescribed
diet as advised by the doctor such as less pulses &
tomato.
Likewise another participant of similar age (94 yrs)
mentioned that, "I have swelling in knee (Right)
occasionally. It is difficult for me to walk up and down due
to my knee problem When I went for checkup doctor has
prescribed medicine and told to take restricted diet.
So, I am taking fewer amounts of pulses in my diet."
But sometimes it is found that affected person do not
follow the prescribed diet because of many reasons
among which difficult to change dietary pattern is a
reason. One of the participants said that:
"Sometimes there is swelling in my knee joint particularly
when I eat more pulses and
tomato. Doctor has

790
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

suggested to take restricted diet such as taking very


less amount of tomato , pulses and red meat but I am
not following specific dietary pattern. I am eating
everything that is cooked in my kitchen for the
convenience of my family members "( 74yrs).
1.2 Sensory problem: Among different sensory problem
participant were suffering from hearing and vision
problem. Here, 2/4 participant had problem related to
vision and 1/4 had hearing problem. One participant
delayed treatment of eye surgery because if financial
constrains.
1. 2.1 Vision problem: Difficulties in seeing things from
affected eyes were experienced by two participants of
oldest age. One 91yrs, expressed that:
"I am having problem in my left eye for many years. It is
difficult to see by my left eye. I got fear of losing
remaining vision in this eye. From four/ five months I am
having difficulties in seeing things by my right eyes also. I
cannot see clearly by this affected eye. Doctor has
suggested for surgery".
1.2.2 Delayed treatment for surgery: Managing financial
resources is of a problem to the elderly. Although doctor
has advised for surgery same participant did not go for
follow up because of financial constrains.
Same participant again shared that: "Getting eye surgery
requires large amount of financial expenses. I am unable
to go for surgery due to my financial constraint. I am
financially dependent on my grandson. I do not want to
add financial burden as I am living with him. I will definitely
go for surgery if some health camps would be there for
senior citizens in less cost."
Eye problem can be sometimes corrected through use of
devices as spectacles. One participant said that: Although
I do not have problem seeing things clearly that are near
but it is difficult for me to see things which are far. I need
to wear glasses while seeing things in which are far
(94yrs).
1.2.2 Hearing Problem : Same participant further added
that, I cannot hear clearly with my one ear left ear from
about five six years. People have to talk in loud voice
while talking with me. I think it is because of my advance
age I got this problem.
1.3 Respiratory problem: Among study group (1/4)
participant were suffering from respiratory problem which
is chronic in nature.
Chronic Obstructive pulmonary disease (COPD).
It is the type of respiratory problem which is chronic in
nature experienced by the participants. During the time of
illness participant usually experienced symptoms such as
difficulties respiration, fast breathing, and take rest in
between talking. Here one participant said that
I used to have fast breathing while walking ups and
downs. While walking fast I used to have fast breathing &
had to take long breathing) in between. For getting relief
of this problem, I am consulting physician and taking
medicine twice in a day after food for many years (74yrs).
Sometimes fear of being dependent in medical remedies
makes the client not compliance with medical regimens
completely. She also added that "Doctor has given me
a inhaler (puff) to use during the time of severe breathing
problem but I am not taking it as I think that it will be

habitual on using it and it will make me dependent. I am


ok with taking medicines only.
1. 4 Endocrinal problem: Diabetes: Hormonal problem as
elevated blood sugar level in blood serum causing
chronic diseases conditions is identified in one participant.
She was experiencing different symptoms during illness.
One participant of (86yrs) said
"I am having symptoms of rise blood sugar since the last 8
years. Sometime when my sugar level increases I feel
weak, burning sensation in palm and dry mouth.
For controlling blood sugar within normal range level same
participant are taking regular medicine before food.
Further she emphasized that
"As per the advice of the doctor I am taking medicines
twice a day before my food. I am going for my routine
follow up in every three to four month. And till date it is
within control".
1.5 Gastro intestinal problem:
Gastritis: Gastrointestinal symptoms causing uneasiness
and related problem are also the experienced problem as
one participant said
"I am taking two tablet of enzyme regularly for my gastric
problem. Gastric problem causes indigestion and
recurrent diarrhea usually. I have this problem since many
years after the surgery of gallbladder (91 yrs).
1.6 Accidental injuries
Fall injury: Risk of getting fall injuries increases with
advancing age, here also one participant had this episode
in a given time period as the participant stated that
I had an episode of fall injury by slipping in bathroom at
night time. I was alone at that time but I got up by myself
as there was no serious injury. I just had pain in left hand
(86 yrs).
Considering the cause of fall injury she mentioned that
less light during night time might be the cause
I dont have diagnosed medical problem in my eye. Till
now I do not have problem in seeing things clearly. May
be because of poor light during night time I fell in
bathroom.
2. Functional Activities Impairment
Usually functional impairment in doing some basic
activities is categorized in three different forms: Can
perform basic activities without help (Independent). Can
perform activities with some assistance (Partially
dependent).Cannot perform activities at all. Here it has
been found that one oldest old participant is partially
dependent even in doing some of her basic activities of
daily living where as other participant (3/4) need
assistance in doing intermediate activities like going far
place, walking outside house.
One participant of 91yrs she said "I can do all these
activities such as eating, doing morning care, and wearing
clothes (Saree), in local word but I need assistance while
bating. I can take bath slowly but it might cause water to
split everywhere so my daughter in law helps me by
putting water while bathing. Two of the participants were
suffering from impairment in doing intermediate activity
particularly while going far places independently. They
said that although I can walk inside and outside the house,
I cannot go far places since last year. I need help of some
family members for going little far place (91yrs). Since last

791
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

two three year my strength of walking inside house has


decreased. I live upstairs and it's been a long time I went
down in garden. It is difficult for me to move up and down.
My leg gets tiered easily so I just walk little in one floor
(94yrs).
Sometimes diseases related condition such as swollen
knee joint and pain in extremities also decrease the
strength of mobility. Here one participant who had more
than one chronic health problem added that
It's been two three years that I have less energy to go far
paces. I cannot walk fast because of my breathing
problem. So I just walk in near places nowadays (74yrs).
3. Experiences of Psychological problems
Here, loneliness and decreased memory power are the
problems experienced by different participants.
3.1. Loneliness:
Among older people, loneliness is considered as a
common psychological problem causing emotional
distress associated with depression. Here one participant
in spite of living with her son's family was expressing
loneliness. She shared that
"I feel lonely most of the time. Although I am living with my
sons family, most of the time I feel alone as there is no
one to share my feelings. I have two daughters in laws but
they are busy in doing household activities. And
granddaughters are busy in their study. Sometimes I go
to meet my elder sister of my own age who lives nearby
and share my feeling with her " ( 86 yrs ).
3.2. Cognitive impairment
Decreased Recent Memory:
Alteration in ability to
remember things of recent and remote activity are
considered as cognitive impairment. It has been
categorized as mild, moderate and severe depending
upon its effect altering functional activities of daily living.
Here, (2/4) participants sometimes were having problem
with their recent memory with more or less no effect in
their daily living. One said that: "I have problem in
remembering some recent activities in daily living such as
whether I picked flowers for worshipping God or not. In
local language "Puja koo phul aaja tipee ki chhainaa (86
yrs)
Likewise 91yrs said that "I sometimes forget things for
short time such as where I keep my key. In local language
"Saanchho kahhaa rakhee hola ". But after sometime I
can recall it automatically. Sometimes what happens is
that when I see the things which I forget I automatically
recall it".
4. Social problem (Elder abuse) Elderly abuse is act or
lack of appropriate action occurring within any relationship
where there is an expectation of trust which causes harm
or distress to an older person. We found that some
Participants were facing problems related to maltreatment
or abuse in their homes.
4.1 Improper care during sickness: When a sick person
does not receive adequate assistance for his/her health
check up the person feels sad for this. Here one elderly
does not get companionship for her routine health check
up as family members are functionally busy in their
daily
work at
house
which makes her distress
sometimes as she shared

"In every regular blood check up for diabetes I go myself


without having my family member. Even when I feel that
my blood sugar has increased causing some physical
illness, I go for blood sugar test alone. I do not call my
family members to give me companionship as I know that
nobody has time to come with me for health checkup. All
of them are busy in their daily schedule (86yrs).
4.2 Neglected in family: If a person does not received
adequate respect, dignity and feeling of belonging person
feels neglected and isolated. In this study one participant
said that: "My elder son's family doesn't talk with me
nicely. They did not look after me even when I was sick.
They do not come to meet me even once in a year. It has
been a long time since my son called me by saying the
word 'mother' In local language saying "AAmma to me"
(91yrs).
She further added that financial reasons might be the
cause of being abandoned. She shared that "I have
noticed that loss of power over my own property seems to
be the cause of being isolated. I distributed all my
property that my spouse had left to me among my two
sons. After getting the property my elder son and his
family became in different to me. Thats why I am living
with my grandson of younger son. My younger son left
house long time ago; we do not know where he went. His
wife is living in next house which was made by us (me &
my husband). She is also careless in nature and does not
care about me. I sometimes feel very distress for all these
situations and want to leave the place where I am living."
(3) Theme Development process: Above data were
thematically analyzed by using Gibson's qualitative data
analysis method in five stages. Initially, in first stage
researcher read and read verbatim and transcribed. In
second stage, researcher again reread it several times to
identify meaning. Thirdly, by grouping those meaning and
by giving keywords researcher identified codes
(categories). In fourth stage codes were grouped to the
context to develop super code (concepts). Effort was
made to get collective meaning from those super codes.
Fifth stage: Further analysis was done by combining
related concepts to create Supra Code (theme). A
different stage of analysis is presented in Table (2)

Table

2: Different Stages of Thematic Analysis


Codes
Joint pain

Frequenc
y
3

Poor vision in eye.

Loss of vision in one


affected eye.
Fear of losing in vision
completely in affected
another
Delayed eye surgery
Need to use assistance
device (eye glasses
Decreased
hearing
capacity in one ear
Chronic
Obstructive
Pulmonary Diseases.
Diabetes

Super Codes
Musculoskeletal
problem

Supra
code
Physical
Health
Problems

Sensory
impairment

1
1
1
1
1

Respiratory
problem
Endocrine

792
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

problem
Gastritis

Fall injury with less


effect in one hand.

Cannot take
bath
independently
Decreases stamina to
go outside

Decrease strength to
walk vigorously
Need assistance for
going far places
Fear of getting disability
Forget some recent
activities

Loneliness
Not having assistance
during illness
Ignored
by
sons
family

1
2

Gastrointestinal
problem
Accident and
injury
Basic Functional Functional
activity
Impairment
decreased
Intermediate
functional
activity
decreased

4
3
2

Impaired
Cognition
Depressed
Family
Mistreatment

Psychologi
cal
Problems
Social
problem

Table shows that 20 codes by analysis, comparing and


matching were created in 12 super codes (sub theme) and
those 11 super codes were further analysis and developed
into 4 supra codes (theme).
DISCUSSION
Socio demography: The socio demography data
revealed that all respondents were widow and were living
with their families in joint family structure.
Meanings of physical health problems: In this study, the
meanings of physical health problems were having non
communicable diseases such as joint problems, chronic
respiratory diseases, diabetes, vision & sensory problem
and fall jury. This finding is consistent with other studies
findings which revealed these chronic diseases such as
hypertension, rheumatoid diseases, heart diseases, and
[20,23]
diabetes was prevalent among elderly
. Similar study
findings conducted in Kathmandu city which showed that
prevalence of diabetes was high among elderly living in
[9] .
urban city .
Concerning the functional abilities this study found that 1/4
participants with advance age need assistance in doing
some basic activities like while taking bath properly while
3 participants need assistance in doing some of the
instrumental activity of daily activities such as going
outside the house, walking vigorously, going far places
causing them partially dependent to others. This finding is
similar to other studies findings which revealed that that
instrumental activities deficit were found in oldest old age
group and elderly with this group more assistance in doing
[24,25]
basic activities of daily living
. Concerning about
having experiences of psychological problems (2/4)
respondents had symptoms related to depression such as
loneliness. This finding is compatible to study findings
which showed that 14% -20 % of elderly had depressive
[13, 26]
symptoms depression in home settings
.
Here, loneliness is experienced by elderly who had been
not cared by family members during illness. This finding is

consistent with studies which revealed that loneliness is


common problem in widow female who experienced social
isolation by their family members. In such situation elderly
used to lessen their loneliness and boredom by engaging
[27]
with their friends .
Elder maltreatment
Here, half of the respondents were dissatisfied with their
family relationship and suffered from maltreatment by their
family members. This finding is similar to the study in
Nepal which revealed that 38.5% of abuse occurs mostly
[19]
within home . This might be as a result that majority of
the elderly in Nepal are living in home setting. In this study
emotional abuse such as being isolated from son's family
after giving up of financial asset to them was commonly
identified among. This study findings differs from other
studies in developed countries which showed physical
abuse like physical assault and restrain were common
[29,30] .
followed by financial abuse
. This findings might be a
result of different life style and diseases patterns
affecting health conditions of old age people in different
regions. Further, in this study all the elderly were abused
by their son and daughter in law. This finding is similar to
study conducted in one country of South East Asia which
showed that son and daughter in laws were the
[31]
perpetrator of elder abuse .
Limitations: Since this was report of pilot study, to
generalize findings of experiences of only four elderly
need to be careful. Similarly, it was difficult to generalize
findings to those elderly having mental illness and problem
with communication.
CONCLUSION
Most of the elderly are suffering from chronic illnesses
such as joint pain, chronic obstructive pulmonary disease,
diabetes, sensory problem like vision and hearing deficit.
Most of them need assistance in performing their
intermediate activities of daily living. Some are also
experiencing loneliness & recent memory power deficit.
Also improper care during illness, neglected from by their
family members, delay in getting treatment due to financial
constraints are the experienced problems. Thus, health
promotional activities need to be promoted for decreasing
morbidity among elderly. Family members need to be
focused in the care of elderly through national policy.
Acknowledgement: I would like to acknowledge my
research advisor Prof. Dr. Sarala Joshi, Institutional
Review Board (IOM) and all elderly who participated in the
study.
Conflict of Interest: Nil
REFERENCES
1.

2.

UNFPA. Ageing in the Twenty First Century: Report .A Celebration


and Challenges. 2012. www.unfpa.org /publication/ageing-twenty-first
century (Accessed on 4Dec2014)
World Health Organization. Ageing and Life Course.
Report of Global population Ageing. 2012.
www.intageing/event/idop-rational/en
/index
(Accessed on 4 Dec 2014).

793
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

3.

4.

5.
6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Population Reference Bureau. World. Population


Sheet. 2013. Avalable from www. prb.org /pdf 13/
2013- world population data sheet. (Accessed on 4
Dec 2014).
Central Bureau of Statistics. Nepal in Figures. 2012.
GON, National Planning Commission Secretariat,
Ramsahapath, Kathmandu, Nepal.
Yancik R. Population aging and Cancer: A cross
national concern. Cancer Journal. 2005; (11): 437-41.
SiddhikS ,Rampal L, Afifi M. Physical and Mental
Health problems of the Elderly in a Rural Community
of Sepangor. Malasian .Journal of Medical Sciences.
2004; 11(1):52-59.
Bloom DE, Supan A,Gee Seike A. Population Ageing:
Facts, and Responses. Program on the Global
Demography of Ageing.2011.Working Paper No.71.
www.hsph.hard.edu/pgda/working (Accessed on 15
Jan2014)
Barua A, Hazarika J, Basiliio M.A, Soans S, Colin M,
& Kamath A. Functional Impairments in Elderly.
Indian Journal of Gerontology. 2011; 24(2):61-63.
Chhetri, M R, & Chapman R S. Prevalence and
Determinants of Diabetes among the Elderly
Population in Kathmandu Valley of Nepal. Journal of
Nepal Med Coll.2009; (1): 34-38.
Wild S, Roglic G, Green A, Sicree R, King H.
American Association of Diabetes. Global Prevalence
of Diabetes. Estimates for the year 2000 & projection
for 2030. Diabetes Care. 2004; 27 (5):1047-53
Chalise H. N, Saito T, Kai I. Functional Disability in
Activities of Daily Living and Instrumental Activities of
Daily Living among Nepalese Newer Elderly. Journal
of Royal Institute of Publication. 2008; 122,394-396
www.elsevier.health.com/lournal/pubh (Accessed on
4Dec2014)
Chalise H.N. Socio Economic and Health Status of
Nepalese Elderly. Indian Journal of Gerontology.
2012; 26 (2): 151-60.
Subedi S, Tausig M, Subedi J, Broughton, CL &
Wikkaims B S. Mental Illness and Disability among
Elders in Developing Countries: the case of Nepal.
Journal of Aging and Health. Sage Publication. 2004;
16 (1):71-87.
Ghimire H, Pokhrel P K, Shyangwa, PM, Baral D,
Arayal A, Mishra, A.K. Are Elderly Living In Old
Age Homes , Less depressed than Those of
Community ? Findings from a Comparative Study.
Journal of Chitwan Medical College, 2012; 1 (2): 5-8.
Kim J, Choe M, Chae Y. Prevelance and Predictors of
Geriatric Depression in Community-dwelling Elderly.
Elsevier. Asian Nursing Research. 2009; 13 (3): 12129.
Apostolova G, Cumming L. Neuro Psychiatric
Manifestation in Mild Cognitive
Impairment: A
systematic
review of the literature, Dementia
Geriatric. Cog Disorder. 2008; 25,115-26.
Teng E, Tassiyo K, Lu P, Psy D. Reduced Q O L
Rating in Mild Cognitive Impairment: Analysis of
Subjects
and
informants responses. American
Journal for geriatric Psychiatry. 2012;

18. Petorson J S, Gass, D A. Screening for Cognitive


Impairment and Dementia in the Elderly. Canadian
Journal of Neurologc Science 2001; (28): 42-51.
19. Geriatric Center Nepal. Baseline Study on Reported
Cases of Elder Abuse in Nepali press: 2011; United
Graphic Printers.
20. Karla S, Jamb R, Ruchi R. Profile of Medical and
Psychological Disorders in Elderly attending Tertiary
care Hospitals in Delhi. Journal of Indian Academy of
clinical Medicine. 2011; 22(1):21-26.
21. Naughton C, Drennan J, Treacy,M.P, Lafferty L,
Lyons I, Phelan A, Quins S, Louhlin A & Delaney L.
Abuse and
Neglect of Older People in Ireland.
2010; Report on the national study of elder abuse
and neglect. Report Summary. University College
Dublin.
22. Gibsob W. Thematic Content Analysis. Available from
www.avetra.org.ac/wp-content/uploas/2011.
Retrieved on (15th june 2015)
23. Ayranci U, Ozdog N. Old Age And Its Related
Problems Considered From An Elderly Perspective In
a Group of Turkish Elderly. The international journal
of Geriatric and Gerontology, 2004; (2): 1-10.
24. Jose C, Clenti M ,Tubio J, Frenadez S , M, Abratdes,
,Lerenzo T, Frenadez T , Masda A. Prevalence of
functional disability in activities of daily living (ADL),
instrumental activities of daily living associated
factors, as predictor of morbidity and mortality.
Elsevier:
Archives
of
Gerontology
and
Geriatrics.2010;
5:
Available
from
www.elseviser.com/locate /archger.
25. Mohanty S, Gangil O, Kumar S. Instrumental
Activities of Daily Living and Subjective Wellbeing in
Elderly Person Living in Community. Indian Journal of
Gerontology. 2012; 26 (2): 193-06
26. Luppa M, Sikorsia C, Luck T., Ehreke L, Konnopka,
A, Wise B, Weyerer S, Konig, H
& Heller, R. Age
and Gender Specific Prevalence of Depression in
Latest Life-Systematic Review and Meta Analysis.
Elsevier. Journal of Affective Disorders. 2012; 136.
212-21
27. Grundberg A, Ebbeskog B, Dahlgreen M, Religa D.
How community dwelling seniors with multi
morbidity conceive the concept of mental health
and
factors
that
may influence
it: A
phenomenographic
study. International Journal
Qualitative Stud Health Wellbeing. 2012; (7): 1-13.
28. Pate V., Prince. Ageing and Mental health in a
developing country: Who cares? Qualitative Studies
from Goa, Psycholoical mediciene. India 2001; (31):
29-38.
29. Acierrno R, Hermandez M, Amstadter, B, Resnick,H,
Steve,K, Muzzy,W & Kilppsterick,D . Prevalence and
correlates
of
emotional, physical, sexual and
finance abuse and potential neglect in the United
States: The national elder abuse mistreatment
study. American Journal of Public Health.2010; 100
(2):292-97.
30. WHO. Elderly Abuse. Ageing and Life Course. 2002.
Available from www. who. Int/ageing publication
report (Accessed on 4 Dec 2014).

794
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

31. Kataria V, Patel S. Elderly Abuse and Health Status


of Ageing
Population in West Delhi, India. The
Journal of Public Health. 2013; (15): 19-52.
32. Joshi S. Qualitative Research: Approaches for Health
Personnel.
Kathmandu:
Makalu
publication
house;2008.

795
Archana et al.,

Int J Med Res Health Sci. 2015;4(4):789-795

DOI: 10.5958/2319-5886.2015.00157.5
Open Access

Available online at: www.ijmrhs.com


Research article

ASSOCIATION BETWEEN BODY MASS INDEX OF MOTHER AND ANTHROPOMETRY


OF NEWBORN
1

*Nagmoti SA , Walvekar PR , Mallapur MD


ARTICLE INFO
th

Received: 14 June 2015


th
Revised: 13 Aug 2015
th
Accepted: 12 Sep 2015
1

Authors details: Intern, Professor,


3
Asst. Professor / statistician, Dept of
community
medicine,
Jawaharlal
Nehru
Medical
College, K.L.E.
University, Belgaum, Karnataka, India
*Corresponding author: Soumya A

Nagmoti
Dept
of
community
medicine,
Jawaharlal Nehru Medical College,
K.L.E.
University,
Belgaum,
Karnataka, India
Email: soumya160@gmail.com
Keywords:
Body
mass
index,
Anthropometry, Newborn, Maternal
height, Maternal weight

ABSTRACT
Introduction: Maternal body dimensions are the first determinants of neonatal
biometrics, especially their birth weight and length. Mothers nutritional status is
also known to be a key indicator of infants body dimensions and its early
growth features. Birth weight and length are clearly based on mothers
nutritional and anthropometric factors hence the present study was done to find
the association between BMI of mother and anthropometry of newborn among
all the delivered women in tertiary care hospital Aim: To study association
between BMI of mothers and anthropometry in newborn. To know the other
factors responsible for anthropometry of newborn. Methodology: 216 delivered
women were taken consent by predesigned questionnaire information was
collected regarding the socio-demographical data and the anthropometry of
newborn and mother was recorded. Statistical analysis was done by using
percentage and analysis of variance. Results: Our study showed association
between maternal BMI and weight with neonatal parameters except mid arm
circumference. There was no association between maternal heights with any of
the neonatal parameters. Conclusion: In our study we found the association
between Maternal BMI and Anthropometry of Newborn, Maternal Weight and
Anthropometry of Newborn, But no association was found between Maternal
height and Anthropometry of Newborn, so, by carrying out some intervention
during pregnancy to improve nutrition of the mother which has better effect on
the Anthropometry of newborn.

INTRODUCTION
.
Humans, including the embryo transfer, the size at birth is
primarily determined by the mother, whose influence acts
more through the intrauterine environment and transmitted
[1]
to her baby . There is interrelation between the body
physique of the mother, her nutritional status,
haemoglobin levels, socioeconomic class and her
exposure to passive smoking during pregnancy and
intrauterine growth and birth size of her neonate.
Significant positive correlations between maternal
anthropometric parameters and neonatal birth dimensions
were observed. These effects were more evident in female
babies than male babies as regards to BMI and head
circumference. This indicates that neonatal growth as
reflected by birth weight, length and head circumference,
are mostly influenced by maternal size. A study done in
Egypt showed that best predictor of birth weight as a
continuous variable was maternal weight at registration
compared to combination of initial weight and height of the
mother. A maternal pre gestational weight, weight at
delivery, gestational weight gain and height correlated
[1]
significantly with neonatal birth weight and birth length .
Birth weight determines the perinatal morbidity and
mortality, and maternal body dimensions are first
[2]
determinants of neonatal biometrics . Many studies have
been done to find association between non biometric
maternal factors and neonatal anthropometry.
Maternal nutritional status which is indicated through
weight, height and BMI could be considered to predict the
neonatal anthropometry hence the present study.

MATERIALS AND METHOD


Study design: Present study was a cross-sectional,
analytical study
Place of research & Period: The study was conducted in
Dr.Prabakar Kores Charitable hospital during the month of
August 2014.
Ethics approval: Ethical clearance was obtained from
Institutional ethical committee for human subjects.
Informed consent was taken from all the study
participants.
Inclusion criteria: The study included all the mothers
giving birth to singleton babies during the study period.
Exclusion criteria: women with severe anemia, diabetes ,
hypertension to avoid influence of these factors on
anthropometry of the new born and we also excluded
women with babies requiring Neonatal Intensive Care Unit
Admission (as it was difficult to collect measurements of
the babies).
Sample size: Totally 216 women and the newborns were
included in the study.
Methodology: BMI was not available for all pregnant
women in first trimester; hence BMI of 5 months was
included in the study. BMI was calculated using the
(
2
formulae: BMI=WEIGHT (kg)/HEIGHT mts) Predesigned
[8]
and pretested questionnaire
was used to collect the
relevant data. Data was collected regarding sociodemographic, obstetric history etc and maternal weight
and height was measured, and calculated and neonatal
birth weight (within one hour of birth), length, mid arm

796
Nagmoti et al.,

Int J Med Res Health Sci. 2015;4(4):796-798

circumference, head and chest circumference were


measured.
Statistical
analysis:
Numerical
outcome
were
summarised by mean and Standard deviation and they
were compared among the groups by analysis of variance.
Categorical outcome were summarised by rates. The
percentage and analysis of variance, f value was
calculated, p<0.05 statistically significant.
RESULT
In the present study total 216 were participated. The
height participant age range was between 20- 24years.
(Table 1 ) and most them were studied high School level
education, most of the participant were vegetarian,
primigravida.

Table I: Socio-demographic & Obstetric profile of


pregnant women
PARTICULARS
NUMBER
%
Age Years
15-19

06

2.8

20-24

161

74.6

25-29

34

15.7

30-34

15

6.9

Place of residence
Rural

111

51.4

Urban

105

48.6

Educational status of mother


Primary

01

0.5

Secondary

23

10.6

In the present study 65.7% of women had haemoglobin


High school
180
>11 gm %. Folic acid tablets were taken by 81.9%, Iron
tablets by 99% and Calcium tablets by 76.8 %. Among the
>Than high school
12
newborns, male babies were 51.9% and female babies
Educational status of father
were 47.1%. Weight of 89% of the new born babies was
Primary
10
>2.5kg and 11% were <2.5kg. Maternal height was >150
Secondary
146
cm in 57.9 % of women and only 1.9% were having height
nd
less than 140cms. Maternal weight in 2 trimester was
High school
60
between 41-50 kg in 64.4 % of the participants and 13%
Food habits
had weight less than 40kgs.
Vegetarian
130
The association between maternal BMI and anthropometry
of newborn shown in table 2, maternal weight and
Mixed
86
anthropometry of newborn shown in table 3, maternal
Obst score
height and anthropometry of newborn shown in table 4.
Primi para
142
Abbreviations used in tables
Para 2
55
HC: Head circumference
CC: Chest circumference
Para 3
12
MAC: mid arm circumference
> Para 3
7
P<0.05 consider as statistically significant
Table 2: Association between maternal BMI and anthropometry of newborn
Maternal BMI
<18.5
18.5-24.9
25-29.9
F2,207
No. of mothers
48
156
6
Parameters Newborn
Birth weight (kg)
2.760.43
2.960.44
3.280.61
5.784
HC(Cm)
33.021.57
33.751.81
342.28
3.305
CC(Cm)
30.831.56
31.741.62
32.51.51
6.908
Length (cm)
42.873.03
44.414.45
47.162.85
4.170
MAC (cm)
8.960.74
9.353.11
100.63
0.589
Table 3: Association between maternal weight and anthropometry of newborn
Maternal weight
<40
41-50
>50
No. of mothers
28
139
43
Parameters Newborn
Birth weight(kg)
2.650.43
2.910.43
3.170.44
HC (Cm)
33.031.5
33.491.87
34.31.5
CC (cm)
30.671.61
31.471.61
32.391.49
Length (cm)
42.893.49
43.734.32
46.253.53
MAC (cm)
8.820.72
9.353.29
9.370.72
Table 4: Association between maternal height & anthropometry of newborn
Maternal height (cms)
<140
141-150
>150
No. of mothers
4
87
125
Parameters-Newborn
Birth weight (kg)
2.770.49
2.920.42
2.930.48
HC
322
33.871.91
33.521.69
CC (Cm)
30.251.25
31.811.67
31.441.61
Length(cm)
44.54.43
44.283.59
444.53
MAC (cm)
9.250.50
9.040.70
9.473.46

83.3
5.6
4.6
67.6
27.8
60.2
39.8
65.7
25.5
5.6
3.2

0.004
0.039
0.001
0.017
0.556

F2,207

12.234
5.125
10.481
7.796
0.495

<0.001
0.007
<0.001
0.001
0.622

F2,213

0.252
2.706
2.640
0.131
0.635

0.777
0.069
0.074
0.878
0.531

797
Nagmoti et al.,

Int J Med Res Health Sci. 2015;4(4):796-798

DISCUSSION
Our study showed that maternal weight was positively
associated with birth weight of the newborn as the
maternal weight increased weight of the new born also
increased which was statistically significant with P value of
<0.001.Similar results were observed in the study done in
[3]
Sri Lanka with r value of 0.27
,similar findings in other
[1,4,5,6,7]
studies
.Our study showed that maternal weight was
positively associated with head circumference, chest
circumference and length of newborn. Similar results
[1]
were found in . Our study did not show association
between maternal weights with mid-arm circumference of
the newborn.
In our study maternal BMI was positively associated with
[1,2,3,5,10]
BW of newborn
. Similar results were found in
[6]
[7]
[8]
studies done in Saudi Arabia , Nigeria
,Nepal ,
[9]
Romania Our study showed that maternal BMI was
positively associated with HC of newborn. Similar results
[6]
were found in . Our study also showed that maternal BMI
was positively associated with CC of newborn. Our study
also showed that maternal BMI was positively associated
[1,10]
with length of newborn. Similar result were found in
.
Our study did not show association between maternal BMI
with MAC of newborn.
Our study did not show association between maternal
height and BW, Length, HC, CC and MAC of the newborn.
[11]
In contrast to our study, a study done in Australia
found
positive correlation between maternal height and HC of the
[1,9]
new born. Similar results were found in
CONCLUSION
In the present study we found positive association between
Maternal BMI and weight with anthropometry of Newborn
except for mid arm circumference. But maternal height was
not associated with any of the foetal parameters. Hence we
suggest some interventions during pregnancy to improve
nutritional status of the mother by which it is possible to
improve the Anthropometry of the newborn.
Limitation: Study was conducted for a period of 1 month
only hence it was not a representative study.
Acknowledgment: We thank the HOD and Staff of OBG
Department of JNMC, KLE University for permitting to
collect the data and the nurses of the postnatal ward for
their participation in the data collection.
Conflict of interest: Nil

in SriLanka. Tropical Agricultural Research 2009;


21:1:89 98.
4. Kapoor S, Bhasin P, Dhall M, Verma D, Gupta S,
Tungdim M G. Maternal Predictors of Newborn
Somatometrics. Journal of Anthropology 2012; 7:
639345.
5. Bisai S. Maternal anthropometry and birth outcome
among Bengalis in Kolkata in April 2009 Institute of
development studies kolkata IDSK working paper 4.
6. Wahabi HA, Mandil AA, Alzeidan RA, Bahnassy AA,
Fayed AA. The independent effects of second hand
smoke exposure and maternal body mass index on the
anthropometric measurements of the newborn Wahabi.
BMC Public Health 2013; 13:1058
7. Ugwa AE. Maternal anthropometric characteristics as
determinants of birth weight in NorthWest Nigeria: A
prospective study. Nigerian Journal of Basic and
Clinical Sciences 2014;11:1:8-12
8. Winther II. Maternal Anthropometry as a Predictor of
Birth Weight http://www.duo.uio.no/ in 2013
9. Georgescu C , Georgescu B , Mihu D, Porumb C,
Duncea I. Relationships of umbilical and maternal
adiponectin, resistin and osteoprotegerin to maternal
and newborn anthropometric characteristics general
endocrinology. Acta Endocrinologica 2011;7:1:11-22.
10. Kalk P, Guthmann F, Krause K, Relle K, Godes M,
Gossing G et al. Impact of maternal body mass index
on neonatal outcome. European Journal of Medical
Research 2009;14:216-222
11. Sykova V. Relation between maternal Anthropometry
and infant visual Recognition memory in southern
Ethiopia. Dessertation submitted to Bachelor of
Science in Nutritional science Oklahoma state
university. 2004.

REFERANCES
1.

2.

3.

Koepp UMS, Andersen LF, Dahl-Joergensen K, Stigum


H, Nass O, Nystad W. Maternal pre-pregnant body
mass index, maternal weight change and offspring
birth weight. Acta Obstet Gynecol Scand 2012;
91:24349
Hassan NE, Shalaan AH, El-Masry SA. Relationship
between maternal characteristics and neonatal birth
size in Egypt. Eastern Mediterranean Health Journal
2011; 17: 4 284-87.
Jananthan R, Wijesinghe DGNG, Sivananthawerl T.
Maternal Anthropometry as a Predictor of Birth Weight

798
Nagmoti et al.,

Int J Med Res Health Sci. 2015;4(4):796-798

DOI: 10.5958/2319-5886.2015.00158.7
Open Access

Available online at: www.ijmrhs.com


Research article

STUDY OF THE FREQUENCY OF DOWN SYNDROME IN A NORTH EAST INDIAN


POPULATION
1

Das Hirak , Kusre Giriraj , Shankarishan Priyanka , Nirmolia Tulika , Panyang Rita , Gogoi Arpita

ARTICLE INFO
Received: 16th Jun 2015
Revised: 12th Sep 2015
Accepted: 24th Sep 2015
Author
details1Assistant
Professor,
2
Associate Professor, Dept of Anatomy,
Comprehensive Facility for Diagnosis and
Management
of
Genetic
Diseases
(CFDMGD), Assam Medical College,
Dibrugarh, Assam, India
3
Scientist B, 4Senior Research Fellow,
Diagnostic Genetic Lab (CFDMGD),
Assam Medical College, Dibrugarh,
Assam, India
5
Assistant Professor of Pediatrics, Genetic
OPD (CFDMGD), Assam Medical College,
Dibrugarh, Assam, India
6
Assistant Professor of Pediatrics, Genetic
OPD (CFDMGD), Assam Medical College,
Dibrugarh, Assam, India
Corresponding author: Das Hirak
Assistant
Professor
of
Anatomy,
Comprehensive Facility for Diagnosis and
Management
of
Genetic
Diseases
(CFDMGD), Assam Medical College,
Dibrugarh, Assam, India
Email: ripples2006@rediffmail.com

ABSTRACT
Context: Down Syndrome or Trisomy 21, with three sets of chromosome
number 21 is the commonest chromosomal abnormality in newborn. There
are three types of Trisomy 21: Free Trisomy 21, Translocation Trisomy 21
and Mosaic Trisomy 21. Aims: The study aimed at finding the frequency of
Down syndrome and its various cytogenetic types in a population from
North East India. Methods and Materials: Karyotyping from G-Banded
peripheral lymphocyte of patients with suspected chromosomal abnormality
was done from peripheral blood and stained with Giemsa stain as per the
Standard Operating Protocol of the Diagnostic Genetic Laboratory
(CFDMGD). One to three ml of blood was withdrawn aseptically from each
patient. 20-30 spreads were analyzed for each case. For mosaics, 30-50
spreads were studied. The slides were analysed for detection of various
chromosomal abnormalities including Down syndrome (Trisomy 21). For the
translocation Down Syndrome cases, parents were investigated to
determine the parental carrier status. Results: 38 cases of Trisomy 21
were detected. Free Trisomy 21 was found in 92.11% cases, translocation
trisomy 21 was seen in 2.63% case and Mosaic Trisomy 21 was seen in
5.26% cases. Male: female ratio was 1.38:1. Conclusions: Knowledge of
the cytogenetic types has important clinical implications as it helps
clinician/geneticist determine the recurrence risk in subsequent pregnancies
and helps couples take an informed decision. This in turn would help in
decreasing the load of the disease in society.

Keywords: Down syndrome, Trisomy 21,


Free trisomy 21, Translocation trisomy 21,
Mosaic, North East India

INTRODUCTION
Down Syndrome (DS) or Trisomy 21 is the commonest
[1]
autosomal chromosomal abnormality in the newborns .
Incidence of Down Syndrome varies from 1 in 600 to 1 in
[1,2]
1000 in live born infants . In India, the reported
[1].
incidence of Down syndrome is 1 in 1250
Down syndrome is recognizable at birth. Dr. Langdon
Down (1828 1896) was the first to describe the clinical
[3]
features of Down Syndrome children precisely . Patients
present with characteristic phenotypic features of the face,
eyelids, tongue, etc., with retarded physical and mental
[4]
growth . However, the diagnosis may be difficult with the
diagnostic accuracy ranging from 100% in non disjunction
[5]
and translocation to as low as 37% in mosaicism .
Therefore confirmation of diagnosis by chromosomal
analysis is needed. This in turn helps to determine the risk
[2]
of recurrence and guides genetic counseling .
Down Syndrome patients may present in three varied
cytogenetic types: Free Trisomy 21, translocation trisomy
[6]
21 and mosaic trisomy 21 . Free trisomy 21 is the most
common variety, seen in 95% cases and occurs due to
[1]
paternal meiotic non disjunction .

Das Hirak et al.,

Translocation Down Syndrome is seen in 4% cases of


[1]
Down Syndrome . The extra chromosome 21 is
translocated to the acrocentric chromosome of D group
(Chromosome 13,14,15) or G group (Chromosome 21,22).
[1]
Such translocations are usually Robertsonian in type .
Non homologous Robertsonian translocation between
chromosome 14 and 21 [rob(14q;21q)] is the most
common
type
while
homologous
Robertsonian
translocation between chromosome 21 and 21
[1]
[rob(21q;21q)] is the second most common type .
Translocation Down Syndrome can be inherited from
[6]
carrier parents . It can also be created spontaneously de
novo during the process of gametogenesis in one of the
[6]
parents . In a sporadically created translocation Down
Syndrome, the risk to the second offspring is small. But in
case of a 21q21q Robertsonian translocation in one the
parent, all the gametes shall be unbalanced and the risk to
[6]
the second offspring is 100% . Hence karyotype of the
parents is needed to locate the source of translocation and
to estimate the risk of recurrence.
The third variant of Down Syndrome is mosaicism for
[1]
chromosome 21, reported at 1% . The patient has two

Int J Med Res Health Sci. 2015;4(4);799-802

799

cell lines, one with 46 chromosomes and the other with 47,
+21. The typical features of Down Syndrome may be less
marked depending on the percentage of normal to trisomy
[1]
21 cell lines . As diagnostic accuracy in such cases is
[5]
less , confirmation by cytogenetic tests is necessary.
However the incidences in Down syndrome show wide
variations among different populations. North East India
has a unique ethnic population different from the rest of
India. As no such study on Down syndrome have been
done so far in this region to the best of our knowledge,
this study may throw some light on the ethnic variations in
the frequency of Down syndrome.

noted in 2.63% cases while mosaics were seen in 5.26%


cases (Table 1). One case of translocation DS (21q; 21q)
was detected. On cytogenetic analysis of both parents, de
novo translocation was seen, with both the parents having
normal karyotypes. Male: Female Sex ratio observed in
this study was 1.38:1.

MATERIALS AND METHODS


Study design: This was observational study
Ethical approval: The study was ethically approved with
prior Institutional Ethical clearance obtained; proper
informed consent was taken from the participants
Inclusion criteria: Included children with congenital
malformations or suspected chromosomal abnormalities.
Exclusion criteria: Subjects suspected with other genetic
diseases like single gene disorders, inborn errors of
metabolism and multi factorial genetic diseases were
excluded from the study.
Sample size: 38 cases of Down syndrome were analyzed
cytogenetically.
Study duration and place: Children with congenital
malformations or suspected chromosomal abnormalities
were studied in the Cytogenetic Unit, DBT-sponsored
Diagnostic Genetic Lab, Comprehensive Facility for
Diagnosis and Management of Genetic Diseases
(CFDMGD) and the Cytogenetic Viability Lab, Department
of Anatomy, Assam Medical College, Dibrugarh, Assam.
The study was done from August 2011 to March 2015.
Methodology: Karyotyping was carried out for peripheral
lymphocytes, cultured from peripheral blood and stained
with Giemsa stain as per the Standard Operating Protocol
of the Diagnostic Genetic Laboratory (CFDMGD). Leica
Cytogenetic Workstation (Manufacturer name: Leica
Microsystems, Kolkota, India; model:Leica DM6000B and
Leica CTR6000) was also used during the study.
One to three ml of blood was withdrawn aseptically from
each patient. 20-30 spreads were analyzed for each case.
For mosaics, 30-50 spreads were studied. The slides were
analysed for detection of various chromosomal
abnormalities including Down syndrome (Trisomy 21). For
the translocation Down syndrome cases, parents were
investigated to determine the parental carrier status.
Statistical analysis: The data found in this study were
compared with similar findings of other authors in other
country or in a different part of India and statistically
analysed manually using two proportional Z-Test.
RESULTS
Of the 38 cases of DS studied, Free trisomy 21 (Fig: 1)
was noted in 92.11% cases; translocation DS (Fig: 2) was

Das Hirak et al.,

Fig.1.Karyotype showing Free Trisomy 21

Fig.2.Karyotype showing Translocation Trisomy 21


Table 1:
Trisomy 21

Frequency

Type
Free Trisomy 21
Translocation Robertsonian
trisomy 21
translocation

of

various

13q;21q
14q;21q
15q;21q
21q;21q
21q;22q
Others
Reciprocal translocation
Mosaic trisomy 21
Total

types

of

Male Female %
22 13
92.11
1
2.63
2
5.26
22
16
100

DISCUSSION
The percentages of various types of trisomies were
compared with those found by other authors (Table 2).
Among the cases of Robertosonian translocation, Jyothy
[9]
[1]
et al.
and Jayalakshmma et al.
reported higher
percentage of t(14q;21q) (47.47% and 62.34%
respectively).

Int J Med Res Health Sci. 2015;4(4);799-802

800

Table 2: Comparison of the frequency of various types of trisomy 21 among different authors
Author

Mokhtar et al. (2003)


5

Devlin et al. (2004)


8
Azman et al. (2007)
2
Amayreh et al. (2009)
1
Jayalakshamma et al (2010)
3
Podder et al. (2012)
6
Kolgechi et al.
(2013)
Present study (Das et al.)
[6]

Source/Populatio
n/Study group

Tota
l No.

Free
21

Egypt

673

Ireland
Malaysia
Jordan
Karnataka, India
West Bengal, India
Kosova
Albanian
Population
Dibrugarh, Assam

Translocati
on trisomy
21

Mosaic
trisomy 21

Non
classic

642(95.4%)

18(2.7%)

5(0.7%)

8(1.2%)

208
149
80
874
85
305

197(94.7%)
141(94.6%)
74(92.5%)
759(86.9% )
78(91.8%)
285(93.4%)

3(1.45%)
1(0.7%)
2(2.5%)
77(8.8% )
2(2.4%)
17(5.6%)

8(3.85%)
7(4.7%)
3(3.8%)
38(4.3%)
5(5.9%)
3(1%)

0
0
1(1.3%)
-

32

29(90.63%)

1(3.13%)

2(6.25%)

However, Kolgeci et al.


found t( 21q;21q) translocation
to be the most common (58.8%) type. The only
translocation found in this study was t (21q;21q), which
therefore formed the most common type. This matches the
[6]
results of Kolgeci et al .
Most de novo rearrangement of 21q;21q are isochromosomes derived from a single parent #21 and only a
[10,11]
small proportion are true Robertsonian translocation
.
[6]
Translocation can also be reciprocal. Kolgeci et al. found
0.3% cases with reciprocal translocation between
chromosome 21 and 8.
The results of this study were compared with one Indian
[1]
[7]
study
and one study abroad
and statistically
analyzed by manual method using two proportional Z-test.
Although Free trisomy 21 and translocation trisomy 21 did
not show significant difference when compared with both
the authors, mosaic trisomy 21 showed a significant
[7]
difference with the Egyptian population .
The Sex ratio of 1.38:1 showed a male preponderance.
This was in conformity with the findings of other authors as
well. Higher male sex ratio may be due to the inherent
tendency of Y chromosome belonging to the G group
(acrocentric chromosomes) which also includes the
[1]
chromosomes 21 and 22 .
Recurrence risk is <1% in a de novo translocation Down
Syndrome. In familial Robertsonian translocation, the
recurrence risk is about 10%, which increases to 15% at
amniocentesis. For male carrier, the recurrence risk is
[12]
about 1% . In families with a de novo translocation Down
Syndrome and parents with normal karyotype, the risk of a
second child with Down Syndrome is small (1-2%). For
couples who are carriers of silent Robertsonian
translocation t (21q; 21q), the risk of having a second child
with Down Syndrome is 100% and they shall be unable to
[6]
have healthy baby . In t(21q; 21q), if one parent is a
carrier, the recurrence risk is 100% while in t (21q; 22q) if
one parent is a carrier, the recurrence risk is <5%. If
mother is a carrier, the recurrence risk is 10% but if father
is the carrier, the recurrence risk is <5% in case of a D/G
[9]
translocation .
Parental karyotype is therefore essential for all patients
with translocation Down Syndrome. Prenatal diagnosis
must be offered if any of the parents shows an abnormal

Das Hirak et al.,

trisomy

[9]

karyotype . Earlier clinical diagnosis helps parents to


make crucial medical decisions.
CONCLUSION
The study showed interesting variations in the frequency
of Down Syndrome in a North East Indian population.
Knowing the type of translocation and status of the parent
is important to estimate the risk of recurrence in future
pregnancies. This information, assisted with advances in
prenatal diagnosis can help parents in decision making
and reduce the burden of Down syndrome births in the
society.
Limitation of the study: The relatively small sample size.
This is because, the disease is relatively rare and the
awareness of the need for genetic test among the public in
this area is still in its infancy. Further study with more
number of participants with the developing awareness
shall bring out more information from this region.
Conflict of interest: Nil
Acknowledgments: The authors acknowledge the
Department of Biotechnology, Government of India for
providing the entire financial support (including manpower,
equipments and consumables) to carry out the present
study under the CFDMGD project, Assam Medical
College, Dibrugarh, Assam. We appreciate the technical
support provided by our laboratory technicians Mr.
Rupjyoti Lahon, Mrs. Mitali Barman, Miss. Pompi Saikia
and Miss. Arunima Borah. We are also thankful to Miss.
Debashri Boruah for her help in statistical analysis. We
thank the Genetics Unit, Department of Paediatrics, All
India Institute of Medical Sciences, New Delhi for assisting
us in quality control. We are grateful to Prof. A.K. Adhikari,
The Principal-cum-Chief Superintendent and Dr. J. Lahon,
Professor and Head of Anatomy, Assam Medical College
for their support and encouragement. We thank all the
referring doctors who have made this study possible.
REFERENCES
1.

Jayalakshamma MM, Amudha S, Tilak P, Devi R,


Rajangam S. Cytogenetic Analysis in Down
Syndrome. Int J Hum Genet 2010; 10, 95-99

Int J Med Res Health Sci. 2015;4(4);799-802

801

2.

3.

4.
5.

6.

7.

8.

9.

10.

11.

12.

Amayreh W, Al Qaqa K, Ali AH, Issa K. Clinical


and Cytogenetic Profile of Down Syndrome at
King Hussein Medical Centre. JRMS 2012; 19,
14-18.
Podder G, De A, Adhikari A, Halder A, Banerjee J,
Madhusnata De. Assessment of Down Syndrome
Patients In West Bengal, India. Pacific Journal of
Medical Sciences 2012; 10, 28 35.
Ward OC and Down JL. The man and the
message. Downs Syndr Res Pract 1999; 6, 19-24.
Devlin L and PJ Morrison. Accuracy of the clinical
diagnosis of Down syndrome. Ulster Med J 2004;
73, 4-12.
Kolgeci S, Kolgeci J, Azemi M, Shala-Beqiraj R,
Gashi Z, Sopjani M. Cytogenetic Study in Children
with Down Syndrome Among Kosova Albanian
Population Between 2000 and 2010. Mat Soc Med
2013; 25, 131-135.
Mokhtar MM, Abd El Aziz AM, Nazmy NA, et al.
Cytogenetic profile of Down syndrome in
Alexandria, Egypt. Eastern Mediterr. Health J.
[online] 2003; 9: Nos 1/2. Available at:
www.emro.who.int/publications/emhj/0901_2/cytog
enetic.htm.
Azman BZ, Ankathil R, Siti Mariam I, et al.
Cytogenetic and clinical profile of Down syndrome
in Northeast Malaysia. Singapore Med. J. 2007
Jun; 48(6): 550-554.
Jyothy A, Rao GN, Kumar KS, Rao VB, Devi BU,
Reddy PP. Translocation down syndrome. Indian J
Med Sci 2002; 56, 122-126.
Shaffer LG, McCaskill C, Haller V, Brown JA,
Jackson-Cook CK. Further characterization of 19
cases of rearrangement (21q21q) and delineation
as isochromosome or Robertsonian translocations
in Down syndrome. Am J Med Genet 1993; 47,
1218-1222.
Sheth F, Rao S, Desai M, Vin J, Sheth J.
Cytogenetic Analysis of Down Syndrome in
Gujarat. Indian Pediatrics 2007; 44, 774 777.
Gardner RJM, Sutherland GR. Chromosome
abnormalities and genetic counseling. 2nd edition.,
Oxford University Press, 1996; Oxford.

Das Hirak et al.,

Int J Med Res Health Sci. 2015;4(4);799-802

802

DOI: 10.5958/2319-5886.2015.00159.9

Available online at: www.ijmrhs.com

Research article

Open Access

SURGICAL OUTCOME OF TRIPLE PROCEDURE AS PENETRATING KERATOPLASTY


WITH EXTRACAPSULAR CATARACT EXTRACTION WITH POSTERIOR CHAMBER
INTRAOCULAR LENS IMPLANTATION IN PATIENTS WITH BOTH CENTRAL
CORNEAL OPACITY AND ADVANCED CATARACT AT RURAL SET UP
1

Shubhangi Nigwekar , Kishor Badhe , Neeta Misra , Surekha Bangal .

ARTICLE INFO
th

Received: 16 Jun 2015


th
Revised: 28 Jun 2015
th
Accepted: 8 July 2015
1

Authors details: Professor,


Department of Ophthalmology, Rural
Medical College of PIMS (DU), Loni,
Maharshtra, India
Corresponding author: Shubhangi
Nigwekar
Professor,
Department
of
Ophthalmology, Rural Medical College
of PIMS (DU), Loni, Maharshtra, India
Email: shubhangi2501@yahoo.in
Keywords: Triple procedure, Cataract
with corneal opacity, Triple surgery.

ABSTRACT
Purpose: To study the surgical outcome of triple procedure as penetrating
keratoplasty (PKP) with conventional extra capsular cataract extraction (ECCE)
with posterior chamber intraocular lens (PCIOL) implantation in patients with
both central corneal opacity and advanced cataract at rural set up.
Introduction: When corneal opacity and cataract present together then wellestablished and effective triple procedure is indicated. Prognosis for a clear
graft is good in triple, as graft endothelium does not touch the hard nucleus
which may occur in two steps or sequential surgery. It provides faster visual
rehabilitation. Being single step procedure it reduces patients hospital stay,
postoperative care and follows up visits. Methodology: In this hospital based
observational , three years longitudinal study, we studied the surgical outcome
of relatively rare one step triple procedure as PKP with conventional ECCE with
PCIOL implantation in sulcus or in bag, in patients with both central corneal
opacity and advanced cataract at rural set up. The outcome measures included
graft clarity on slit lamp, postoperative unaided visual acuity with Snellens chart
and the occurrence of postoperative complications after taking IEC permission
and informed written consent in local language from study patients. Results:
Out of 13 study patients mean age was 61.15yrs (Range50-80yrs). Follow up
range was 9-34 months. At final follow up 9 patients (69.23%) had clear grafts
and 61.52% patients gained visual acuity >6/24. Graft failure was the most
common post operative complication in 30.76% followed by Posterior capsular
opacification (PCO) in 15.38% patients which was treated well with YAG laser
capsulotomy. Conclusion: Triple procedure gives good results in respect to
graft clarity, unaided vision, and faster rehabilitation.

INTRODUCTION
Status of the cornea is crucial to achieve good outcome
after cataract extraction with intraocular lens implantation.
Pre-existing corneal disease must be managed
appropriately to get good results of cataract surgery.
Many times the corneal opacity and cataract present
together. In such cases, performing only penetrating
keratoplasty or only cataract surgery does not give good
visual outcome. Actually corneal pathologies needing
keratoplasty are often associated with cataract and
therefore combined surgery is mandatory. Triple
procedure
with
penetrating
keratoplasty
and
simultaneous cataract extraction with intra ocular lens
(IOL) implantation is usually preferred as single step
surgery because theoretically visual rehabilitation is more
rapid and patients require less post operative follow ups.
[1, 2]

Rural patients loose follow up for second step IOL


implantation and prefer very poor or no vision even with
clear corneal graft. Prognosis for a clear corneal graft is
good in triple, as graft endothelium never touches the
hard nucleus which may occur in two step or sequential
[3]
surgery. So in our rural set up we studied the surgical

outcome of triple procedure in patients presenting with


both corneal opacity & cataract.
Aims and objectives: To study the surgical outcome in
relation to graft clarity on slit lamp examination (SLE),
postoperative uncorrected visual acuity (UCVA) and
postoperative complications of rare triple procedure at
rural set up.
MATERIAL AND METHODS:
Study design: Descriptive longitudinal, hospital based
study.
Ethical approval: The present study was approved by
the Institutional Ethical committee and written inform
consent was obtained prior to the study from all patients.
Inclusion criteria: Patients of 50 years and above with
significant senile cataract and central corneal opacity with
normal posterior segment on B-scan and who were fit for
General anaesthesia have been included. We used
clinically good, fresh donor corneas.
Exclusion criteria: All patients suffering with corneal
vascularisation,
raised intra ocular pressure (IOP),
anterior staphyloma, and posterior segment problems on

803
Nigwekar S et al.,

Int J Med res Health Sci. 2015;4(4):803-806

B-scan and previous ocular surgery except PKP were


excluded.
Sample size: Thirteen cases of triple procedure
performed all under general anaesthesia.
Duration: 3 years (from January11-December13, and
followed for 12 - 36 months)
Methodology:
Operation procedure: The uniformity of surgical
procedure was maintained as follows:
Preparation of donor corneal button, removal of corneal
opacity with trephine, release of iris adhesions at angle
and posterior synechiae, continuous curvilinear
capsulorrhexis (CCC) or can opener capsulotomy,
removal of nucleus with cystitome and vectis, removal of
cortex, implantation of polymethylmethacrylate (PMMA)
rigid one piece PCIOL in bag or in sulcus depending on
type of capsulotomy, 2 peripheral buttonhole iridectomies
(PBI)s, intermittent 16- equidistant- radial 10-0 nylon
sutures, anterior chamber (AC) reformation with air and
saline, application of bandage contact lens (BCL),
subconjunctival (S/C) injection of antibiotic-steroid and
postoperative eye patch and bandage was given to all
patients for 18-24 hours. Topical antibiotic steroid drops
and lubricating drops were prescribed post operatively.
Systemic antibiotics, anti-inflammatory, analgesics, IOP
lowering agents, and steroids were used as per

st

need.Follow up examinations were carried out on 1 to


7th day in indoor rural patients. We recorded findings
from Slit lamp examination, Ophthalmoscopy, Snellens
visual acuity chart and Non contact tonometry (NCT).
Parameters studied: We recorded postoperative
uncorrected visual acuity (UCVA), slit lamp examination
(SLE) and Intra Ocular Pressure with NCT at 1 month, 3
months follow up. Epithelial and endothelial graft
rejections were treated medically as far possible. Further
interventions like repeat PKP or YAG laser capsulotomy
and their results were observed.
RESULTS
Table 1: showing Age & Sex distribution of 13 study
cases
Age (Years)
Male
Female
Total
41-50
2
2
51-60
5
1
6
61-70
2
2
4
71-80
1
1
TOTAL
7
6
13
There were 7 males and 6 females. Maximum patients
th
were in 6 decade and the mean age group was 61.15yrs
(Range 50-80yrs).

Table 2: showing all study cases data: indication, pre and postop vision, complications and management
INDICATIOPKP/ EYE

Pre
V/A

Failed Graft / LE

CF 1F

Failed Graft/LE
Corneal Scar/RE
Corneal Scar/LE
Corneal Scar/RE
Corneal Scar/LE
Healed
Herpes
simplex keratitis /RE
Uveitis & Scar / RE
Corneal Scar /LE
Uveitis & Scar /LE
Corneal Scar /RE
Corneal Scar /RE
Failed Graft /RE

OP

Early
P.OP.V/A

Intervention

Graft clarity
at
last
follow up

final V/A

YAG
Laser
Capsulotomy
Refused PKP

Clear

6/12*

Hazy

HM

30
30
24
24
20

Endothelial
Graft Rejection
-----------------------------------------Graft Ulcer
CA-larynx death

Clear
Clear
Clear
Clear
Hazy

6/24
6/18
6/24
6/12
CF 1M

18
18
16
14
14
12

Graft Failure
-----Graft Failure
------------PCO

Hazy
Clear
Clear
Clear
Clear
Clear

HM
6/18
CF 4M
6/24
6/60
6/18*

Etiology
less V/A

6/18

Last
follow up
in months
36

HM

CF 2M

36

CF 2M
CF 1M
CF 2M
CF 5M
CF 1F

6/24
6/18
6/24
6/12
6/18

PL+
CF 1M
PL+
CF 1M
HM
CF 1M

CF 5M
6/18
CF 4M
6/24
CF 5M
CF 4M

PCO

of

Refused PKP
----Repeat PKP
-----------YAG

RE- Right Eye, LE- Left Eye, CF- Counting Finger, HM-Hand Movements, PL- Perception of Light.
Study showed all triple procedures were unilateral out of which 7 were performed in right eye. All patients had
preoperative visual acuity in the range of Perception of light (PL) + to counting finger (CF2) Meters. Most common
indication for the PKP was corneal scars and failed grafts. Out of 13 study patients (69.23%) 9 patients had clear grafts
and four (30.77%) graft failures
Table 3: showing graft failure complication in 4 patients and management outcome.
Indication Of PKP
Early Post
Etiology Of Less V/A
Intervention
Graft Clarity At
operative V/A
Last Follow Up
Endothelial graft rejection
Failed Graft
CF 2M
Refused Re PKP Hazy
Be Old HSV
6/18
Graft Ulcer
Ca-Larynx Death Hazy
Uveitis & Scar
CF 5M
Graft Failure
Refused Re PKP Hazy
Uveitis & Scar
CF 4M
Graft Failure
Repeat PKP
Clear

Final V/A
HM
CF 1M
HM
CF 4M

804
Nigwekar S et al.,

Int J Med res Health Sci. 2015;4(4):803-806

Out of these 4 graft failure patients, the indication for PKP


was due to corneal scars either due to old uveitis or HSV
or previous failed grafts. 1 patient had immune related
sterile keratitis that died of ca-larynx, 2 patients refused
regraft and 1patient who was one eyed, underwent
regraft.
Table 4: showing % of all postoperative
complications
Post Operative
No Of Patients & %
Complication
Epithelial Defect
3 (23.07%) Treated Medically
Glaucoma
1 (7.69%) Treated Medically
Graft Failure
4 (30.76%)
Uveitis
2 (15.38%)
IOL Decentration
0 (0%)
Suture Vascularization 1 (7.69%)
PCO
2(15.4%)Treated YAG Laser
Postoperatively 30.76% patients had graft failure and
23.07% patients had epithelial defects, 7.69% patients
had glaucoma and vascularization while 15.38% patients
had Uveits and PCO. All cases had well centered
PCIOLs and thus there was 0% decentration of IOLs.
Table 5: showing final visual outcome at last visit
Final visual acuity
No. of Cases - and (%)
6/12
2 (15.38%)
6/18
3 (23.07%)
6/24
3 (23.07%)
6/60
1 (7.69%)
CF- HM
4 (30.77%)
TOTAL
13 (100%)
In this study 38.46% i.e. 5 cases had postoperative
UCVA 6/18 or better and 61.52% had V/A >6/24.
Most cases had better postoperative V/A than
preoperative V/A. Early postoperative V/A ranged from
6/12 to 6/60. In 2 patients there was PCO, who
underwent YAG capsulotomy and regained good vision.

Fig 1: Photos of various study patients at their follow ups:


A: 1st Post operative day showing clear graft with air bubble
in AC, B: 1 week Post operative photo - clear graft , C: 1
year Post operative photo.

DISCUSSION
Triple procedure which was first described by Taylor in
1976, has now became a well-established and effective
surgical treatment for patients with both corneal and
lenticular opacities and indicated in whom corneal
[4]
surgery may accelerate the cataract formation Single
step triple procedure, reduces the patients hospital stay,
postoperative care and follows up visits especially in
elderly patients who usually have geriatric health

problems. Triple procedure gives faster visual


rehabilitation and is more preferred than sequential or 2
step surgery i.e. first PKP and after suture removal ECCE
with PCIOL implantation. However surgeons have to be
aware of surgical conditions during open-sky surgery,
because vitreous pressure is not counterbalanced by
[5]
anterior chamber pressure
Performing only PKP in patients with corneal opacity in a
rural senile patient reduces the patients ultimate visual
outcome as these patients loose follow up for second
step IOL implantation and prefers very poor vision or no
vision even with clear corneal graft.
In early periods there was a challenge of IOL power
calculation for triple procedure due to corneal scars
however now it is answered by use of standard constant
keratometry value of 44 D and fellow eye keratometry is
[6, 7]
also an option.
In two step or sequential surgeries we get more accurate
[8]
IOL power after removal of sutures of PKP. However
early removal of sutures in elderly patients lead weak
unhealed grafts which may lead slippage of transplants.
Even a minor trauma may lead globe rupture up to 5
[9
years postoperatively. ] Actually PKP hastens cataract
formation, particularly in eyes with moderate pre-existing
cataracts due to surgical trauma and inflammation as well
as the postoperative topical steroid therapy. In
sequential or two step surgery there may be endothelial
cell loss from the precious survived clear corneal graft
during cataract surgery and with borderline endothelial
cell count, corneal decompensation can occur. Thus
simultaneous or one step triple surgery may remain a
justified option for good visual outcome in such patients.
Advantages of classic triple procedure are quick visual
rehabilitation, fewer induced refractive errors, minimal
[10]
postoperative discomfort and corneal integrity.
In this triple procedure study, 69.23% (9 cases) patients
had clear grafts and rest 4 patients had hazy grafts due
to graft failure. Clear corneal graft after the triple
procedure has been found to range from 60% to 100% in
the literature. Similar results were seen by Mohammad
[11]
AJ et al.
Out of these 4 graft failure patients, the indication for PKP
was due to corneal scars either due to old uveitis or HSV
or previous failed grafts. Indications for corneal
transplantation have a significant effect on graft
[12, 13]
survival.
In this study, 30.76% patients had graft failure and
23.07% patients had epithelial defects, 7.69% patients
had glaucoma and vascularization while 15.38% patients
had Uveits and PCO. These results were similar to
[14]
Meyer RF et al.
There was no decentration of PCIOL in any patient
though we used both capsulotomy techniques i.e.
Capsulorrhexis or Can opener capsulotomy. Borderie VM
et al found better visual acuity, controlled IOP and clear
grafts without oedema in his study when the triple
procedure
included
capsulorrhexis
and
[15]
phacoemulsification with PK.
In present study, 38.46% cases had postoperative UCVA
6/18 or better and 61.52% had UCVA > 6/24. Claou C

805
Nigwekar S et al.,

Int J Med res Health Sci. 2015;4(4):803-806

et al and Crawford GJ et al reported comparable


outcomes and showed postoperative UCVA > 6/9 ranging
[16, 17]
from 38% to 64% of eyes.
Success rate in our study may be due to patients
selection, minimal surgical intervention, use of good
donor cornea, viscoelastic material, good IOL placement,
proper estimation of IOL power, 2 PBIs, indoor patients
for 7 days and regular follow ups with slit lamp
examination which allowed proper and timely
postoperative intervention like YAG laser capsulotomy
and use of systemic steroids to prevent or treat early graft
failure.
CONCLUSIONS
Triple procedure gives good results in respect to graft
clarity, unaided vision, and faster rehabilitation. However
patients selection should be proper to reduce problems
of graft failure.
Limitations of study: As our sample size and follow up
period is small, further study with more sample and
longer follow ups will be needed.
REFERENCES:
1.
2.

3.

4.

5.

6.

7.

8.

9.

Muraine M. Keratoplasty combined with cataract


surgery. J Fr Ophthalmol. 2012; 35(7):546-54.
Busin M, Arffa RC, McDonald MB, Kaufman HE.
Combined
penetrating
keratoplasty,
extracapsular cataract extraction, and posterior
chamber
intraocular
lens
implantation. Ophthalmic Surg. 1987;18:272- 5
Muraine M et al. Keratoplasty combined with
cataract surgery. J Fr Ophthalmol. 2012;
35(7):546-54.
Shimmura S, Ohashi Y, Shiroma H, Shimazaki J,
Tsubota K. Corneal opacity and cataract: triple
procedure
versus
Secondary
approach.
Cornea. 2003; 22:234238.
Flowers CW, McLeod SD, McDonnell PJ, Irvine
JA, Smith RE. Evaluation of intraocular lens
power calculation formulas in the triple
procedure. J Cataract Refract Surg. 1996;
22:116122.
Crawford GJ, Stulting RD, Waring GO, Van Meter
WS, Wilson LA. The triple procedure. Analysis of
outcome, refraction, and intraocular lens power
calculation. Ophthalmology. 1986; 93:817824.
Katz HR, Forster RK. Intraocular lens calculation
in combined PKP, cataract extraction and
intraocular lens implantation. Ophthalmology
1985; 92:12037.
Davis EA, Azar DT, Jakobs FM, Stark WJ.
Refractive and keratometric results after the triple
procedure: experience with early and late suture
removal. Ophthalmology.1998; 105:624630.
Mader TH, Yuan R, Lynn MJ, Stulting RD, Wilson
A, Waring GO. Changes in keratometric
astigmatism after suture removal >1yr after
penetrating keratoplasty. Ophthalmology. 1993;
100: 119126.

10. Pineros OE, Cohen EJ, Rapuano CJ, Laibson


PR. Triple vs nonsimultaneous procedures in
Fuchs
dystrophy
and
cataract. Arch
Ophthalmol. 1996; 114:525528.
11. Preschel N, Hardten DR. Management of
coincidental corneal disease and cataract.Curr
Opin Ophthalmol. 1998 Feb; 9(1):39-45.
12. Mohammad AJ, Sepehr F, Hamid RM
Simultaneous Penetrating Keratoplasty and
Cataract Surgery J Ophthalmic &Vis Res. Jan
2013; 8(1): 3946.
13. Coster DJ. Some factors which affect the visual
outcome of corneal transplantation. Eye 1991;
5:26578.
14. Meyer RF, Musch DC. Assessment of success
and complications of triple procedure surgery. Am
J Ophthalmol. 1987; 104:233240.
15. Borderie VM, Touzeau O, Bourcier T, CarvajalGonzalez S, Laroche L. The triple procedure: in
the bag placement versus ciliary sulcus
placement of the intraocular lens. Br J
Ophthalmol. 1999; 83:458462.
16. Claou C, Ficker L, Kirkness C, and Steele A.
Refractive results after corneal triple procedures
(PK+ECCE+IOL). Eye (Lond) 1993; 7:446451.
17. Jonas JB. Factors influencing visual outcome
after penetrating keratoplasty combined with
intraocular lens implantation. Eur J Ophthalmol.
2003; 13:134-8.

806
Nigwekar S et al.,

Int J Med res Health Sci. 2015;4(4):803-806

DOI: 10.5958/2319-5886.2015.00160.5
Open Access

Available online at: www.ijmrhs.com


Research article

HYBRID FIXATOR -FIXATION MODALITY IN COMPOUND COMMINUTED


FRACTURES OF TIBIA
1

Dhruvilkumar Gandhi , Sanjay Mulay , Tushar Chaudhari , Mayank Patel

ARTICLE INFO
th

Received: 17 Jun 2015


th
Revised: 4 Aug 2015
th
Accepted: 12 Aug 2015
1,3,4

Authors details:
Junior Resident,
2
Professor,
Department
of
Orthopaedics, Rural medical college,
Pravara Institute of Medical Science,
Loni, Ahmednagar, Maharashtra, India
Corresponding author: Dhruvilkumar
Gandhi
Junior Resident, Department of
Orthopaedics, Rural medical college,
Pravara Institute of Medical Science,
Loni, Ahmednagar, Maharashtra, India
E-mail: drgandhi25@gmail.com
Keywords: Proximal third fractures,
distal third fractures, tibial plafond
fracture, tibial plateau fractures,
Hybrid fixator

ABSTRACT
Background: Tibial plateau fractures, Tibial plafond fractures, proximal 1/3
fractures of tibia are serious type of injuries which are found to be difficult to
treat. The injury is caused by high velocity RTA which apart from causing
fractures, cause extensive damage to soft tissue envelop. Aim: To study
functional and radiological outcome of compound comminuted fractures of
proximal and distal third tibia. Method: This is a descriptive longitudinal study
carried out in 15 patients operated for hybrid external fixation for compound
comminuted fractures of proximal and distal third tibia. Every patient was
assessed for common fracture site, healing time and functional outcome.
Results: Out of 15 patients 13 has good result 1 had varus deformity and
average fracture healing time with full weight bearing walking was 20 to 24
weeks. Conclusion:-The comminuted fractures of the proximal third or the
distal third fractures pose serious problems due the injury/ degloving of the
soft tissue envelop. The risk of infection secondary to internal fixation is very
high. Also it has been noted to have high incidence of post injury residual
deformity, & knee joint stiffness. Hence less invasive method of hybrid fixator
was tried which would minimize these problems and allow the biological
healing of the fracture. This technique is simple, user friendly, & can allow
adjustment even after frame application.

INTRODUCTION
Tibial plateau fractures, Tibial plafond fractures, proximal
1/3 fractures of tibia are serious type of injuries which are
found to be difficult to treat. The injury is caused by high
velocity RTA which apart from causing fractures, cause
extensive damage to soft tissue envelop.
The mechanism of injury is initial axial loading which
cause impaction fracture, or/ and Further continuation of
angular forces mainly valgus force leading to
comminution of fractures not only in tibial plateau but
[1]
also in proximal 1/3 of tibia.
Deforming force due to high velocity trauma caused
extensive damage to protective soft tissue cover, which
[2]
results in extensive skin & muscle necrosis. This is
secondarily complicated in a) deep infection, b) stiffness
of knee joint. This was more common in Schatzker type
[3, 4, 5]
IV, V, VI injuries.
All of these complications
causes poor outcome.
Initially these fractures were conserved and treated with
linear traction. But the incidence of varus or valgus
deformities with knee joint stiffness was much high.
Whenever open reduction is used for these fractures and
poor choice of incision is taken and it increases soft
tissue dissection causes flap necrosis, infection as well
as delayed union due to loss of haematoma.
Hence some less invasive technique was tried that would
help in the following:

Use the principle of ligamentotaxis

Gandhi et al.,

To make an attempt to restore the anatomical


alignment

Restore the joint congruity

Provide the stable fixation.


That is now called as Hybrid fixator. A semicircular ring
is fixed either to the proximal tibial metaphysis or near
the ankle mortise, with the help of 2-3 olive wires or
[6]
bayonette wires. The tension given to the wires, which
provides stable trampoline at the proximal end / distal
end of tibia. The fractures are stabilized with 2-3 shanzs
pins fixed in diaphysis. Hence a study was planned to
evaluate clinical utility of Hybrid fixation
Aims & objectives
1. To find out the common type of comminuted fracture
of Tibia.
2. To find out average time for healing of the
comminuted fracture of Tibia.
3. To study and grade the functional outcome of
comminuted fracture of tibia using Hybrid fixators
4. To assess the time lag from the date of injury to
surgical intervention.
MATERIAL & METHODS
Study design: This is a descriptive longitudinal study

807
Int J Med Res Health Sci. 2015;4(4): 807-810

almost 9 months. (Elderly female with comminution of


lower third fracture of tibia)
Average time of healing of fracture is 20 -24 weeks (fig
1), Out of 3 compound fractures wound healed well in all
the cases, ROM of knee joint was bet 0-120 degrees. 1
patient had varus angulation of the lower third of tibia,
due to early weight bearing & not using support (PTB
brace). No extension lag was seen in any of the cases.
The final outcome was 13 good and 2 were fair
Table1: Age wise distribution of participants
Age in years
Male
Female
Total
20-29
3
3
30-39
4
5
40-49
2
2
4
50-59
1
1
60-69
2
2

RESULTS
Total fifteen patients were treated with hybrid fixator out
of this 9 were male and 6 were female. The age range of
the patients shown in table 1. The average hospital stay
was 12 -15 days, duration between injury & surgery was
10 -15 days. Non weight bearing followed up for 10 -12
weeks. Partial weight bearing started after 12 16
weeks. Frame was removed after 16 weeks, after the
removal of frame the patient was given long knee brace /
PTB brace. In 2 cases we had to continue PTB brace for

Gandhi et al.,

No of Patients

Ethical approval: The study was approved by the


institutional ethical committee & inform consent was
obtained from the patients
Place of research: Department of Orthopaedics, PIMS
(DU), rural medical college, Loni,
Inclusion Criteria: All patients with comminuted
fractures of proximal 1/3 or distal 1/3 of the tibia were
enrolled between 24 yrs. to 68 yrs. age group; Patients
who has compound Proximal or Distal Tibia Fractures
only, Classification used for compound injury is Gustilo
[7]
Anderson classification.
Exclusion Criteria: Any co morbidity that prevents the
patient from early mobilization, Patients medically unfit
for surgery, Patients who did not come for follow-up
Sample Size: 15 patients were treated with hybrid fixator
out of which 12 were simple comminuted fractures of
tibial plateau /tibial plafond / proximal third or distal third
of tibia, & 3 were compound comminuted fractures.
Study duration: All the 15 patients scrutinized in this
study were followed for 1 year from the time of surgery
for radiological and functional evaluation.
Parameters used for observation
All the patients who were satisfying above mentioned
inclusion / exclusion criteria were studied for following.
1. Type of fracture
Proximal 1/3 or distal 1/3.
2. Duration between the time of injury and the surgery.
3. Average time of healing of fractures: Clinical
healing, Radiological healing.
Preliminary treatment included cleaning & debridement,
longitudinal traction, haematological & radiological
evaluation. Surgery was performed after 5-7 days, so
that soft tissue swelling / edema subsides & patient is
hemodynamically stable.
2 wires are passed in proximal Tibia,
a) One of the wires transfixing fibular head with tibia.
b) Semicircular ring fixed after giving adequate tension
to the wires.
Distal shaft fractures fixed with 2-3 shanz pins. In tibial
plafond fractures, semicircular ring is attached nearer to
ankle mortise & shanz pins are passed in tibial diaphysis.
Alignment of fracture achieved under C-arm control & the
fracture fixed with minimal distraction.
Patient advised active knee mobilization of knee & ankle
joint from 5 day onwards. Non weight bearing walking
and partial weight bearing was started after showing
clinical union of fracture frame removed after radiological
union conformed followed by PTB brace followed by full
weight bearing. Data of average time for these protocols
collected.

4.5
4
3.5
3
2.5
2
1.5
1
0.5
0

6-10
week
s

11-14
week
s

15-18
week
s

19-22
week
s

23-28
week
s

Proximal

Distal

0
Proximal

2
Distal

Fig 1: Time for Fracture healing in weeks


Table 2: Details of the Patients
Fracture Duration Of Time
Site

for

Full

injury&

Healing

Weight

Surg.

(In

Bearing

( In days)

Weeks)

(In

Result

weeks)
Proximal

11

12

15

Good

Distal

12

26

28

Fair

Proximal

11

23

24

Good

Proximal

13

25

24

Good

Distal

15

25

28

Fair

Proximal

10

16

18

Good

Distal

13

20

24

Good

Distal

13

22

25

Good

Proximal

10

21

24

Good

Distal

12

26

28

Good

Proximal

12

26

28

Good

Distal

14

15

19

Good

Proximal

15

23

27

Good

Distal

14

09

14

Good

808
Int J Med Res Health Sci. 2015;4(4): 807-810

Distal

10

17

20

Good

Fig 2:X-rays of different cases of Distal Tibia


Fractures shows near anatomical alignment of
fractures with frame

Fig 3: X-rays of different cases of Distal Tibia


Fractures shows near anatomical alignment of
fractures with frame

Fig 4: X-rays of different cases of Proximal Tibia


Fractures shows near anatomical alignment of
fractures with frame
DISCUSSION
Our major chunks of the cases were having comminuted
fractures in proximal or distal third of tibia, rather than
tibial plateau or plafond fractures. Duration between
injury & surgery in any of the case was never less than
10 15 days. (Patients were admitted quite late after the
injury, hence we did not have much scope for ORIF).
As mentioned earlier, the goal of treatment were

Gandhi et al.,

i)

Anatomical /near anatomical reconstruction of


proximal third or distal third of tibia.
ii) To restore alignment of the limb
iii) To restore normal anatomical position of tibial
plateau or tibial plafond.
iv) To fix & stabilise the metaphysio- diaphyseal
comminution.
v) Early knee mobilisation
vi) Early weight bearing
vii) To allow biological union of the fracture.
All these things were achieved with hybrid fixator.
1 patient who developed varus angulation, she was
having OA knee with G. Varus and the residual curve in
tibial shaft existed even before surgery. Another reason
was that she did not use PTB brace after removal of
fixator due to financial constraints. Delayed union was
seen 3 cases, all of which were 55yrs or above. Hence
as a protocol we advocated use of long knee brace /
PTB brace, after removal of the frame. Regular dressing
of the pin tracts & removal crusts along pin tracts can
easily minimize the incidence of pin tract infection.
There are more than one modalities treatment for these
kind fractures which are also in study phase but compare
to other studies done for this kind of fractures this study
shows similar results and better outcome functionally as
well as radiologically after 1 year follow up, less post[10]
operative complications and early mobilization.
This is a simple & user friendly technique. This frame
fixation does not require meticulous pre-operative work
[11, 12, 13]
like that required in Ilizarov technique.
Since the
hematoma is not touched / opened, this technique
promotes biological healing of the fracture. Less
incidence of soft tissue or bone necrosis, results in less
morbidity. Post-surgery changes in alignment were
possible in the frame. Incidence of knee stiffness can be
significantly reduced by early mobilization of the knee. It
is good technique for fixing comminuted prox. third distal third fractures, tibial plateau, and tibial plafond
fractures with reasonably good functional outcome.
However in this study we did not compare our results
with the other modalities of fixations. Our limitation for
this study was if fracture occurred at tibial plateau or
plafond with intra articular extension then fixation
becomes more difficult. Also the sample size of our study
was also small due to multimodalities of treatment for
this kind of fractures and less numbers of cases with
types of difficult fractures. In fact we need to continue our
follow up on larger sample size wherein we can more
elaborately compare our results with other modalities of
fixation & over longer duration.
CONCLUSION
The comminuted fractures of the proximal third or the
distal third fractures pose serious problems due the
injury/ degloving of the soft tissue envelop. The risk of
infection secondary to internal fixation is very high. Also
it has been noted to have high incidence of post injury
residual deformity, & knee joint stiffness. Hence less
invasive method of hybrid fixator was tried which would
minimize these problems and allow the biological healing

809
Int J Med Res Health Sci. 2015;4(4): 807-810

of the fracture. This technique is simple, user friendly, &


can allow adjustment even after frame application.
Acknowledgement: Special thanks to Dr K Vilas Babu
Prof. & Head and sincere thanks supporting staff of
Operation Theatre & Department of Orthopaedics, Rural
Medical College, Loni
Conflict of interest: None declared
REFERENCES
1.

2.

3.

4.

5.
6.

7.

8.

9.

10.

11.

12.

13.

Kataria H, Sharma N, Kanojia RK. Small wire


external fixation for high energy tibial plateau
fractures.
Journal of Orthopaedic Surgery
2007;15(2):137-43
Aditya K. Aggarwal, OnkarNagi. Hybrid external
fixation in periarticular tibial fractures Good final
outcome in 56 patients.
Actaorthop.Belg,
2006;72:434-40
George C. Babis, Dimitrios S. Evangelopoulos High
energy tibial plateau fractures treated with Hybrid
external fixation. Journal of Orthopaedic Surgery &
Research 2011;6:35
Schatzker J. Fractures of the tibial plateau. In :
Chapman MW, Bray TJ, Spiegel PG, Green SA
(eds). Operative Orthopaedics. JB Lippincott ;
Philadelphia, 1988, pp 671-684.
Appley AG: Fractures of the tibial plateau. Orthop
Clin North Am 1979, 10:61-74.
fixation, David P Moss Nirmal C Tejwani.
Biomechanics of external Bulletin of NYU Hospital
for Joint diseases 2007;65(4):294-9
Gustilo RB, Anderson JT. Prevention of infection in
the treatment of one thousand and twenty five open
fractures of long bones : Retrospective and
prospective analysis J Bone Joint Surg 1976 ;58-A :
453-458
Jhanwar, Harish kumar Jain. Management of tibial
plateau fractures with compromised soft tissue using
minimal internal & hybrid external fixation. Journal of
Pharmaceutical & Biomedical Sciences J Pharm
Biomed Sci 2014;04(05):427-433
Venkatesh Gupta, Gottipati Sunil. Management of
tibial metaphyseal fractures by Hybrid external
fixator. Open Journal of Orthopaedics, 2014;4: 8489.
Mayil Vahanan Natarajan, Chethan Nagaraj, R
Selvaraj, B Pasupathy, Antony Vimal Raj, P
Sankarlingam Management of periarticular fractures
of long bones of the lower extremity by hybrid
external fixation IJO 2004 vol 40 issue 3 page 177179 .
El Barbary H, Abdel Ghani H, Misbah H, Salem K.
complex tibial plateau fractures treated with ilizarov
external fixator with or without minimal internal
fixation. Int Orthop 2005 ; 29 : 182-185
Kataria H, Sharma N, Kanojia RK. Small wire
external fixation for high-energy tibial plateau
fractures. J Orthop Surg 2007 ; 15 : 137-143
Chapman WM. Chapman Orthopedic surgery.
Management of fractures, nonunion and malunion
with Ilizarov technique. Philadelphia, PA:Lippin cott
rd
William and Wilkins 2001 3 Edn third.pp 1082-1089

Gandhi et al.,

810
Int J Med Res Health Sci. 2015;4(4): 807-810

DOI: 10.5958/2319-5886.2015.00161.7
Open Access

Available online at: www.ijmrhs.com


Research article

A SURVEY OF KNOWLEDGE, ATTITUDE AND PRACTICES OF SELF


MEDICATION IN PUNE REGION
Kasabe Gauri H, Tiwari Smita A, Ghongane Balasaheb B

ARTICLE INFO
th

Received: 20 Jun 2015


th
Revised: 30 Jul 2015
st
Accepted: 31 Aug 2015
Authors details: Department of
Pharmacology,
BJ
Government
Medical College, Pune, Maharashtra,
India
*Corresponding author: Kasabe
Gauri H
Department of Pharmacology, BJ
Government Medical College, Pune,
Maharashtra, India
Email: gauri.kasabe248@gmail.com
Keywords: Antibiotic resistance, self
medication, over-the-counter drugs,
post graduatemedical students

ABSTRACT
Background: Paucity of drug related information and easy accessibility to
over-the-counter drugs has contributed to the high incidence of selfmedication. Strict regulations regarding drug dispensing and community
awareness of related issues is need of the hour. Aim: To do the Survey of
Knowledge, Attitudes and Practices about self medication in medical, non
medical and patients group in Pune region. Methods: This questionnaire
based study was carried out in postgraduate medical students,non-medical
graduate students and patients.Results: 30 from each group- Postgraduate
medical students, non-medical graduate students and patients participated
in the study. All of the post graduate medical students and non-medical
graduate students self medicate, 90% of patients self medicate. The reason
for self medication of 87% of post-graduate students is convenience and
that form on-medical graduate students and patients is commonly cost
saving. Conclusion: Media and pharmacists play an important role in
decision of self-medication in lesser educated population; this can be
modified into an advantage by utilizing it for creating awareness about the
growing antibiotic resistance in the society amongst the common population
and also making them aware of certain drug schedules of primary concern
to them. The awareness needs to be created in the common population ,
that certain patient sub-groups e.g. Patients on polypharmacy, pregnant
patients, those with liver/ kidney disorders and extremes of age should
possibly consult a physician before self-medicating even with OTC for
safety concerns. Therefore future research may be needed to study the
outcome of such patient education and its impact.

INTRODUCTION
Self-medication is defined as the selection and use of
medicines by individuals (or a member of the individuals'
family) to treat self-recognized or self-diagnosed
[1]
condition or symptoms
Paucity of drug related
information and easy accessibility to over-the-counter
drugs has contributed to the high incidence of selfmedication. Strict regulations regarding drug dispensing
and community awareness of related issues is need of
the hour.An epidemiological studyconducted in Brazil
included 1,509 working nurses, it reported a prevalence
[2].
of 24.2% of self-medicationin this subset of population
This study makes us aware of the fact that internationally
too, self medication has been on the rise.
In India certain common problems viz. headache, fever,
flu, diarrhoea and sore throat are being treated at home.
Whereas some minor ailments can be relieved with over
the counter (OTC) medications such as Paracetamol or
with some other traditional or herbal medicines, without
.[3]
physician consultation The trend is increasing among
[4]
youths and common among students.
Antibiotic resistance is a worldwide growing problem, with
negative patient outcomes. Antimicrobial-resistant
pathogens have become a threat to patients and have
5
also increased health care costs. Noncompliance with
infection control precautions and the inappropriate use of
antimicrobial agents have been identified as the main risk

Kasabe et al.,

[6,7]

factors for the emergence of antimicrobial resistance .


It also lead to increase in the economic burden as many
patients have to be started on higher antibiotics.
There are potential risks of self-medication practices such
as incorrect self-diagnosis, delays in seeking medical
advice when needed, infrequent but severe adverse
reactions, dangerous drug interactions, incorrect manner
of administration, incorrect dosage, incorrect choice of
therapy, masking of a severe disease and risk of
.[8]
dependence and abuse . Medicines act as a double
edged sword they can restore your health and improve
the quality of your life; at the same time, if it is not used
correctly can cause serious harm to your body. In this
purview, Dr Mashelkar report advises inclusion of OTC
(Over The Counter) drugs in Schedule K to ensure quality
and timely availability of commonly required medicines to
.[9]
the lay population . The phrase OTC has no legal
recognition in India, all the drugs not included in the list of
prescription-only drugs are considered to be nonprescription drugs (or OTC drugs). OTC Drugs means
drugs legally allowed to be sold Over The Counter by
pharmacists, i.e. without the prescription of a Registered
.[9]
Medical Practitioner Over the counter drugs (OTC) are
meant for self medication and are of proven efficacy and
safety ,yet their improper use due to lack of knowledge of
their side effects and interactions could have serious

811
Int J Med Res Health Sci. 2015;4(4):811-816

implications, especially in extremes of ages (children and


old age) and special physiological conditions like
[10].
pregnancy and lactation
The problems due to self
medication are magnified when non-OTC drugs are also
used for self medication .The literature suggests that no
sector of the medical community is immune to the
problem of drug abuse of which the worst offenders
[11,12].
include physicians
Both general drug knowledge and
access to prescription medications are potential factors
[13]
for self-prescribing
The details of rational and good prescribing practices are
imbibed in all medical students who study allopathic
medicine forfour and half years .Other than writing
prescriptions they are also trained for identifying , the
drug related adverse effects and drug interactions
.Suchexpertise and skills get honed with increasing
[14]
experience and practice of the physician.
Other
reasons that are responsible for self-medication or self
prescription among physicians include the complaint of
extensive demands on their time and relatively
unpredictable schedules; special issues of privacy and
confidentiality also do arise such that their own medical
knowledge may alter their needs or perceived needs for
[14]
care delivered by others Similarly, various studies have
unraveled the fact that self-medication is a common
phenomenon amongst doctors and they too are reluctant
[15]
to seek professional help even if required. A study
reported that the rate of self-medication with antibiotics
amongst doctors was nine out of 10 , and that of
antidepressant drugs was 50%. An Australia done
recently evaluated the beliefs about self-medication in
doctors.It found that, 90% doctors supported selfmedication in case of acute illnesses whereas 25% of
[16].
them supported the same in chronic illnesses.
Aim: To evaluate their current Knowledge, Attitudes and
Practices regarding the Self Medication.
MATERIALS AND METHODS
Study design: Analytical Cross sectional survey based
study
Ethical approval: The study was approved by the
BJGMC, Institutional Ethics committee and informed
consent was taken from all the volunteers.
Study period: A period of 3 months i.e. June, July and
August 2014
Inclusion criteria: Random selection of post graduate
medical students, non-medical graduate students and
patients attending various OPD at B.J. Govt. Medical
College and SGH Pune, a tertiary care teaching hospital
in Western Maharashtra.
Medical Group includes normal healthy volunteers of
medical
post
graduate
students
of
various
departmentsi.e.
Medicine,
Surgery,
Anatomy,
Pharmacology, Pathology, Physiology, Preventive and
Social Medicine and Non Medical group includes
students of Engineering final yearand Patients group
includes patients attending Medicine, Surgery, Skin and
Chest medicine OPD. Volunteers vary in age group from
18 years to 60 years of both sexes.
Exclusion criteria: Any past or present Psychiatric
history.

Grouping: A survey was conducted among the three


groups namely, Post graduate medical students, Nonmedical graduate students and Patients
Sample size: N=90 (In each group n=30)
Methodology
The survey was a performed using a semi-structured
questionnaire designed by experienced faculty of
Pharmacology and these questions were approved by
Ethics Committee.It included 20 questions pertaining to the
responders Knowledge, Attitudes and Practices regarding
the self medication.The questionnaire was distributed to fill
the answer among 30 post graduate medical students, 30
non-medical graduate students and 30 patients attending
various OPD. [Questionnaire mentioned in annexure 1]
Statistical analysis: The data was entered in Microsoft
excel 2007 for record and calculations. All the results are
presented as percentages of total responses.
RESULT
Total of 90 volunteers, 30 from each group- Postgraduate
medical students, non-medical graduate students and
patients participated in the study. All of the post graduate
medical students and non-medical graduate students self
medicate, 90% of patients self-medicate.(Fig 1)

No

10

Patients

Yes

90
0

Medicos

100
0

Non-medicos

100
0

50

Percentage

100

150

Fig1: Percentage of self-medication among various groups

Paracetamol was the most commonly used drug for self


medication was in all groups namely post graduate medical
students, non-medical graduate students and patients
attending various OPD. All of the patients had suffered from
running nose and cough and self medicated for the same
,whereas educated non-medical students had running nose
, cough and fever for which they self medicate.(Fig 2)

Fig 2: Most common indication among various groups

87% of post graduate medical students self medicate


due to convenience, In 73.33% ,cost saving is the reason
for self medication.Among Graduate medical students
and patients ,cost saving is the most common reason for

812
Kasabe et al.,

Int J Med Res Health Sci. 2015;4(4):811-816

self medicate.66.67% of medical students take drugs for


self medication as per their own experience.60% of
graduate non- medical students follow opinion of family
member
for
drugs
to
be
taken
for
self
medication.56.66%take drugs according own experience
and previous doctors prescription.(Fig 3)

according to price and indication of drug. (Fig 4)

6.67

Brand of the drug

56.67

Previous doctor's
prescription

60

Type of drug
0

Recommendation of on
line data base

Patients
Patients

Medicos

23.33

Opinion of friends

Non-medicos

20

40

60

100

percentage

60% medical students have knowledge of doses,duration


of therapy,Side effect and interaction of drugs they have
used. 36.66%of nonmedical students and only 16%of
patients have knowledge of doses, duration of therapy,
side effect and interaction of drugs they have used. 50%
medical students check package inserts to know the
dosage of drug. 60% of nonmedical students consult
pharmacist and 63.33% of patients take drugs according
to their previous experience. (Table 1)

90

Recommendation
community pharmacist

Medicos

0
50
Non-medicos

Fig 4 :Criteria for selection of drug

43.33

Opinion of family
member

63.33

Price of the drug

53.33

The advertisement
publish on newspaper

63.33

Indication/Purpose of
he use

50

My own experience

16.67

Adverse reaction

80 100

Fig 3:Methods for selection of drug among various groups

And 90% patients follow community pharmacist to take


drugs for self medication.83.33% of medical students
take drugs according to indication for which it is used.
70% of graduate non- medical students use drugs as per
the indication of drugs.63.67% of patients take medicines

Patients

30.00

Switching antibiotics reduces adverse reaction

Medicos
Non-medicos

53.33

Switching antibiotics will enhance the drug effect

50.00

Lower doses result in less adverse condition

76.67

Higher does results in faster recovery


Broad spectrum antibiotics are better than narrow
spectrum antibiotics

80.00

If you take antibiotics as self medication,did you ever


switch antibiotics during the course of self-medication?

36.67

Do you think that, too much use of antibiotics Leads to


antibiotics resistance?

33.33

Did you ever change the dosage of antibiotics


deliberately during the course of self-medication?

50.00
73.33

Did you ever use Antibiotics for self-medications?


0

20 %

40

60

80

100

120

813
Kasabe et al.,

Int J Med Res Health Sci. 2015;4(4):811-816

Fig 5: Knowledge about Antibiotic Resistance among


various groups
86.67% of medical students,53.33%of nonmedical
students, 73.33% patients take antibiotics for self
medication.43.33%of medical students,10%of nonmedical
students, 73.33% patients change the dosage of
antibiotics deliberately during the course of selfmedication. 96.66% of medical students, 73.33%of
nonmedical students, 33.33% patients t think that, too
much use of antibiotics Leads to antibiotics resistance.
50% of medical students, 26.67% of nonmedical
students, 60% patients experienced side effect of any
drug. 66.66% of medical students, 56%of nonmedical
students, 80% patients
think that Broad spectrum
antibiotics (Antibiotics acting over a wide range of
infections /or which kill most of the infection ) are better
than narrow spectrum (Antibiotics acting over a small
range of infection/or which kill selected bacteria)
antibiotics. 76.67 % of patients think that Higher does
result in faster recovery. 53.33% of medical
students,43.33%of nonmedical students, 76.67 %
patients think self medication is a good practice for self
health care (Fig 5)
Table 1: Comparison of knowledge among groups
about Self Medication (Refer Annexure 1)
Parameter
(expressedPG
Non
Patients
as a percentage ofmedical medical
whole)
students graduate
students
Knowledge of doses,
60%
36.66% 16.66%
duration of Therapy,
Side effect and drug
interaction( %)
Knowledge of package 90%
56.66% 20%
inserts ( %)
Knowledge about co- 33.33% 46.66% 60%
prescription of
alternative pathiesAyurveda( %)
DISCUSSION
In present study, Paracetamol was the most commonly
used drug for self medication was in all groups namely
post graduate medical students, non-medical graduate
students and patients attending various OPD. One of the
reasons for this could be attributed to fever being the
most common indication for self medication followed by
running nose and cough .These results are in accordance
with another study done in second year nursing students
of nursing college of Haryana, where Paracetamol
(59.05%), analgesics (39.05%) and antibiotics (26.67%)
were commonly used as self medication. Whereas
headache (42.86%) was also a contributing factor in this
[17]
study which prompted use of self-medication .
Criteria for selection of drug in patients was cost-driven,
whereas in post graduate medical students, non-medical
graduate group it was the indication for use, which
governed the selection of drug. It is found that, The
knowledge about dose, duration of therapy, side effects
and interaction was sound in post graduate medical
students but it was relatively limited in patients group .A

Kasabe et al.,

similar study done in nursing students reported that


59.66% of students had knowledge regarding drugs and
[ 17 ]
51.26% were aware of possible adverse.
In present study, the knowledge of package inserts was
also limited in the patient group. Regarding use of
medication from other pathies the literate population, e.g.
post graduate medical and non-medical graduate
students consumed it to a limited extent ,but the lesser
educated group i.e the patients (in this study) followed
alternative pathies (e.g. Ayurveda etc) far more
stringently hence landed up more commonly in drug
interactions due to such polypharmacy.
Most patients were influenced by community pharmacist
(90%), TV advertisement or newspaper (56.6%) while
selecting drug for self medication which means a big
representative fraction of society as compared to the
educated graduate and postgraduate group which relied
less on such information sources. These results are also
reinforced in a few studies, which concludes that rural
[ 18]
pharmacist do have a role as drug counsellors
and
media and reading material (14.10%) add in further
knowledge to assist in choosing drugs for self .[19]
medication
The patients also used previous doctors prescription in
certain cases which may or may-not be suited for the
respective clinical condition, on the contrary may account
for additional adverse effects or worsening of the
symptoms. On the other hand the more educated group
i.e. graduate non medical students follow opinion of
family members or rely on their own experience for self
medication.
Antibiotic resistance is a known problem worldwide and is
ever growing. One of the main reason is the meagre
knowledge about the antibiotic resistance in common
population. As rightly pointed in one of the studies that
self-medication can lead to incorrect or delay in diagnosis
or increased resistance among pathogens due
inappropriate use and selection of resistant bacterial
[20,21]
strains
. Irrespective of level of education, people
amongst all groups in the present study, took antibiotics
as a self medication. Although this study no assess
specific indications for antibiotic self-medication but one
such study quotes that common cold, sore throat, and
sinusitis were the leading cause in European countries
and it also emphasized the fact that these conditions are
commonly known to be of viral origin , requiring no
[21].
antibiotic treatment
In the present study 50% of lesser
educated group had the belief that, lower doses of
antibiotic have lesser adverse effect ,76% believed that
higher doses result in faster recovery and 80% of them
preferred taking broad spectrum antibiotics as against
narrow spectrum with the thought that, the earlier have
better results. The fascinating paradox is that though
educated group was well with aware that antibiotics come
under schedule H, they used them for self-medication
(86.6% and 53.3%).The other important finding of the
study is that the lesser educated group despite of having
limited knowledge about antibiotic resistance yet changed
doses of antibiotics and switch to other antibiotics as and
when they felt appropriate. The relevance of this finding
lies in the fact that there is an urgent need to sensitize the

814
Int J Med Res Health Sci. 2015;4(4):811-816

common population about the growing perils of antibiotic


resistance.An interesting was study done in university
students that compared the practise of self-medication
with antibiotics.This study reported that though such
practises were lesser amongst the pharmacy and nursing
colleges as compared to nonmedical students; yet they
were irrational asknowledge did not correlate with the
[22]
behaviour
therefore driving home the point that level of
education is not an excuse for violating rules of schedule
H.

6.

7.

8.
CONCLUSION
All of the students receiving education of graduate level
or above ,self-medicate with the only reason of
convenience and the false belief that they have adequate
knowledge of drug ,dosage schedule and adverse effects
.Whereas lesser educated population mainly self
medicate to cut down cost on health-care ,though their
knowledge is totally limited about drugs ,schedule and
adverse effect. Media and pharmacists play an important
role in decision of self-medication in lesser educated
population; this can be modified into an advantage by
utilizing it for creating awareness about the growing
antibiotic resistance in the society amongst the common
population and also making them aware of certain drug
schedules of primary concern to them. The awareness
needs to be created in the common population , that
certain patient sub-groups e.g. patients on polypharmacy,
pregnant patients, those with liver/ kidney disorders and
extremes of age should possibly consult a physician
before self-medicating even with Over The Counter
Drugs OTC for safety concerns. Therefore future
research may be needed to study the outcome of such
patient education and its impact.
Limitation of study:sample size is small so more
research is required to study the effect of Self Medication
on antibiotic resistance and drug-drug interactions and
more research is required to study Self Medication in
patients suffering from different diseases .
Acknowledgements: I sincerely thank the College of
Engineering students and the Department of Medicine,
Surgery, Pharmacology, Skin, B.J.G.M.C. for their help.
Conflict of interest: Nil

9.

10.

11.

12.

13.

14.

15.

16.
17.

REFERENCES
18.
1.

2.

3.
4.

5.

Gholap MC, Gholap VR. Assesss the self medication


practices among staff nurses. Indian journal of
sciences. 2013;4(1):81-84
Griep RH, Rotenberg L. Self medication among
nursing workers from public hospitals. 2009 ;6:10151022
Eldalo. Parent self-medication to children. Saudi
Journal for Health Sciences .2013;2 2:105
Alkhaja KAJ. Evaluation of the knowledge, attitude
and practice of self medication among first year
student.Medical
practice
and
principle.
2006;15(4):270-275.
Cosgrove SE. The relationship between antimicrobial
resistance and patient outcomes, mortality, length of

Kasabe et al.,

19.

20.

hospital stay, and health care costs. Clin Infect Dis.


2006; 42 ( 2): S82S89
Ward MA, Diekema DJ, Yankey JW. Implementation
of strategies to prevent and control the emergence
and spread of antimicrobial-resistant microorganisms
in US hospitals. Infect Control HospEpidemiol. 2005;
26:21-30
Kollef MH, Micek ST. Strategies to prevent
antimicrobial resistance in the intensive care unit. Crit
Care Med. 2005; 33:1845-1853.
Kenna GA, Wood.Prescription Subscription Use by
Pharmacists and Other Health Professionals. Journal
of the American Pharmacy Association.2004;44(6
):684- 693.
Ministry Of Health And Family Welfare Government
Of India , November 2003, Report Of The Expert
Committee On A Comprehensive Examination Of
Drug Regulatory Issues, Including The Problem Of
Spurious
Drugs
cdsco.nic.in/html/html/Final%20Report%20mashelkar
.pdf cited at 18 June 2015 at 12:10 pm
Gholap MC , GholapVR.Assesss the self medication
practices among staff nurses.Indian journal of
sciences .2013;4(1):81-84
Murray MD, Callahan CM .Improving Medication Use
for Older Adults: An Integrated Research Agenda.
Annals of Internal Medicine.2003; 139: 2425-2459
Dabney AD, Onset of Illegal Use of Mind-Altering or
Potentially Addictive Prescription Drugs among
Pharmacist. Journal of the American Pharmaceutical
Association. 2001; 41(3): 392-400
Dabney AD, Onset of Illegal Use of Mind-Altering or
Potentially Addictive Prescription Drugs among
Pharmacist. Journal of the American Pharmaceutical
Association. 2001; 41(3): 392-400
Balbisi EA, AmbizasEM. Self Prescribing of Non
controlled Substances Among Pharmacists. Am J
Health-Syst Pharm. 2005; 62(23):2508-2511
Rosen, Ilene M, Christie, Jason D, Bellini, Lisa
M,Rucinski. J., Cybulska, E .Mentally Ill Doctors.
British Journal of Hospital Medicine.2004;33:90-94
Sexton R. Maintaining the Wellbeing of GPS. British
Medical Journal.2003;326:7391, S1014
Goel D., Gupta S., Self-medication patterns among
nursing students in North India.Journal of Dental and
Medical Sciences.2013;11(4 ) : 14-17
Shakirat
Bello, Ibrahim K Bello, community
pharmacist impacts on self-medication management
among rural
Dwellers
kwara state
central.nigeria.International Journal of Research and
Development in Pharmacy and Life
Sciences
.2013; 2(5): 611-619
Girma Belachew Gutema , Girma Belachew Gutema,
Diriba
Alemayehu
Gadisa,
Zerihun
Abebe
Kidanemariam, Derbew Fikadu Berhe, Abera Hadgu
Berhe, Mussie ,Ghezu Hadera, Self-Medication
Practices among Health Sciences Students: The
Case of Mekelle University .Journal of applied
pharmaceutical sciences. 2011;01 (10): 183-189
Hughes CM. Benefits and risks of self-medication.
Drug Saf. 2001; 24: 1027-1037.

815
Int J Med Res Health Sci. 2015;4(4):811-816

21. Nalini G K,Self Medication in Allopathic medical


doctors in Karnataka,India.British journal of medical
practitioner .2010;3(2):325
22. Ansam F. Sawalha, A descriptive study of selfmedication practicesamong Palestinian medical and
nonmedical university students. Research in Social
and Administrative Pharmacy.2008(4):164172

Kasabe et al.,

816
Int J Med Res Health Sci. 2015;4(4):811-816

DOI: 10.5958/2319-5886.2015.00162.9
Open Access

Available online at: www.ijmrhs.com


Research article

COMPARISON OF POST OPERATIVE PULMONARY FUNCTION BETWEEN OPEN


SURGERIES AND LAPAROSCOPIES
1

* Abdul Raoof Omer Siddiqui , Aliya Siddiqua , Nikhat Yasmeen , Madhuri Taranikanti , Sanghamitra Panda

ARTICLE INFO

ABSTRACT

Received: 28th Jun 2015


Revised: 2nd Aug 2015
Accepted: 9th Sep 2015
Authors details: 1Department of
Physiology, Shadan Institute of Medical
Sciences, Hyderabad, India
2
Princess Durru Shehvar Hospital,
Hyderabad, Telangana, India
*Corresponding author: Abdul Raoof
Omer
Siddiqui,
Department
of
Physiology, Shadan Institute of Medical
Sciences, Hyderabad, India
Email: sufyansiddiqui2000@yahoo.co.uk

Laparotomy,
surgery,
Laparoscopy,
Spirometry, Blood gas
Keywords:

Open
Lungs,

Background: Respiratory function is depressed after abdominal surgery.


Less trauma to the abdominal wall results in early postoperative recovery.
Aim: The study was planned to compare recovery of postoperative
respiratory functions between open surgeries and laparoscopic surgeries
in the Indian population. Materials and Methods: 50 patients undergoing
open surgery and 50 patients undergoing laparoscopy underwent tests on
pulmonary functions (Forced Vital Capacity [FVC], Forced Expiratory
Volume in first second [FEV1], Forced Expiratory Flow between 25% and
75% [FEF25%-75%]), Peak Expiratory Flow [PEF]and capillary blood gas
analysis (paO2, paCO2) before surgery and after two days following
surgery using RMS MEDSPIROR and blood gas analysis of capillary
blood. Results: Change in FVC, FEV1, FEF25%-75% , PEF, pO2 and pCO2
to 65.9%, 66.9%, 66%, 64.9%,92% and 99% respectively of the
preoperative value following open surgery and to 82.5%, 84%, 86%,
82.5%,97.5% and 102% respectively of the preoperative value following
laparoscopic surgery. Conclusions: Respiratory function recovery is
better in laparoscopic surgery compared to open surgery.

INTRODUCTION
Respiration is carried out by movements of thorax and
abdominal wall. Abdominal surgery involves division of
abdominal muscles which results in pain and restriction of
movements. This also associated with changes in
[1,2]
diaphragmatic function and atelectasis of the lung . A
fall in oxygen tension without significant change in carbon
dioxide tension has been reported by recent
[3,4]
studies .These changes are common in open surgeries.
Laparoscopic surgeries employ smaller incisions, inflation
of gas and are now replacing some procedures which
were done with open surgeries. As the incisions are small,
there is less pain and early recovery of respiratory
functions. With computerized spirometry it is possible to
measure several parameters in a relatively short
procedure.
Aim: The aim of our study was to compare recovery of
postoperative pulmonary function between open surgeries
and laparoscopic surgeries in the Indian population, as
few studies have been done in this region.
MATERIAL AND METHODS
Study design: The study was analytical, carried out
prospectively.
Inclusion criteria: Inclusion criteria were subjects of both
genders with age between 20 to 60 years, negative history
of respiratory illness, negative history of smoking habits,
and negative history of occupational exposure to irritants,
normal preoperative respiratory function and elective
surgery.
Exclusion criteria: Exclusion criteria were emergency
surgery, history of pulmonary disease and smoking habits.

Sample size: on a total of 100 patients going for elective


abdominal surgery at Gandhi Hospital, Secunderabad
between January 2011 and July 2011.
Ethical approval: Ethics Committee of Gandhi Medical
College, Secunderabad approved the proposed study,
consent was obtained from the participants
Grouping: The subjects consisted of two groups. Group I
consisted of 50 patients scheduled for elective laparotomy
and Group II consisted of 50 patients scheduled for
elective laparoscopy.
Methodology
Both groups were tested for respiratory functions using
MEDSPIROR (RMS systems Chandigarh) with the
subject lying in the supine posture as postoperative pain
prevented the patients in assuming the erect posture. The
patients were instructed to breathe out forcibly into the
spirometer after taking a deep breath. A demonstration
was given by the examiner before recording the readings.
[5]
Values were noted down after taking three readings .
Blood gas analysis was carried out using capillary blood
obtained from the fingers or toes after warming the area to
[6]
approximately 45 degrees Celsius . The tests were
performed preoperatively and after 48 hours of surgery. All
measurements on the subjects were done after taking
informed consent.
Statistical analysis: Mean and standard deviation values
of all parameters were calculated. Students t test was
used to compare Group I with Group II.
RESULTS

817
Siddiqui et al.,

Int J Med Res Health Sci. 2015;4(4):817-819

The demographic data of the 100 subjects is given in


Table 1. There was no significant difference between the
groups in age and weight. There were significantly more
females in Group 2 (p<0.05). Group 1 subjects were
significantly higher than their counterparts in Group 2
(p<0.05).
Table 1: Anthropometric data
Group
1, Group
2,
Parameter
(Laparotomy)
(Laparoscopy)
Number
50
50
Sex (M,F)
28, 22
19, 31
Age (years)
33.869.25
34.048.73
Height (cms)
159.429.15
156.226.71
Weight (kg)
54.928.62
53.986.25
Last 3 values as MeanSD
Preoperative respiratory functions and capillary blood gas
analysis were normal. There was a decrease in respiratory
functions in the postoperative period in both groups (Table
2). On the second postoperative day a decrease was seen
in FVC, FEV1, PEF and FEF 25%-75% in Group I
(laparotomy) to 65.9%, 66.9%, 64.9% and 66%
respectively of the preoperative value and in Group II
(laparoscopy) to 82.5%, 84%, 82.5% and 86%
respectively of the preoperative value. Postoperative
change in all parameters when compared to preoperative
values was highly significant (p<0.001). Difference in all
parameters between the groups was significant (p<0.05)
(Table 2).
Blood gas analysis showed a fall in pO2 level in the
postoperative period that was highly significant (p<0.001)
in Group I and significant (p<0.05) in Group II, when
compared to preoperative values. Rise in pCO2 level in the
postoperative period was significant (p<0.05) in Group I
but was insignificant in Group II. Difference between the
groups was not significant. (Table 2)
Table 2: Pulmonary function tests and blood gas analysis
preoperative and on second postoperative day

Paramet
er
FVC (L)
FEV1 (L)
FEV3 (L)
PEF (L/s)
FEF25%75% (L/s)
FEF 0.2 - 1.2
(L/s)
FEV1/FV
C (%)

Group
(Laparotomy)
Preoper
D2
ative
2.380.6
1.90.5
2.270.57
6.361.27

1.570.4
1.30.35
1.520.40
4.130.83

Group
(Laparoscopy)
Preoper
D2
ative
2.120.41
1.70.35
2.020.39
5.551.11

1.750.36**
1.420.30*
1.690.35**
4.580.92**

3.100.60 2.050.40 2.840.35 2.440.46***


5.291.29 3.500.86 4.820.88 4.17 0.77***
80.12.04 81.82.07 79.382.9 80.443.36**

FEV3/FV
C (%)

95.31.33 96.51.22 95.21.44 95.3 1.44***

paO2
(mmHg)

89.684.9 82.884.9 88.64.25 86.344.36***

paCO2
(mmHg)

41.23.18 41.03.11 40.043.2 41.022.75

pH

7.390.03 7.380.03 7.40.03

Bicarbonate

(mEq/L)

7.390.03

24.062.4 24.82.11 24.082.4 24.482.24

nd

D2: 2 postoperative day; Values as MeanSD


* p<0.05,**p<0.01,***p<0.001

Our study indicates that there is a significant decrease of


lung volumes and expiratory flow rates along with a
substantial degree of hypoxemia after abdominal surgery
and these changes are more with open surgeries in
comparison to laparoscopic surgery. In patients
undergoing laparoscopic surgery the values recorded on
the second postoperative day were near normal. All the
patients who took part in the study had normal respiratory
functions before surgery according to the norms set for the
[7,8,9,10]
Indian population
. Post operative decrease in FVC
in Group I and II was 65.9% and 82.5% respectively.
Karayiannakis et al reported a decrease to 67% and 79%
[11]
from preoperative values in Group I and II respectively .
Change in mid expiratory flow rates was similar to the
[11]
findings of Karayiannakis et al for Group I . Decrease in
respiratory functions after abdominal surgeries is well
[11-18]
documented from previous studies
. Upper abdominal
surgery especially laparotomy is followed by a restrictive
[19]
pulmonary change
. This is due to longer incisions,
division of respiratory muscles, and disturbance in
diaphragmatic function and atelectasis. With laparoscopic
surgery there is less pain and less trauma to the
abdominal wall resulting in early recovery of respiratory
functions.
However
gas
used
for
creating
pneumoperitoneum can result in increased CO2 levels in
the postoperative period. Gas pockets can also interfere
[20,21,22]
with respiratory movements
. Changes in lung
volumes and flow rates in the open surgery group to about
60%-70% and in the laparoscopy group to about 80%90% of the preoperative value is concordant with the
previous studies. A fall in arterial oxygen saturation has
been noted in many studies, even without pulmonary
[23,24]
complications
. Arterial carbon dioxide, pH and
bicarbonate do not show any change in the postoperative
period. Changes in blood gases are confirmed with the
[25,26]
previous studies
. Limitations: The limitations were
that we could not measure the length of the wound,
spirometry had to be done in the supine rather than erect
posture due to ethical reasons and capillary blood gas
analysis was done instead of arterial blood gas analysis
due to ethical constraints.
CONCLUSION
Abdominal surgery is followed by reduced respiratory
functions evident from reduced volumes and capacities
and decreased oxygen tension. Post operative changes in
lung volumes and capacities are mostly restrictive. Minor
obstructive changes are seen with laparotomy. Hypoxemia
and all changes in spirometry are greater with laparotomy.
We conclude that laparoscopic surgery is followed by
earlier recovery of pulmonary functions in comparison to
laparotomy.
Acknowledgment: We duly acknowledge the valuable
suggestions given by Dr. Surinder, Dr. B. SrinivasaRao
and Dr. Irshad Hussein Askari of Gandhi Medical College,
which helped us in completing this work.
Conflict of Interest: Nil
REFERENCES

DISCUSSION

818
Siddiqui et al.,

Int J Med Res Health Sci. 2015;4(4):817-819

1.

2.

3.

4.

5.

6.
7.

8.

9.

10.

11.

12.
13.

14.

15.

16.

17.

Frazee RC, Roberts JW, Okeson GC, Symmonds RE,


Snyder SK, Hendricks JC, et al. Open versus
laparoscopic cholecystectomy: a comparison of post
operative pulmonary function. Ann Surg 1991;
213:651-54.
Berggren U, Gordh T, Grama D, Haglund U, Rastad
J, Arvidsson D. Laparoscopic versus open
cholecystectomy:
hospitalisation,
sick
leave,
analgesia response. Br J Surg 1994;81:1362-65
Ravimohan SM, Lileswar Kaman, Ravul Jindal,
Rajinder Singh, Jindal SK. Postoperative pulmonary
function
in
laparoscopic
versus
open
cholecystectomy: prospective, comparative study.
Indian J Gastroenterol. 2005; 24(1):6-8.
Osman Y, Fusun A, Serpil A, Umit T, Ebru M, Bulent
U, et al. The comparison of pulmonary functions in
open versus laparoscopic cholecystectomy. J Pak
Med Assoc. 2009; 59(4):201-4.
Miller MR, Hankinson J, Brusasco V, Burgos F,
Casaburi R, Coates A, et al. Standardisation of
Spirometry. EurRespir J. 2005; 26(2):319-38.
Higgins C. Capillary blood gases: to arterialize or
not.MLO Med Lab Obs. 2008; 40(11):42, 44-7.
Kamat SR, Sarma BS, Raju VRK, Venkataraman C,
Balakrishna M, Bhavsar RC, et al. Indian norms for
Pulmonary function. JrAssoPhysInd 1977 ; 25(8)
:531-40
Morris JF, Koski A, Johnson LC. Spirometric
Standards for Healthy non smoking adults. Am Rev
Respir Dis 1971; 103(1):57-67.
Kory RC, Callahan R, Boren HG, Snyder JC. The
Veterans Administration Army Cooperative study of
Pulmonary functions: Clinical spirometry in normal
men. Am J Med 1961; 30: 243-58.
Cherniack RM, Raber MC. Normal standards for
Ventilatory function using an Automated Wedge
Spirometer. Am Rev Respir Dis 1972; 106(1):3846.
Karayiannakis AJ, Makki GG, Mantzioka A, Karousos
D, Karatzas G. Postoperative pulmonary function after
laparoscopic and open cholecystectomy. Br J
Anaesth 1996; 77(4):448-52.
Craig D B. Post operative recovery of pulmonary
function. AnaesthAnalg (1981); 60(1): 46- 52.
Hedenstierna G. Mechanisms of postoperative
pulmonary dysfunction. ActaChirScandSuppl 1989;
555: 152-58.
Churchill ED, McNeill D. The reduction in vital
capacity following operation. SurgGynecObstet 1927;
44: 483-88
Engberg G, Wiklund L. Pulmonary complications after
upper abdominal surgery: their prevention with
intercostals blocks. ActaAnaesthsiolScand 1988;
32(1): 1-9.
Ross WB, Tweedie JH, Leong YP, Wyman A,
Smithers BM. Intercostal blockade and pulmonary
function after cholecystectomy. Surgery 1989;105(1):
166-69.
Latimer RG, Dickman M, Day WC, Gunn ML, Schmidt
CD. Ventilatory patterns and pulmonary complications
after upper abdominal surgery determined by
preoperative
and
postoperative
computerized

18.

19.

20.

21.

22.

23.
24.

25.

26.

spirometry and blood gas analysis. Am J Surg1971;


122(5): 622-32.
Manikian B, Cantineau JP, Betrand M, Keiffer E,
Sartene R, Viars P. Improvement of diaphragmatic
function by a thoracic extradural block after upper
abdominal surgery. Anesthesiology 1988; 68(3): 37986.
Schauer P, Luna J, Ghiatas A, Glen M, Warren J,
Sirine K. Pulmonary function after laparoscopic
cholecystectomy. Surgery 1993; 114(2): 389-99.
Jackson SA, Laurence AS, Hill JC. Does post
laparoscopy pain relate to residual carbondioxide?
Anesthesia 1996; 51:485-87.
Alexander J1, Hull MG. Abdominal pain after
laparoscopy: the values of gas drain. Br J
ObstetGynaecol 1987; 94: 267-69.
Fredman B, Jedeikin R, Olsfanger D, Flor P, Gruzman
A. Residual pneumoperitoneum: a cause of post
operative pain after laparoscopic cholecystectomy.
AnesthesiaAnalg 1994; 79: 152-54.
Conway CM, Payne JP. Post-operative hypoxaemia
and oxygen therapy. Brit Med J 1963 Mar; 1: 844-845.
Troell L. Post-operative changes in circulation and the
effects of oxygen therapy. ActaChirScand 1951;
102(3): 203-14.
Linderholm H, Norlander O. Carbon dioxide tension
and bicarbonate content of arterial blood in relation to
anesthesia and surgery. ActaAnaesthesiolScand
1958; 2(1): 1-14.
Palmer KNV, Gardiner AJS. Effect of partial
gastrectomy on pulmonary physiology. Br Med J 1964
Feb; 1: 347-49.

819
Siddiqui et al.,

Int J Med Res Health Sci. 2015;4(4):817-819

DOI: 10.5958/2319-5886.2015.00163.0
Open Access

Available online at: www.ijmrhs.com


Research article

ASSESSMENT OF PROLIFERATIVE POTENTIAL OF TUMOR CELLS USING KI-67


EXPRESSION AND MORPHOMETRICAL ANALYSIS FOR PROGNOSTICATION OF
ORAL SQUAMOUS CELL CARCINOMAS
1

Rakheja Mahima , Singh Pratyush , Shergill Ankur K , Guddattu Vasudeva ,*Solomon Monica C

ARTICLE INFO
th

Received: 29 June 2015


th
Revised: 14 Aug 2015
th
Accepted: 9 Sep 2015
1,2

Authors details:
Post graduate
3
Student,
Assistant
Professor,
5
Professor and Head, Department of
Oral Pathology and Microbiology,
Manipal College of Dental Sciences
Manipal University, Manipal
4
Senior Lecturer, Department of
Biostatistics,
Manipal
University,
Manipal
Corresponding author:
Solomon
Monica C, Professor and Head,
Department of Oral Pathology and
Microbiology, Manipal College of
Dental Sciences,
Email: solomonmc@gmail.com
Keywords: Oral squamous cell
carcinoma,
Cell
proliferation,
Immunohistochemistry,
Ki-67
expression, Morphometry, Prognosis

ABSTRACT
Background: Cancer cells exhibit a characteristic intrinsic ability of
uncontrolled cell proliferation which plays a vital role in tumor development and
progression. The Ki-67 antigen expression is strictly associated with cell
proliferation which detects the cells entering the cell cycle. In addition,
computer aided image analysis provides an objective and highly reproducible
histological evaluation of OSCC. Assessment of Ki-67 expression along with
morphometry may help in early and precise diagnosis and prognostication of
OSCC. Aims: To correlate the ki-67 expression and the morphometrical
parameters of oral squamous cell carcinomas and to assess the efficacy of the
correlation in OSCC prognostication. Methods and material: OSCC cases
(n=105) were examined immuno histochemically using Ki-67 antigen The
nuclear area (NA), cell area (CA), nuclear perimeter (NP) and cell perimeter
(CP) assessed using image J 1.34 software. The data was statistically
analyzed. Results: Highly significant correlation was found between Ki-67
expression and the advancing grades of OSCC (p<.0001). NA (p=0.025), CA
(p<.0001), NP (p=.027) and CP (p<.0001) of poorly differentiated OSCC were
significantly lower than well differentiated and moderately differentiated OSCC.
Follow up analysis revealed nuclear area and cell area to be higher in the
recurrent cases than the non recurrent ones. Conclusion: Assessment of Ki67 expression and morphometry help in early and precise diagnosis and
prognostication of OSCC. A correlation between Ki-67 expression and
morphometrical analysis could not be ascertained in this study. Further studies
with a larger sample number may provide more definitive results.

.
INTRODUCTION
Oral cancer ranks eighth in the cancer incidence ranking
worldwide. The World Health Organization anticipates a
worldwide escalation in the incidence of oral squamous
[1]
cell carcinomas (OSCC) in the subsequent decades .
Despite the steady improvements in treatment
modalities, the 5 year survival rate of OSCC is about
55% and it continues to stand poor. This implies the
need for early and accurate detection of OSCC in order
to bring down the associated high morbidity and mortality
[2]
rates . Upon its onset, OSCC progresses imperceptibly,
becoming evident only in a dangerously advanced state.
This may be due to patients negligence as it initially
presents with no remarkable symptoms, or due to
inappropriate diagnostic and prognostic assessment on
the behalf of the clinician and the pathologist. The latter
may be a result of lack of availability or utilization of
reliable techniques for the same. The current scenario
urges an enhanced comprehension of the tumor
behavior.
The intrinsic capacities of limitless replicative potential
and self-renewal are characteristics of cancer cells.
Uncontrolled proliferation indicates that the cells are
capable of acquiring further cellular alterations that
contribute to full malignant phenotype. The expression of

Mahima et al.,

the human Ki-67 protein is strictly associated with cell


proliferation and is present during all active phases of
cell cycle (G1, S, G2, and mitosis), but is absent from
resting cells (G0). Thus it represents the growth fraction
of the tumor and serves as a reliable nuclear marker for
[3]
cell proliferation in malignancies . Cell proliferation
serves as a guide for prognostication of malignancies as
a high proliferative activity is associated with a poor
[2]
prognosis .
Histological examination is regarded as the gold
[4]
standard for identifying and diagnosing OSCC .
However, there is wide variation among pathologists
regarding the subjective evaluation of histopathological
features. This necessitates the use of a more
sophisticated
technique
of
computer-assisted
morphometry to investigate the cellular and nuclear
changes in correlation with the clinical behavior of the
lesions. There are many variables observable in
microscopic images which are acquiescent to
morphometrical analysis and the outcome is more
[5]
objective,
reliable
and
reproducible .
The
morphometrical criteria considered in this study are:
nuclear area, cell area, nuclear perimeter and cell
perimeter.

820
Int J Med Res Health Sci. 2015;4(4):820-826

Fairly extensive research has been conducted on the


application of Ki-67 in head and neck cancer establishing
[2,3,6,7]
its use as a proliferative marker
. Morphometry has
also been employed in a few studies in relation to the
[4,5]
head and neck cancer . However, they have not been
studied in conjunction before, for their implication in
diagnosis and prognosis of head and neck squamous
cell carcinoma. In this study, we attempt to determine the
association between the Ki-67 expression and the
morphometrical values as a useful adjunct to the routine
histopathological examination. Our attempts are also
directed to find out whether this association can enable
us to use morphometrical values alone as an accurate
and cost effective diagnostic tool for the underprivileged
Indian oral cancer patients. To the best of our
knowledge, such an association has not yet been
established in the literature in relation to the head and
neck squamous cell carcinoma.
MATERIAL AND METHODS
A retrospective cohort study
Ethics: Institutional ethics committee approval was
obtained to carry out the study (IEC 526/2012)
Inclusion criteria: Only the cases which were
histologically confirmed cases of OSCC of the buccoalveolar complex and the floor of the mouth and the
patents in whom the treatment (radiotherapy or
chemotherapy) had not begun at the time of initial
diagnosis were included.
Exclusion criteria: Cases of oral cancer other than oral
squamous cell carcinoma, cases of oral squamous cell
carcinoma undergoing treatment, cases with history of
recurrence of oral squamous carcinoma and cases of
oral squamous cell carcinoma with systemic conditions
were excluded.
Methodology
A total of 105 formalin fixed paraffin embedded (FFPE)
cases of OSCC were studied. 35 cases each of well,
moderate and poorly differentiated OSCC of buccoalveolar mucosal complex and floor of the mouth were
studied. The selected cases were diagnosed and treated
at the University Hospital from the year 2008 to 2013. 5
tonsil tissue specimens were used as controls along with
5 cases of healthy oral mucosal tissues. Relevant
clinicopathologic details including the tumor staging, the
histologic grading, and the development of recurrence or
metastasis were attained from the medical record files.
Immunohistochemistry
Thin sections of 4m were cut from FFPE tumor blocks.
The section were mounted on amino-propyl-tri-ethoxysilane (APES) coated glass slides and stained with
monoclonal antibody against ki67 (RTU - Ki67 MM1:
Novacastra)
using
indirect
streptavidin
biotin
immunoperoxidase technique. Tissue sections obtained
from tonsil tissue specimens were taken as positive
controls for Ki-67 immunohistochemistry. As a negative
control for immunohistochemical procedures the primary
antibody was replaced with normal mouse IgG in
[2]
appropriate concentration .
Evaluation of Ki -67 expression: The immunoreactivity of
Ki-67 was nuclear. The nuclei with clear brown color,

Mahima et al.,

regardless of staining intensity, were regarded as


positive. The positive cells of the tumor cells were
evaluated in 5 representative fields at 40x magnification.
The histological sections with uniform and good intensity
staining were assessed. (Figure 1 a,b) The histological
section of tonsil tissue stained with Ki-67 was used as
positive controland confirmed against a negative control
(Figure 2a,b). The ki-67 labelling index was calculated
[8]
using the formula : (Ki67-positive) (Ki67-positive +
Ki67-negative) x 100
Based on the labeling index, the sections were scored
[9]
from 1 to 3 for ki-67 expression as follows :
Ki-67
Extent
of Percentage
of
expression
proliferation
positive cells
1
High
>50 %
2
Moderate
30 to 50%
3
Low
<30%
Morphometry: Tissue sections of 5m thickness were cut
from FFPE tissue blocks, stained with Harriss
Haematoxylin and Eosin and subsequently subjected to
morphometric analysis. Only clearly defined cells were
measured. The 4 morphometrical parameters considered
were: Nuclear area (NA), cell area (CA), nuclear
perimeter (NP) and cell perimeter (CP)
The scale for morphometrical analysis was standardized
using an eye piece graticule and a stage grid in 40X
magnification. For each case, pictures of 3 fields were
taken under 40X magnification. Ten clearly defined cells
were analyzed from each field. A total of 3150 cells were
morphometrically analyzed. Image analysis was done
[10]
using Image J 1.34 software available at website:
http://rsb.info. nih.gov/ji/.
In order to assess the slides in image J, the images were
captured onto the hard drive of the computer, following
which they can be opened in Image J for evaluation,
[8,11]
using the various tools provided in the panel
.
Statistical analysis: SPSS (Statistical Package for Social
Sciences) version 16.0 for windows was used. P-value
(p) <0.05 was considered significant for all statistical
analysis.

Inter-class correlation (ICC) carried out for interobserver reproducibility between two observers.

Chi square test was done to study the association


between ki67 labelling index and Ki-67 expression.

One- way ANOVA (Analysis of Variance) was used


for comparing the mean Ki-67 labeling index among
the different grades. Comparison of the mean ki-67
labeling index between groups was made using
multiple comparison test by Tukey-HSD procedure

One- way ANOVA (Analysis of Variance) was used


for comparing the morphometrical parameters for
multiple groups. Comparison of the mean nuclear
and cellular area and diameter values between
groups was made using multiple comparison test by
Tukey-HSD procedure.

Pearson Correlation test was done to analyse the


association between ki-67 expression and each of
the 4 morphometrical parameters.

Chi-square test was applied to study the correlation


between Ki-67 expression and OSCC grades.

821
Int J Med Res Health Sci. 2015;4(4):820-826

Ki-67 expression and Ki-67 labelling index also showed a


highly significant association through Chi-square test
(p<.001).
In addition, an analysis of the ki-67 expression and the
intra-oral site of OSCC was also done. Ki-67 expression
of nine different sites of the oral cavity was assessed and
its mode was calculated. The tongue (dorsal/ventral
aspect), vestibule and floor of the mouth and buccal
[1]
mucosa with alveolus show lowest ki-67 expression ,
whereas angle of mandible, alveolar region and buccal
[2]
mucosa show moderate ki-67 expression and tongue
(lateral border), alveolar region and lips show highest ki[3]
67 expression
and least degree of tumoral
differentiation. (Table 4)
Nuclear area: The mean nuclear area of poorly
2
differentiated OSCC was found to be 162.04 . One Way
ANOVA test showed the value of mean nuclear area to
be statistically significant among the grades of OSCC
(p= 0.025). Comparison between the groups using PostHoc test with Tuckey HSD method showed the value of
poorly differentiated OSCC to be significantly lower than
well differentiated OSCC (p= 0.05) and moderately
differentiated OSCC (p= 0.042)
Similarly, the mean cell area (p<.0001), mean nuclear
perimeter (p= 027) and mean cell perimeter (p<.0001)
were found to be statistically significant among the
grades of OSCC. Comparison between the groups using
Post-Hoc test with Tuckey HSD method has been
depicted in Table 5 and 6
However no statistically significant correlation was seen
between ki-67 and any of the 4 morphometrical
parameters. (Table 7)
Follow up and recurrence analysis:
Among the 105 cases, 62 were available for follow up,
out of which 8 patients showed loco-regional recurrence
(12.9%). After their morphometrical analysis it was seen
that nuclear area, cell area and nuclear perimeter were
higher in the recurrent cases as compared to the non
recurrent ones. (Figures 3 and 4)
Recurrence was also correlated with Ki-67 expression
with chi-square analysis, which indicated it to be
statistically insignificant.

Chi-square analysis was done subsequently to


correlate the Ki-67 expression with the disease
recurrence.

RESULTS
In the test group which included 105 OSCC cases,
positive Ki-67 expression in the nuclei of proliferating
tumor epithelial cells was found positive in all the cases
(100%). 5 tonsil cases were used as controls. 5 cases of
normal oral mucosa were also used for comparative
assessment of staining. The inter observer reproducibility
was analysed with inter-class correlation which revealed
a good reproducibility between the 2 observers
(ICC=.925)
Among the 105 cases of squamous cell carcinomas in
49/105 (47%) 30-50% of tumor cell expressed Ki 67.
Among the 35 cases of well differentiated tumors in
13/35 (37%) 30-50% of tumor cells expressed Ki 67
while in 17/35 (49%) cases <30% of cells were positive
for the biomarker. Among the 35 cases of moderately
differentiated tumors in 20/35 (57%) 30-50% of tumor
cells expressed Ki 67 while in 1/35 (2%) cases <30% of
cells were positive for the biomarker. Among the 35
cases of poorly differentiated tumors in 16/35 (46%) 3050% of tumor cells expressed Ki 67 while in 16/35 (46%)
cases <30% of cells were positive for the biomarker. On
statistical analysis with chi-square test, a highly
significant correlation was found between Ki-67
expression and the advancing grades of OSCC.
(p<.001)(Table 1)
The Ki-67 expression and labelling index was assessed
in the 105 cases of oral squamous cell carcinomas. The
mean labeling index among the well, moderate and
poorly differentiated OSCC was 29.84 13.04; 48.10
13.41 and 32.015 13.89 respectively. A one way Anova
test showed that there was a significant (p <.001)
variation in mean Ki-67 labeling index between the tumor
grades. A post hoc test with Tukeys HSD showed that
there was a significant (p <.001) association between Ki67 labelling index of well differentiated and moderately
differentiated and that between moderately differentiated
and poorly differentiated tumors.(Table 2 and Table 3)

Table 1: Association between tumor grade and Ki-67 expression


Tumor Grade

Moderate
Proliferation
13 (37%)

Low
Proliferation
17 (49%)

Total

X2 Value

Well

High
Proliferation
5 (14%)

35

25.050

Moderate

14 (40%)

20 (57%)

1( 3%)

35

Poor

3 (8%)

16 (46%)

16 (46%)

35

df
4

P
value
.000

Table 2: One way Anova to compare the mean Ki-67 labelling index

Between groups
Within groups
total

Mahima et al.,

Sum of squares
.6964
18475.855
25439.988

df
2
102
104

Mean square
3482.066
181.136

F
19.224

Sig
.000

822
Int J Med Res Health Sci. 2015;4(4):820-826

Table 3: Comparison of the mean labelling index among the different grades Tukey HSD
(I) Grade
(J) Grade
Mean difference Std. Error
Sig.
95% confidence interval
(I-J)
Lower bound
Upper bound
Well

-18.25729*
3.21724
.000
-25.9092
-10.6054
-2.16686*
3.21724
.779
-9.8188
5.4850
Moderate
18.25729
3.21724
.000
10.6054
25.9092
16.09043*
3.21724
.000
8.4385
23.7423
Poor
2.16686
3.21724
.779
-5.4850
9.8188
*
Moderate
-16.09043
3.21724
.000
-23.7423
-8.4385
* The mean difference is significant at the .05 level.
Table 4: showing the relationship of Ki-67 expression with site of OSCC cases
site
Number of cases Number of cases of
Number of cases of Ki-67 Expression
of
Well Moderately
Poorly differentiated occurring with highest
differentiated
differentiated
OSCC
frequency (Mode)
OSCC
OSCC
Tongue - lateral border 2
14
6
3
(left/right)
Tongue - ventral/dorsal 2
1
1
aspect
Buccal mucosa
9
6
4
2
Buccal mucosa and 4
1
1,2
alveolus
Alveolar region
5
6
2
3
Retromolar region
2
1
2
Angle of mandible
1
1
2
lips
1
3
3
Vestibule and floor of
1
3
1
the mouth
Total cases (With the 26/35
31/35
18/35
details of the site of
OSCC)
(Ki-67 expression: 1 = high proliferation, 2 = moderate proliferation, 3 = low proliferation)
Table 5: Statistical analysis using One Way ANOVA test and multiple comparisons test (Post-Hoc test) with
2
Tuckey HSD method (values in micron )
Criteria
Grade of OSCC
Mean
Standard
Confidence
P-value
deviation
limit
Nuclear Area Well differentiated (a)
190.77 54.48
172.05, 209.49 .025
Moderately differentiated 192.11 46.86
176.02, 208.21 Post hoc:
(a) and (c)= .05
(b)
(b) and (c)= .042
Poorly differentiated (c)
162.04 52.57
1443.98,
180.10
Cell Area
Well differentiated (a)
542.29 139.91
494.23, 590.35 <.0001
Moderatelydifferentiated (b)
553.98 127.48
510.19, 597.77
Poorly differentiated (c)
414.72 127.68
370.85, 458.58 Post hoc:
(a)and (c)= <.0001
(b)and (c)= <.0001
Table 6: Statistical analysis using One Way ANOVA test and multiple comparisons test (Post-Hoc test) with
2
Tuckey HSD method (values in micron )
Criteria
Grade of OSCC
Mean Standard deviation Confidence limit
P-value
Nuclear
Well differentiated (a)
48.28 6.47
46.06, 50.51
.027
Perimeter
Post hoc:
Moderately differentiated 48.92 5.86
46.91, 50.94
(b) and (c)= .03
(b)
Poorly differentiated (c)
44.88 7.49
42.30, 47.46
Cell Perimeter
Well differentiated (a)
86.82 12.17
82.63, 91.00
<.0001
Post hoc:
Moderately differentiated 88.88 9.95
85.46, 92.30
(a) and (c)= . 001
(b)
(b) and (c) <.0001
Poorly differentiated (c)
76.38 13.08
71.89, 80.88

Mahima et al.,

Moderate
Poor
Well
Poor
well

823
Int J Med Res Health Sci. 2015;4(4):820-826

Table 7: Showing statistically insignificant correlation


between Ki-67 labelling index and the morphometrical
parameters

Morphometrical
Parameter
Nuclear area (NA)
Cell area (CA)
Nuclear perimeter
Cell perimeter

R (Pearson
Coefficient)
.123
.194
.148
.207

correlation

Fig4: Showing comparison between recurrent and non


recurrent cases with respect to nuclear perimeter (NP) and
cell perimeter (CP) (values in micron2)

DISCUSSION

Fig 1a: Photomicrograph of well differentiated Squamous


Cell Carcinoma (H & E staining, 40x). Arrows indicate the
tumor epithelial cells.
Fig1b: Photomicrograph of well differentiated Squamous
Cell Carcinoma (IHC staining with Ki-67, 40x). The arrows
indicate Ki-67 staining taken up by the cells undergoing
proliferation.

Fig 2a: Photomicrograph of tonsil tissue used as positive


control stained with Ki-67 (IHC staining with ki-67, 20x). The
arrows indicate Ki-67 staining taken up by the tonsillar cells
undergoing proliferation.
Fig 2b: Photomicrograph of tonsil tissue stained
Immunohistochemically with the exclusion of primary
antibody, used as negative control (20x)

Fig 3: Showing comparison between recurrent and non


recurrent cases with respect to nuclear area (NA) and cell
area (CA) (values in micron2)

Mahima et al.,

Oral squamous cell carcinoma (OSCC) is known for its


unpredictable progression and severe damage of the
tissues involved. Conventionally, OSCC is evaluated with
clinical staging and histological grading system, which
are essentially subjective and not efficiently reproducible.
It is certain that it will take more than just routine
histological methods to detect and control this disease
before its characteristic progression to serious
impairment.
Expression of proliferation markers such as ki-67 for
lesions of oral mucosa has been shown to be correlated
[12]
with the severity of the lesion . The expression of the
human Ki-67 protein, a nuclear marker, provides an
accurate estimation of the tumour growth rate in a
[7]
relatively cost and time effective manner .
A study conducted by Dragomir L.P et al. on 34 cases of
OSCC, showed that the increased expression of Ki-67
was associated with the decrease of the degree of
[13]
tumoral differentiation and with high degree dysplasia .
al[14]
Recently, the findings of Dwivedi N et
confirmed that
the expression of Ki67 provides an objective criteria for
determining the histological grading of OSCC. They also
assessed the severity of epithelial dysplasia using Ki-67
expression.
In our study the immuno expression of Ki-67 was seen in
all the 105 cases (100%) of OSCC and our results were
[12]
closely similar to the observations of Kannan et al. ,
[15]
[16]
Premlatha et al.
and Bryant et al.
On statistical
analysis with chi-square test, a highly significant
correlation was found between ki-67 expression and the
advancing grades of OSCC (p<.001). This indicated that
the rate of cell proliferation tends to increase with the
decrease in the degree of tumor differentiation in OSCC.
We correlated the Ki-67 expression with the site of
OSCC to attain the site with highest ki-67 expression.
Nine different sites of the oral cavity were assessed
namely Tongue - lateral border (left/right), Tongue ventral/dorsal aspect, Buccal mucosa, Buccal mucosa
with alveolus, Alveolar region, Retro molar region, Angle
of mandible, lips, Vestibule and floor of the mouth. Mode
was calculated for the ki-67 expression among the
different sites. Results showed that tongue (lateral

824
Int J Med Res Health Sci. 2015;4(4):820-826

border), alveolar region and lips show highest ki-67


expression and least degree of tumoral differentiation.
Our study also showed a highly significant correlation
between ki-67 labelling index and ki-67 expression
(p<.001). Furthermore, the Ki-67 labeling index was
found to increase with the advancing grades of OSCC.
The moderately differentiated OSCC showed a
significantly higher proliferation than well differentiated
OSCC (p<.001). Thus higher Ki-67 labelling index could
indicate a poor prognosis, as was demonstrated by
[9]
Maheshwari et al. Our results supported the cogency of
Ki-67 as a potential proliferative marker for OSCC.
The analysis was quick and easy and there was good
reproducibility between the two different observers.
(ICC=.925)
In addition, we studied the expression of Ki-67 in 5
specimen of normal oral mucosa and the expression was
found to be present in the basal and parabasal layers.
[17]
This finding was similar to that made by Rendon et al.
[18]
and Birajdar et al.
Although certain other immunohistochemical markers
such as PCNA, Cyclin D and CENP-F may also be used
to assess cellular proliferation, the present study uses Ki67 due to its intense nuclear staining which is evident in
all the phases of the cell cycle except G0 phase and the
[3,7,9]
background staining is nominal
. It can thus be
interpreted efficiently with ease.
The present study further attempts to correlate ki-67
expression
with
computer-aided
morphometrical
analysis, in order to develop an index which may enable
the use morphometrical values alone as an accurate and
cost effective diagnostic tool for the underprivileged
Indian oral cancer patients. Although several systems
are available for morphometrical image analysis. Image J
serves as a more cost effective alternative, developed at
[19,21]
the National Institutes of Health (NIH)
.The validity of
Image J has been demonstrated in our previous study
[22]
conducted with the same set of cases . The previous
study was carried out with 6 morphometrical parameters,
out of which the current study has considered 4
parameters for further analysis, namely nuclear area, cell
area, nuclear perimeter and a cell perimeter. These
parameters have been particularly chosen for the current
study as they can be calculated with ease and minimum
time consumption using the Image j software. The
reliability of these criteria has been emphasized in
previous literature, however this is the first study to take
account of all the four criteria for analysis.
[23]
Giardina et al.
conducted a study to highlight the
significance of nuclear morphometry in OSCC. They
analysed 30 cases to study the relationship between
nuclear shape and survival. They established that
morphometrical analysis could successfully distinguish
patients of the two groups of short term and long term
survival with only a 10% error.
[24]
Similarly, DB Nandini and RV Subramanyam
conducted a study using computer-assisted microscopy
on nuclear features in oral squamous cell carcinoma and
emphasized the reliability of computer-assisted nuclear
morphometry in OSCC grading.
These studies coordinate with the morphometrical results
[22]
depicted in our previous study . NA for poorly

Mahima et al.,

differentiated OSCC, 162.04 , was significantly lower


than both well and moderately differentiated OSCC.
Similarly CA of poorly differentiated OSCC was 414.72
2
which was significantly lower than both well and
moderately differentiated OSCC. NP for poorly
2
differentiated OSCC was 44.88 which was significantly
lower than moderately differentiated OSCC. CP of poorly
differentiated OSCC was significantly lower than well
differentiated OSCC as well as moderately differentiated
OSCC.
These morphometrical values can provide more reliable
information to the clinician and are more comprehensive
for the patients. However no statistically significant
association was observed between ki-67 and any of the
4 morphometrical parameters of the study. This might
have been due to less number of cases or a
consequence of insufficient patient follow up details.
Further research overcoming the limitations of the study
could be more effectual.
Taken together, the data from our study adds weight to
the growing body of evidence that Ki-67 is a powerful
tool to interpret the proliferative potential of the
advancing grades of OSCC and that 4 simple yet reliable
morphometrical parameters can help in prognostication
of OSCC.
CONCLUSION
The study showed Ki-67 to be a reliable proliferative
marker for OSCC, along with a strong diagnostic and
prognostic
significance
of
four
morphometrical
parameters in the advancing grades of OSCC. However
the association of Ki-67 expression with the computer
aided image analysis could not be ascertained. Further
studies based on correlating computer aided image
analysis and immunohistochemistry may help to develop
a simple yet promising adjunct to routine histological
examination
which
helps
in
diagnosing
and
understanding OSCC and can be highly valuable tool in
predicting an accurate and timely prognosis in order to
formulate an effective treatment plan according to the
individual treatment needs of the patient.
Acknowledgements Indian Council
Research for the financial assistance.
Conflict of Interest: Nil

of

Medical

REFERENCES
1.

2.

3.

World Health Organization. The World Oral Health


Report. Geneva: World Health Organization;
2003; 6-7.
Pich A, Chiusa L &Navone R. Prognostic
relevance of cell proliferation in head and neck
tumors. Ann Oncol 2004; 15: 131929.
Boas D.S, Takiya C.M, Sampaio T.L.C, Ribeiro
L.C, Ramos E.A.G, Cabra M.G et al.
Immunohistochemical detection of Ki-67 is not
associated with tumor-infiltrating macrophages
and cyclooxygenase-2 in oral squamous cell
carcinoma; J Oral Pathol Med 2010; 39: 56570.

825
Int J Med Res Health Sci. 2015;4(4):820-826

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Acha A, Ruesga MT, Rodrguez MJ, de Pancorbo


MA M, Aguirre JM. Applications of the oral
scraped (exfoliative) cytology in oral cancer and
precancer. Med Oral Patol Oral Cir Bucal 2005;
10: 95102
T
Smitha, P
Sharada, and HC
Girish.
Morphometry of the basal cell layer of oral
leukoplakia and oral squamous cell carcinoma
using computer-aided image analysis. J Oral
MaxillofacPathol 2011; 15(1): 2633.
Daniel F.I, Fava M, Hoffmann R, Campos M,
Yurgel L.
Main Molecular Markers of Oral
Squamous Cell Carcinoma.
Applied Cancer
Research 2010; 30(3): 279-88.
Myoung H, Kim M, Lee J.H, Ok Y.J, Paeng J.Y,
Yun P.Y. Correlation of proliferative markers (Ki67 and PCNA) with survival and lymph node
metastasis in oral squamous cell carcinoma: a
clinical and histopathological analysis of 113
patients. Int. J. Oral Maxillofac. Surg 2006; 35:
100510.
Mukherjee S, Katarkar A, Ray JG, Chaudhuri K.
2012.
Immunohistochemical
markers
to
differentiate oral precancerous and cancerous
lesion: an integrated tissue based microscopic
analysis. In: Mndez-Vilas A, editor. Current
microscopy contributions to advances in science
and technology: Formatex Research Center, 43338.
Maheshwari, Veena, et al. "Prognostic and
Predictive Impact of Ki-67 in Premalignant and
Malignant Squamous Cell Lesions of Oral Cavity."
Int. J. Head Neck Surg 4 2013: 61-65.
Natarajan S, Mahajan S, Boaz K, George T.
Prediction of lymph node metastases by
preoperative nuclear morphometry in oral
squamous cell carcinoma: a comparative image
analysis study. Indian J Cancer 2010 Oct-Dec;
47(4): 406-11.
Khandelwal S, Solomon MC. Cytomorphological
analysis of keratinocytes in oral smears from
tobacco users and oral squamous cell carcinoma
lesions - A histochemical approach. Int J Oral
Sci2010; 2(1): 45-52.
Kannan S, Jagadeesh G Chandran, Pillai K R,
Mathew B, Sujathan K, Nalinakumary K. R, Nair
M.K. Expression of p53 in leukoplakia and
squamous cell carcinoma of the oral mucosa:
correlation with expression of Ki67. J ClinPathol:
MolPathol 1996; 49: 170-75.
Dragomir LP, Simionescu C, Mrgritescu C,
Stepan A, Dragomir IM, Popescu MR. P53, p16
and Ki67 immunoexpression in oral squamous
carcinomas. Rom J MorpholEmbryol 2012; 53:8993.
Dwivedi N, Chandra S, Kashyap B, Raj V,
Agarwal A. Suprabasal expression of Ki-67 as a
marker for the severity of oral epithelial dysplasia
and oral squamous cell carcinoma. ContempClin
Dent 2013; 4: 7-12.
Premalatha B.R., K. Uma. Analysis of KI-67
antigen in human Oral Squamous Cell Carcinoma

Mahima et al.,

16.

17.

18.

19.

20.

21.

22.

23.

24.

An immunohistochemical study. J. Int Oral


Health 2010; 2(1): 9-16.
Bryant RJ, Banks PM, O'Malley DP. Ki67 staining
pattern as a diagnostic tool in the evaluation of
lymphoproliferative disorders. Histopathology
2006 Apr; 48(5): 505-15.
Torres-Rendon A, Roy S, Craig GT, Speight PM.
Expression of Mcm2, geminin and Ki67 in normal
oral mucosa, oral epithelial dysplasias and their
corresponding squamous-cell carcinomas. Br J
Cancer 2009 Apr 7; 100(7): 1128-34.
Birajdar SS, Radhika M B, Paremala K,
Sudhakara M, Soumya M, Gadivan M. Expression
of Ki-67 in normal oral epithelium, leukoplakic oral
epithelium and oral squamous cell carcinoma. J
Oral MaxillofacPathol 2014; 18: 169-76.
Noguchi M, Kikuchi H, Ishibashi M, Noda S.
Percentage of the positive area of bone
metastasis is an independent predictor of disease
death in advanced prostate cancer. Br J Cancer
2003; 88: 195-201.
Ho CC, Yang XW, Lee TL, Liao PH, Yang SH,
Tsai CH, et al. Activation of p53 signalling in
acetylsalicylic acid-induced apoptosis in OC2
human oral cancer cells. Eur J Clin Invest 2003;
33: 875- 82.
Tchoukalova YD, Harteneck DA, Karwoski RA,
Tarara J, Jensen MD. A quick, reliable, and
automated method for fat cell sizing. J Lipid Res
2003; 44: 1795-01.
Rakheja M, Chauhan A, Guddattu V and Solomon
M. Morphometrical characteristics of tumor cells
are prognostic determinants for oral squamous
cell carcinomas. International Journal of Current
Research 2014; 6(11):9576-82.
Giardina C, Caniglia DM, D'Aprile M, Lettini T,
Serio G, Cipriani T, Ricco R, PesceDelfino V.
Nuclear morphometry in squamous cell carcinoma
(SCC) of the tongue. Eur J Cancer B Oral Oncol
1996 Mar; 32B(2): 91-96.
Nandini DB, Subramanyam RV. Nuclear features
in oral squamous cell carcinoma. J Oral
MaxillofacPathol 2011 May; 15(2): 177-81.

826
Int J Med Res Health Sci. 2015;4(4):820-826

DOI: 10.5958/2319-5886.2015.00164.2
Open Access

Available online at: www.ijmrhs.com


Research article

MENINGIOMAS: A CLINICOPATHOLOGICAL STUDY


Shri Lakshmi S

ARTICLE INFO
st

Received: 1 July 2015


th
Revised: 14 Aug 2015
nd
Accepted: 2 Sep 2015
Author details: Assistant Professor,
Department of Pathology, NRI Medical
Institute
of
Medical
Sciences
Sangivalasa,
Bheemunipatnam,
Vishakapatnam, Andhra Pradesh.
Corresponding author: ShriLakshmi S

Assistant Professor, Department of


Pathology, NRI Medical Institute of
Medical
Sciences
Sangivalasa,
Bheemunipatnam,
Vishakapatnam,
Andhra Pradesh
Email: lakshmi2266@yahoo.co.in
Keywords: Meningioma, Intracranial,
Intraspinal,
Histological
variants,
Grades, Recurrence.

ABSTRACT
Introduction: Meningiomas are tumors that arise from the meningothelial
cells. Most of these tumors are intracranial; some are intraspinal and few
extra cranial. There are many histological variants classified into three
grades depending on clinical behavior. Classification is important for
determining the modality of treatment. Objectives: To study the incidence,
location, sex and age predilection, histological variants and grading of
meningiomas based on WHO 2007 classification and recurrence if present.
Materials and methods: All128 cases of meningiomas. Based on
Histological features, typing and grading of meningiomas was done as per
the WHO 2007 classification of Meningiomas. Age, Sex incidence, Location
of meningiomas were studied. Results: Meningiomas comprised 25.25% of
all CNS tumors during the study period. Of 507 CNS tumors, 128 were
meningiomas. Most of them were intracranial, predominantly involving the
convexities of brain, females and the 41 50 age group. Of these, 116
were benign grade I tumors, 9 were grade II and 3 were grade III. The most
common histological variant was fibroblastic and meningothelial. Intraspinal
meningiomas were 16 (12.5%) cases with the psammomatous variant being
more common. Grade II and Grade III tumors located in parafalcine or
parasagittal area commonly recurred. Conclusion: Meningiomas are slow
growing tumors arising from the meningothelial cells accounting for 25.25%
of all CNS neoplasms showing a variety of histological patterns, more
common in women, predominantly Grade I tumors. Recurrence of tumors
depends on histological grade and extent of surgery.

INTRODUCTION
Harvey Cushing coined the name MENINGIOMA, in
1922 for the most common dural based tumor,
accounting for 15-30% of all primary intracranial
[1]
tumors. Meningiomas are mostly benign tumors but few
are malignant. The incidence of meningioma in India
ranges from 9-15 per cent of all intracranial neoplasms
according to a study by Dr A Vincent Thamburaj. These
tumors also occur extracranialy and intraspinaly. These
tumors are more common in middle aged women with a
th
th
peak during 4 -6 decade.(F: M intracranial 3.5:1 & Intra
spinal 10:1), There is no sex predisposition in elderly or
children. Based on histology and clinical behavior, WHO
classification categorizes meningiomas into three grades,
Grade I (benign), II (atypical) and III (malignant).Grade II
and Grade III meningiomas recur with greater
[2]
frequency. Histological grade of meningioma is
important in deciding subsequent therapeutic intervention
and management. Surgery is the treatment of choice for
Grade I tumors where as Grade II and grade III tumors
require both surgery and radiotherapy. Histological grade
and extent of surgical resection are very important
[2]
parameters to predict recurrence of tumors
Aim: The aim of this study was to determine the
incidence of Meningioma among all CNS tumors
occurring in the same period, Age and Sex predilection of
all meningiomas, their location, any site preference of the
histological variants, extent of surgical resection and
relation of grade to recurrence if present and correlate

Shrilakshmi et al.,

findings with that in other studies on meningiomas found


in medical literature.
MATERIALS AND METHODS
Study design: A meta analysis
Ethical approval: The study was undertaken after
consent and clearance by the ethical committee of NRI
Medical College and Academic Sciences, Chinnakakani.
Inclusion criteria: Of all CNS tumors, only cases of
meningiomas during the period 2007 2012were
included. Meningiomas in all age groups and both the
sexes were included in the study.
Exclusion criteria: Other CNS tumors were excluded.
Sample size: One hundred twenty eight cases of
meningiomas
Methodology: Based on Histological features, typing and
grading of meningiomas was done as per the WHO 2007
classification of Meningiomas. Age, Sex incidence,
Location of meningiomas were studied.
Statistical analysis: It was done by calculating number
and percentage for computing the incidence in various
age groups, in sexes, location and also comparison with
other studies.
RESULTS
Of 507 CNS tumors, Meningiomas constituted 128
(25.25%). The most common affected age group was 41

827
Int J Med Res Health Sci. 2015;4(4):827-831

50 years (Table 1). Females 94 (73.44%) were more


commonly affected compared to males 34 (26.56%).
In all age groups females were more commonly involved
except in the older age group of 71- 80 where males
were more involved. Meningiomas were less common in
the extremes of age with 4 cases in the 11-20 age group
and 6 cases in the 71-80 age group.
The most common location was intracranial 110 (85.94%)
cases with the convexities being commonly involved in 41
(37.27%) cases (Table 2). Of the rare sites within the
intracranial location, 2(1.82%) cases each were seen in
intraventricular location and in the foramen magnum.
Intraspinal meningiomas were 16 (12.5%) cases with
thoracic spine being most commonly involved 12 (75%)
cases (Table3). Extra cranial meningiomas were 2
(1.56%) cases.
The most common clinical symptoms were headache,
vomiting and seizures related to raised intracranial
pressure. The more common radiological findings were
mass lesions with effect on adjacent structures and
peritumoral edema.
The most common histologic types were the fibroblastic
and meningothelial types together comprising 46.88% of
all meningiomas (Table4). The psammomatous variant
was
more
common
in
the
spinal
location
(56.25%)(Table5). Among the benign meningiomas
relatively very rare variants like Angiomatous (2.34%),
Metaplastic (0.78%), Microcystic (0.78%) and Secretory
(2.34%) types were seen. Among the higher grades the
various histological types seen were Clear cell (2.34%),
Atypical (4.68%), Papillary (0.78%), Rhabdoid (0.78%)
and anaplastic variant (0.78%).
Grade I meningiomas were 116 (90.63%), Grade II
meningiomas were 9 (7.03%) and Grade III meningiomas
were 3 (2.34%).Grade I tumors were more frequently
seen in females (77.58%). Grade II (55.55%) and Grade
III (100%) were more frequent in the male gender. Gross
total resection was done in 115
cases and subtotal
resection in 13 cases. Recurrences were more in Grade
II (22.22%) and Grade III tumors (66.67%) mostly
involving the parafalcine or parasagittal location.
Table 1: Age and Sex incidence of meningioma
Age
years
11- 20

in

Table 2: Location of intracranial meningiomas


Location

Female

Male

Total

Convexities

32

41

37.27

Parafalcine

5.45

Parasagittal
Olfactory groove
Basifrontal
Sphenoidal
Suprasellar
Clinoidal
Petrous apex
Petroclival
Tentorial
CP angle
Foramen magnum
Cerebellum
Intraventricular
Total

6
2
6
9
3
1
1
1
3
10
1
1
78

4
1
1
7
1
1
1
1
2
32

10
3
7
16
4
1
1
2
4
10
2
1
2
110

9.09
2.73
6.36
14.54
3.64
0.91
0.91
1.82
3.64
9.09
1.82
0.91
1.82
100

Table 3: Location of Intraspinal meningiomas


Location
Female Male Total
Cervical

%
12.5%

Thoracic
lumbar
Conus
Total

11
1
14

1
1
2

12
1
1
16

75%
6.25%
6.25%
100%

Table 4: Histological Types of Meningiomas


Histological Types
Female
Male Total
Meningothelial
22
8
30
Fibroblastic
26
4
30
Psammomatous
20
8
28
Transitional
17
3
20
Angiomatous
2
1
3
Metaplastic
1
1

%
23.44
23.44
21.88
15.63
2.34
0.78

Secretory

2.34

Microcystic

0.78

Clear cell

2.34

Female

Male

Total

Percentage

Atypical
Papillary

3
-

3
1

6
1

4.69
0.78

3.13%

Rhabdoid

0.78

Anaplastic
Total

94

1
34

1
128

0.78
100

21 30

7.03%

31 40

17

25

19.53%

41 50

30

36

28.12%

51 60

26

28

21.88%

61 70

12

20

15.63%

71 80

4.68%

Total

94

34

128

100%

Shrilakshmi et al.,

Table 5: Histological types in intraspinal region


Histological type
F
M
Total
%
Psammomatous
8
1
9
56.25%
Meningothelial

12.5%

Transitional
Fibroblastic

2
2

0
0

2
2

12.5%
12.5%

Clear cell

6.25%

Total

14

16

100%

828
Int J Med Res Health Sci. 2015;4(4):827-831

DISCUSSION
Meningiomas account for 25 - 30% of all CNS tumours
and are the most common tumours arising from the
[1-3]
meninges. Most benign meningiomas occur in adult
women, but atypical and anaplastic forms seem to be
more common in men and the younger age group.
[4,5]
Childhood meningiomas are less common. Most
1
meningiomas are intracranial. 90% are supratentorial; the
anterior cranial fossa is involved far more frequently than
the posterior. Most of the intracranial tumors occur in the
convexities. Intraspinal Meningiomas constitute 25-46%
of all tumors occurring in the spinal cord and are more
[6,7]
common in the thoracic region.
Extracranial location is
rare. Histologically meningiomas are of three
grades.Grade I meningiomas comprise 90%, Grade II
Atypical meningiomas comprise between 4.7% to 7.2% of
meningiomas, whereas Grade III malignant meningiomas
[1-3]
comprise between 1.0% to 2.8%. Majority are positive
for EMA and 100% for Vimentin. High grade types may
[1]
be negative or weakly reactive for both. Irrespective of
the sex of the patient progesterone receptors are
expressed by many and lack of its expression is
[1-3]
associated with poor outcome.
Recurrence is not limited to meningiomas with malignant
histological features. Benign meningiomas can also recur
following incomplete resection, if large and associated
[8]
with monosomy14 and del(1p36). The extent of surgical
resection depends on the site, size of the tumor and its
relation to vital structures. Higher rates of recurrence are
seen in younger age, male sex, parasagittal location and
an aggressive histologic type. Reported recurrence rates
of grade I, II, and III meningiomas are 7- 25%, 29-52%,
[9,10]
50-94%, respectively.
The treatment in grade I tumors is total
[3,9]
resection. Surgery and adjuvant radiotherapy are the
treatment of choice in grade II and grade III
[9-10]
meningiomas.
Extent of surgical resection is one of
the most important factor in predicting recurrence along
with histological grading. Subtotal resections were
associated with more recurrence or re growth.
In the present study of a total of 507 CNS tumors,
Meningiomas were 128 and they comprised 25.25%
[11]
similar to various studies done by AB Shah et al ,
[12]
[13]
[14]
Ruberti R F , Intisar SH Patty et al , Zalata et al
[15]
and Ejaz Butt et al. The most common age group
involved was the 40- 50year was similar to studies done
[16]
by A B Shah et al, Ruberti et al,J amjoomet al
and
Intisar SH Patty et al. Two cases involved the paediatric
age group, constituting 1.56% which was similar to the
study on meningiomas in children done by Nirav Mehta et
[4]
al where childhood meningiomas accounted for 1.92%
of all meningiomas and a study done by Isabelle M
5
Germano et al where the incidence was 2.9%.
There were 110 intracranial meningiomas, constituting
85.94% of the total meningiomas similar to other studies
done by Jhamjoom et al, Intisar SH Patty et al and Zalata
et al. The most common location was the cerebral
convexities followed by the parasagittal area and the CP
angle similar to the various studies. Supratentorial
meningiomas are more common than infra tentorial

Shrilakshmi et al.,

meningiomas. Rare intracranial location was the


[17]
Intraventricular region constituting about 1.81%. The
most common location in the posterior cranial fossa was
[1]
the CP angle similar to a study Dumitrescu et al Another
rare location is the Foramen magnum accounting for
only 0.3% to 3.2% of all meningiomas with only 2 cases
in this study
constituting 1.82%.Foramen magnum
meningiomas in the present study comprised 13.33% of
all posterior fossa tumors and this correlates with
literature where they comprised between 4.2% and 20%
[18,19]
of
all
posterior
fossa
meningiomas.
Spinal
meningiomas are less common than intracranial
meningiomas comprising 7.5%- 12.7% of all
meningiomas. Intraspinal meningiomas constitute 16
cases and 12.5%of all meningiomas occurring in the
spinal cord similar to a study by Oren Gottfried et al.
Intraspinal meningiomas are common in the 50 -60 age
group, with female to male ratio being 7:1, most
commonly involving the thoracic region similar to a study
done by Oren N Gottfried et al. However in a study done
by done by Nasrin Samadi et al the F: M ratio was
lower1.3:1. Extracranial meningiomas are rare with two
cases, comprising 1.56 % of all meningiomas; one
identified in the infra temporal region and another
involving the parietal bone.
The classical type the Meningothelial variant cases
were 30 (23.44%) cases in the present study being the
most common histological type seen in all the studies by
[20]
[21]
Sangamithra et al Nasrin Samadi et al
S Babu et
[22]
[10]
al Thomas Backer et al
Angiomatous meningiomas
are rare and comprise 2.1% of all the types of
meningioma. Incidence of secretory meningioma varies
from 1.2- 9.3% of all meningiomas being 2.34%in this
study and correlated with the studies done by S Babu et
[22]
[23]
al and Regelsberger et al. Microcystic meningiomas
are rare and comprised 0.78% in the present study.
[24]
Metaplastic meningiomas are rare 0.78%
and
constituted 0.3%in a study by Mayo clinic and 0.001% in
another cohort study with the most commonly
encountered mesenchymal component being mature
adipose tissue similar to cases reported by Uygur et al
[25,26]
and Wayne K W Chan et al.
Psammomatous variant
was the most common variant in the spinal region similar
[6]
to the studies done by S Hoon et al and Gottfried et
[7]
al.
Clear cell meningiomas are rare and constitute around
0.2% of all meningiomas and are more commonly seen in
the spinal or cerebellopontine location with 3 cases in the
[3]
present study. Atypical meningiomas constitute around
[1,2]
4.7 7.2 % of all meningiomas according to WHO with
more than three the following features - increased
cellularity, small cells with high N/C ratio, greater than 4
mitotic figures/ 10HPF, sheeting, prominent nucleoli and
geographic necrosis. Papillary meningiomas are rare and
[27]
constitute 1 2.5% of all meningiomas. Rhabdoid
meningiomas are rare with 1 case. Anaplastic
meningiomas are rare and constitute 1-3% of all
meningiomas and have a tendency to recur.
Meningiomas are graded into Grade I, Grade II and
GradeIII with incidence in a ratio of 90.63%:7.03%:
2.34%in this study similar to a studies done by Nasrin

829
Int J Med Res Health Sci. 2015;4(4):827-831

Samadi et al (86.1%: 8%: 5.9%) and Konstantinos


Violaris
et
al(89.82%:5.82%:4.36%).
Grade
I
meningiomas are benign and rarely recur. Grade II and
Grade III meningiomas tend to recur more frequently. In
all the reference studies Grade I tumors were more
common. Higher incidence of Grade II tumors was noted
[22]
in the studies done by S Babu et al (26%) and Thomas
Backer et al(30.1%).Grade III tumors were less common
in all the studies and comprised only 3 cases i.e 2.34% of
all meningiomas in the present study. Of these, one case
was a recurrent tumor and came with a history of
previous surgery. All the three cases were male patients
and belonged to different age groups. There was one
case each of a papillary, rhabdoid and anaplastic types
confirming that grade III tumors are more common in
males.
Gross total resection (GTR) was done in 115 cases
(89.84%) and subtotal resection was done in 13 cases
(10.16%) in the present study. Surgical resection is the
method of choice in the management of meningiomas
and extent of resection depends on location and
relationship to vital structures. Gross total resection
reduces the risk of both subsequent recurrence and
[3,10]
mortality.
Recurrence of meningiomas was seen in 7 cases, of
which 5 were seen in males. 3 were parafalcine or
parasagittal in location and this correlates with a review
done by Dzuick et al who found that tumors in this
[28]
location tend to recur. Recurrence rate in our study was
5.46%.Recurrence of meningiomas is related to histologic
[1,2,3]
grade and extent of resection.
Grade II and Grade III
tumors behave aggressively and tend to recur. Benign
meningiomas which have been sub totally excised tend to
recur. Age less than 40 years, cranial base meningiomas
and the male sex are associated with recurrence in
[28]
benign sub totally excised tumors. 2 of the recurrent
benign tumors were males. In the present study recurrent
Grade I tumors were 2.59%, Grade II were 22.22% and
Grade III were 66.67% compared to various reported
recurrence rates of grade I, II and grade III tumors which
[9]
were between 7-25%, 29-52% and 50-94%respectively.
Subtotally resected tumors of any grade are more liable
to recur. Our study included only 128 meningiomas and
of these grade II and Grade III were very few in number
compared to other studies.

ACKNOWLEDGEMENT
This article could not have been compiled without the
able guidance of Dr P. Prema Latha, Professor and Head
of Department of Pathology, NRI College and Academic
Sciences, Chinnakakani.
Conflict of Interest: Nil
REFERENCES
1.

2.

3.
4.

5.

6.

7.

8.

9.

10.

CONCLUSION
Meningiomas are slow growing tumors arising from the
meningothelial cells accounting for 25.25% of all CNS
neoplasms with a wide variety of histological patterns.
These tumors are more common in women and Grade I
tumors are predominant, Grade II and Grade III tumors
are less frequent. Recurrence of tumors depends on
histological grade and extent of surgery. The incidence,
sex predilection, histological types and behavior of
meningiomas in this part of the world and other studies
are similar despite geographic distance.

Shrilakshmi et al.,

11.

12.

13.

14.

A Perry, D. N. Louis, B. W. Scheithauer. H. Budka,


A. von Deimling: Meningiomas in WHO Classification
th
of Tumours of the Central Nervous System, 4
Edition, IARC press, Lyon 2007; 1:164-72.
Deborah L. Commins, Roscoe D. Atkinson and
Margaret E. Burnett, Review of meningioma
histopathology; Neurosurg Focus 2007; 23 (4):E3.
Juong lee, Meningiomas;Diagnosis and treatment
th
and outcome of meningiomas. 8 Edition 2008;
Springer Isabelle M. Germano, Michael S. B.
Edwards, Richard L. Davis, DavideSchiffer
Intracranial meningiomas of the first two decades of
life. J Neurosurg 1994; 80:447-53.
Nirav Mehta, SanatBhagwati, and GeetaParulekar;
Meningiomas in children: A study of 18 Cases; J
Pediatric Neurosciences 2009; 4(2): 6165.
Sang HoonYoon, Chun Kee Chung, and Tae
AhnJahng.Surgical Outcome of Spinal Canal
Meningiomas.J Korean NeurosurgSoc2007; 42(4):
30004.
Oren N. Gottfried, Wayne Gluf, Alfredo QuinonesHinojosa, Peter Kan, and Meic H. Schmidt.Spinal
meningiomas: Surgical management and outcome
Neurosurg Focus 2003; 14 (6): 2.
Konstantinos
Violaris,
VasileiosKatsarides,
PavlosSakellariou; The Recurrence Rate in
Meningiomas: Analysis of Tumor Location,
Histological Grading, and Extent of Resection; Open
Journal of Modern Neurosurgery 2012: 2: 6-10.
Thomas Backer-Grondahl, Bjornar H Moen, Sverre H
Torp. The histopathological spectrum of human
meningiomas Int J ClinExpPathol 2012; 5(3): 231
42.
Arie Perry, Bernd W, Scheithauer, Scott L Stafford et
al Malignancy in Meningiomas A clinicopathological
Study of 116 patients, with Grading Implications.
Cancer 1999; 85(9): 2046 56
AB Shah, GA Muzumdar, AR Chitale. Meningiomas:
A Report of a hospital-based registry. Indian J
Pathology and Microbiology 2005; 48(4): 468-71.
Ruberti R F, The surgery of Meningiomas: A review
of 215 cases. African Journal of Neurological
Sciences 2007.
Intisar S.H Patty. Central Nervous System TumoursA Clinicopathological study. J Dohuk Univ.2008; 11,
(1):173- 80
Khaled R Zalata, Dina A El Tantawy, Azaa Abdel
Aziz, Abdel Wahab M Ibraheim, Ahmed H Halaka,
Hasan H Gawish, Mohamed Safwat, Nabil Mansour,
AbdelhadiShebl; Frequency of CNS tumors in the

830
Int J Med Res Health Sci. 2015;4(4):827-831

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

delta region, Egypt; Indian Journal of pathology and


Microbiology 2011: 54(2)299-06
M. Ejaz Butt, Saeed A. Khan, Naseer A. Chaudrhy,
G.R. Qureshi. Intra-Cranial space- occupying
lesions- A morphological analysis.Biomedica 2005;
21.31-35
Zain Alabedeen B Jamjoom, TajuddinMalabarey,
SaleemSadiq et.al. Intra cranial Meningiomas:
Analysis of 53consecutive cases with special
reference to their operability and surgical outcome.
Annals of Saudi Medicine. 1990; 1: 103-12
Prabal Deb, HirdeshSahani, Harjinder Singh Bhatoe
et al Intraventricular cystic meningioma; Journal of
Cancer Research and Therapeutics 2010; 6(2): 21820.
Gabriela-Florena, Dumitrescu, AncaIndrei, M. El
Husseini, DanisiaHaba, N. Ianovici, I.Poeat, Dana
Turliuc, Posterior fossa meningiomas: Correlation
between site of origin and Pathology, Romanian
Neurosurgery 2010; 3: 327 38.
J Hunjan, MYS Soo, T Ng, M Dexter. Foramen
Magnum Papillary Meningioma: Review of Imaging
and Histopathological features. J HK CollRadiol
2008; 11: 35-40
Sanghamitra Mukherjee, SamarendraNath Ghosh,
Uttara Chatterjee, Sandip Chatterjee, Detection of
progesterone receptor and the correlation with Ki-67
labeling index in Meningiomas, Neurology India
2011; 59(6): 817-22.
Nasrin Samadi, Seyed Ali Ahmadi; Meningioma: A
clinicopathological evaluation. Malaysian Journal of
Medical sciences 2007; 14(1): 46-52.
Sashidhar Babu, Shantveer G Uppin, Megha S
Uppin, et al. Meningiomas: Correlation of Ki67 with
histological grade. Neurology India 2011; 59( 2)20407
Jan Regelsberger, Christian Hagel, PedramEmami,
Thorsten Ries, Oliver Heese, Manfred Westphal;
Secretory meningiomas: A benign subgroup causing
life-threatening complications; Neuro Oncology 2009
December; 11(6): 81924.
Jaiswal AK, Mehrotra A, Kumar B, et.al. Lipomatous
meningioma: A study of five cases with brief review
of literature. Neurology India 2011; 59: 87-91.
Uygur
ER,
DogaGurkanlar,
AttilavKazanci,
SerkanSimsek,
Murad
Bavbek;
Lipomatous
meningioma: Report of a case and a diagnostic
pitfall. Turkish Neurosurgery 2006; 16(1): 40 -43.
Wayne K.W.Chan, Kwong-Yau Chan, Ka- Hung
Pang et al Lipomatous meningioma: Diagnostic
pitfalls and pathological updates. Surgical Practice
February 2011; 15(1):21-23.
Singh Avninder, SarjotVermani, Sharma Shruti et al.
Papillary meningioma: A rare but distinct variant of
malignant meningioma. Diagnostic Pathology 2007;
2:3.
Ashok Modha, Philip H. Gutin, Diagnosis and
treatment of atypical and anaplastic meningiomas: A
review. Neurosurgery 2005; 57(3): 538- 50.

Shrilakshmi et al.,

831
Int J Med Res Health Sci. 2015;4(4):827-831

DOI: 10.5958/2319-5886.2015.00165.4
Open Access

Available online at: www.ijmrhs.com


Research article

CETRIZINE INDUCED DROWSINESS: ELECTROENCEPHALOGRAPHIC


CONCOMITANTS
1

1,

Shah Dev K , Khadka Rita , Yadav Ram Lochan , Khatri Sapkota Niraj , Sharma Deepak Yadav Prakash K

ARTICLE INFO
nd

Received: 02 July 2015


th
Revised : 19 Aug 2015
th
Accepted: 15 Sep2015
1

Authors details: Department of


Physiology, Chitwan Medical College
(TU), Bharatpur, Chitwan, Nepal
2

Department of Physiology, B. P.
Koirala Institute of Health Sciences,
Dharan, Nepal
Corresponding author: Shan Dev,
Department of Physiology, Chitwan
Medical College (TU), Bharatpur,
Chitwan, Nepal
Email: devshahdr@yahoo.com
Keywords: Cetirizine, Drowsy, EEG,
Alpha wave, Beta wave

ABSTRACT
nd

Background: Cetirizine, 2 generation antihistamine, has less central


adverse effects compared with the first generation but is not completely
devoid of sedative effect. Electroencephalography (EEG) is one of the tests
to assess sedation. Aims: The aim of this study was to find and compare
the EEG changes in drowsy and non-drowsy subjects after cetirizine
administration. Methods and Material: A crossover, placebo-control,
double-blind study was conducted on consenting 30 healthy male
volunteers. We subjected three (baseline, placebo, cetirizine) 5-min EEG
recordings in eye closed condition to fast Fourier transformation and divided
EEG frequencies into slow (0.5-6.5 Hz), extended alpha (6.5-14 Hz), alpha1
(6.5-8 Hz), alpha2 (8.5-10 Hz), alpha3 (10.5-12 Hz), alpha4 (12.5-14 Hz)
and beta (14.5-32 Hz). Statistical analysis used: The statistical analysis
was done using Friedman followed by multiple comparisons. Results: Nine
out of thirty subjects developed symptoms of drowsiness after cetirizine
administration. In drowsy subjects EEG beta, extended alpha and its subsegment alpha 2 and alpha 3 activities significantly decreased in cetirizine
treated condition as compared to baseline. In non-drowsy subjects, there was
significant increase in EEG slow and alpha1 activity in cetirizine treated
condition as compared to baseline. There was significant decrease in EEG
alpha3 activity at most of the sites when EEG activities between nondrowsy and drowsy subjects were compared. Conclusion: Our study
suggested that cetirizine most likely decreases EEG power of alpha2, alpha3
and beta activities (i.e. above 8.5 Hz) in subjects experiencing drowsiness and
increases EEG slow and alpha1 activities (i.e. below 8.5 Hz) despite no
symptoms of drowsiness. On comparison, EEG alpha3 activity decreased in
symptomatic as compared to asymptomatic subjects.

INTRODUCTION
Despite subjective variations in experiencing the
drowsiness as an adverse effect of histamine H 1
[1]
antagonists can have potential serious implications.
Sedative effects of drugs impair the superior cognitive
functions which can severely impair daytime activities in
which concentration and a high degree of alertness and
skill are required. Under laboratory conditions,
nd
recommended doses of 2 generation antihistamines do
not produce drowsiness; however sedation at therapeutic
[2]
doses have been reported. Cetirizine is more sedating
[3,4]
than loratadine and terfenadine in some clinical trials.
Experiments revealed electroencephalogram (EEG)
power in alpha and theta-band is highly correlated with
[5]
drowsiness. The spectral parameters in EEG recordings
[6]
is useful in assessing the central sideeffects of drugs.
Aim of the study: The aim of our study was to find and
compare EEG changes in drowsy and non-drowsy
subjects after cetirizine administration.
MATERIALS & METHODS
Study design: This was cross-over, placebo-controlled,
double blind experimental study.
Study place: The study was conducted for one year in
the EEG laboratory of B. P. Koirala Institute of Health
Sciences (BPKIHS), Dharan, Nepal

Ethics approval: Prior ethical clearance was obtained


from the institute.
Inclusion criteria: Thirty informed consented right
handed healthy male volunteers (mean age 27.7 2.9
2
years; BMI 22.651.8 kg/m ) participated in the study.
Exclusion criteria: The persons suffering from or having
any history of neurological, hepatic, cardiac, respiratory or
renal disorders were not included in the study. Similarly
the persons under any medication or abuser of any
substance having effect on central nervous system were
also excluded from the study. Females were excluded to
avoid EEG variation due to hormonal fluctuation during
their reproductive cycles.
Sample size: Thirty
Materials
The drug (cetirizine 10 mg) used in the study was
selected from the pharmacy which was available under
the brand name of Cetzine. The tablet of Cetzine was
crushed and packaged into capsule. The placebo used in
the study was glucose which was also packaged identical
to the drug capsule. Digital EEG machine (Nihon KohdenNeurofax: optiplex GXMT5120) with sampling rate 250
was used for acquisition of EEG signals.EEG waveforms
were reduced and analyzed using Focus software
[7]
(version 1.1).

832
Shah Dev et al.,

Int J Med Res Health Sci. 2015;4(4):832-836

Grouping: The health status of all 30 subjects was


taking cetirizine/placebo and third EEG recording was
assessed by taking medical history and physical
done after two hours of cetirizine/placebo administration.
examination. The subjects were randomized into two
After visual inspection of EEG waves, five artifact-free-5
groups- placebo and cetirizine.
sec epochs of EEG were selected from just before the
st
nd
rd
th
th
Methods
end of 1 , 2 , 3 , 4 and 5 minute of recordings.
All subjects were instructed to have normal (minimum 6-8
Thereafter Fast Fourier Transformation (FFT) was
hours) night sleep and provided breakfast (fruit cakeperformed to segregate EEG waveform into different
150gm) two hours before the recordings. The EEG disc
frequencies bands as similar to the study done by Sannita
electrodes were placed according to International 10-20
et al (1996) - slow (0.5-6.5 Hz), extended alpha (6.5-14
system of electrode placement. After 10 minutes of supine
Hz) and beta (14.5-32 Hz) bands. The extended alpha
rest, EEG recording for 5 minutes in eye closed condition
(6.5-14 Hz) band was further divided into four sub
of all the subjects was performed at room temperature of
segments alpha 1 (6.5-8 Hz), alpha 2 (8.5-10 Hz), alpha 3
[8]
262C between 8-10 am to avoid the effect of
(10.5-12 Hz) and alpha 4 (12.5-14 Hz). The spectral
temperature and of diurnal variation in EEG. The
power for each band thus obtained was exported to
referential montage was used to record EEG. Electrodes
Microsoft Excel worksheet files for further analysis. The
impedance was kept less than 5 kilo-ohms. Time constant
powers from five epochs were averaged for each subject.
Statistical analysis: Friedman test was used for overall
was maintained at 0.3Hz. Low cut-off and high cut-off
frequency was maintained at 0.5 Hz and 70Hz
comparison of EEG parameters among baseline, placebo
respectively.
and cetirizine treated conditions followed by multiple
Baseline recording of all 30 subjects i.e. first recording of
comparisons (baseline vs. placebo; baseline vs. cetirizine;
EEG was taken after randomization of subjects into two
placebo vs. cetirizine) using Wilcoxons Sign Rank test.
groups- cetirizine and placebo. Cetirizine/placebo was
Data were presented in the form of median (inter-quartile
administered to the respective group of subjects
range) and analyzed with statistical software SPSS 11.5.
immediately after the first recording and then subjects
A p value of <0.05 was considered statistically significant.
were allowed to relax in laboratory for two hours. The
RESULTS
subjects were asked to report drowsiness if they
experienced during that period. The second EEG
recording was done after two hours of first recording on
Among 30 subjects nine experienced drowsiness after
the same day. After 72 days of second recording and
cetirizine administration, whereas others twenty one showed
cross-over of subjects (i.e. the initial placebo group
no any symptoms of drowsiness.
became the cetirizine group and initial cetirizine group
In symptomatic subjects (who reported drowsiness), the
became the placebo group), cetirizine and placebo were
extended EEG alpha activity overall decreased but the
given to the subjects accordingly. Again subjects were
reduction was significant only at sites Cz, Pz, F8, C4, P4,
asked to report drowsiness if they experienced after
P3 and O1 (shown in Table 1).
Table 1: Comparison of power of EEG extended alpha (6.5-14 Hz), alpha2 (8.5-10 Hz) and alpha 3 (12.5-14 Hz)
activity among baseline, placebo and cetirizine treated symptomatic subjects (n=9)
p
p1
p2
Electrode
Baseline (n=9)
Placebo (n=9)
Cetirizine (n=9)
2
2
2
sites
V
V
V
Extended alpha (6.5-14 Hz) activity
0.032 NS
Cz
126.4(97.72 - 198.96)
129.34(36.02- 150.96) 60.02(32.32 - 82.06)
NS
0.015
Pz
190.48(122.52 -202.48)
164.6(41.4 - 241.38)
57.72(31.34- 115.52) 0.045 NS
0.045 NS
F8
34(22.44 - 53.46)
29.64(10.74 - 56.1)
16.04(8.86 - 21.22)
NS
0.032 NS
0.021
C4
114.56(91.42 - 135.18)
96.32(21.04 - 121.62)
44.06(21.66 - 54.4)
0.045 NS
0.021
P4
177.6(114.84 - 191.72)
116.62(28.84- 191.16) 54.58(24.54 - 99.16)
0.028
P3
115.24(92.52 - 135.08)
103.46(23.18- 150.18) 48.86(17.92- 101.64) 0.045 NS
O1
128.02(79.4 - 199.62)
115.64(24.86- 234.72) 38.88(21.36- 105.26) 0.045 NS
NS
alpha2 (8.5-10 Hz) activity
Pz

67.76(21.84 - 105.62)

25.9(12.24 - 76.1)

11.24(11 - 51.22)

0.045

NS

0.028

C4

29.48(16.34 - 66.18)

19.2(9.52 - 29.14)

8.8(7.32 - 21.72)

0.045

NS

0.021

0.045 NS
51.38(25.08 - 80.26)
30.52(10.06 - 59.36)
11.98(5.24 - 49.62)
NS
0.045 NS
18.32(11.74 - 26.98)
27.2(5.02 - 33.66)
6.76(3.14 - 20.16)
NS
alpha 3 (12.5-14 Hz) activity
0.032 NS
Fp2
3.68(3.08 - 6.72)
5.1(3.38 - 9.74)
2.5(1.96 - 3.58)
NS
0.018 NS
F4
4.58(3.7 - 7.74)
10.22(3.28 - 15.94)
3.54(2.8 - 5.86)
NS
0.016 NS
0.028
Fp1
3.9(2.84 - 7.38)
5.04(2.06 - 13.76)
3.3(1.98 - 4.46)
0.045 NS
0.021
O1
13.34(2.82 - 34.54)
11.08(3.94 - 40.38)
4.56(4.04 - 9.1)
p<0.05, considered statistical significant; NS=no statistical significant difference; p=Overall p value by Friedmans test; p1=
baseline vs. placebo; p2= baseline vs. Cetirizine. Fp1-Left prefrontal,Fp2-Right prefrontal, F4-Right frontal, F8-Right
anterior temporal, T5-Left posterior temporal, C4-Right central,P3-Left parietal,P4-Right parietal,O1-Left occipital,O2-Right
occipital,Cz-Midline central, Pz- midline parietal.
O2
T5

833
Shah Dev et al.,

Int J Med Res Health Sci. 2015;4(4):832-836

On multiple comparisons, we found significant decline in


extended alpha activity in cetirizine treated compared to
baseline at some sites in those subjects. EEG alpha 2
activity also found to be overall decreased after cetirizine
intake however the significant reduction was only at sites
Pz, C4, O2 and T5 (Table 1). Similar changes were found
in alpha 3 activity in drowsy subjects which were
significant at sites Fp2, F4, Fp1 and O1. EEG beta
activities followed the same pattern with significant
change at sites Pz, F4 and O1 (shown in Table 2).
However there was no significant difference in power
spectra of EEG slow, alpha 1 and alpha 4 activities at any
sites in drowsy subjects among baseline, placebo and

cetirizine. In asymptomatic subjects (who did not report


any sign of drowsiness after cetirizine administration),
there was significant increase in EEG slow and alpha1
activities in cetirizine treated condition as compared to
baseline (Table 3). There was no any significant difference
in EEG activity when baseline and placebo was compared.
On comparison of EEG activities between symptomatic
and asymptomatic subjects, there was no significant
change in power of EEG slow, extended alpha, alpha 1,
alpha 2 and beta activities except alpha 3 which
significantly decreased in symptomatic subjects at all the
recordings sites excluding C4, T6 and F7 (Table 4).

Table 2: Comparison of power of EEG beta (14.5-32) activity among baseline, placebo and cetirizine conditions of
cetirizine treated symptomatic subjects(n=9)
Electrode
Baseline (n=9)
Placebo (n=9)
Cetirizine(n=9)
p
p1
p2
2
2
2
sites
V
V
V
0.032 NS
Pz
20.44(12.64 - 31.02)
21.24(15.44 - 29.14)
18.44(12.52 - 23.34)
NS
0.045 NS
F4
19.34(15.92 - 23.76)
24.94(14.3 - 31.58)
18.52(13.74 - 21.02)
NS
0.018 NS
0.028
O1
15.56(9.72 - 29.78)
15.9(10.82 - 16.96)
9.74(5.92 - 12.04)
p<0.05, considered statistical significant; NS=no statistical significant difference; p=Overall p value by Friedmans test; p1=
baseline vs. placebo; p2= baseline vs. Cetirizine. Pz- midline parietal, F4-Right frontal,O1-Left occipital.
Table 3: Comparison of power of EEG slow (0.5-6.5 Hz) activity among baseline, placebo and cetirizine conditions
of cetirizine treated asymptomatic subjects (n=21)
p
p1
p2
Electrode
Baseline (n=21)
Placebo (n=21)
Cetirizine (n=21)
2
2
2
sites
V
V
V
Slow (0.5-6.5 Hz) activity
0.009 NS
0.008
Cz
89.94(79.66 - 128.74)
95.18(80.18 - 129.22) 110.58(87.24- 145.5)
0.001 NS
0.004
Pz
82.2(64.38 - 98.1)
74.84(63.42 - 94.26)
87.88(71.82 - 110.3)
0.010 NS
0.007
T6
33.5(22.34 - 47.34)
31.62(27.64 - 51.96)
36.06(28.96 - 51.42)
0.013 NS
0.009
C3
58.68(48.86 - 70.44)
59.1(50.88 - 85)
63.9(53.52 - 90.48)
Alpha 1 (6.5-8 Hz) activity
0.012 NS
0.006
F3
6.8(5.52-10.64)
6.24(5.34-13.28)
9.26(7.7-11.7)
0.016 NS
0.003
C3
6.9(5.42-8.84)
6.64(4.78-13.44)
9.16(7-11.7)
p<0.05, considered statistical significant; NS=no statistical significant difference. p=Overall p value by Friedmans test; p1=
baseline vs. placebo; p2= baseline vs. Cetirizine. Cz-Midline central, Pz- midline parietal, T6-Right posterior temporal, C3Left central, F3-Left frontal.
Table 4: Comparison of power of EEG alpha 3 (10.5-12
Hz) activity between symptomatic and asymptomatic
subjects in cetirizine treated condition
Asymptomatic
Symptomatic
Electrode
p
subjects (n=21) subjects
sites
2
2
V
(n=9) V
Fz
10.92(6.8 - 17)
4(3.84 - 7.08)
0.015
Cz
13.46(7.96- 21.2) 4.96(4.58 - 7.28) 0.005
Pz
13.76(9.98- 29.9) 7.34(5.54 - 13.4) 0.032
Fp2
5.56(3.16 - 8.52) 2.5(1.96 - 3.58)
0.003
F8
3.78(1.94 - 5.96) 1.58(1.1 - 2.28)
0.012
F4
8.42(4.16- 12.84) 3.54(2.8 - 5.86)
0.009
C4
10.02(7.08- 15.1) 3.88(3.1 - 6.7)
NS
T4
2.24(1.38 - 4.28) 1.2(0.8 - 1.42)
0.009
T6
9.4(4.68 - 18.84) 3.44(2.94 - 8.44) NS
P4
12.62(8.6- 26.82) 7.8(3.9 - 9.7)
0.044
O2
18.24(8.04- 35.3) 5.66(3.62- 14.54) 0.028
Fp1
5.28(3.56 - 7.78) 3.3(1.98 - 4.46)
0.022
F7
2.64(1.94 - 4.4)
1.74(1.6 - 2.04)
NS
F3
6.6(4.68 - 11.78) 3.5(2.5 - 4.3)
0.011
C3
8.8(6.44 - 13.52) 3.66(2.84 - 4.88) 0.003
T3
2.52(1.4 - 3.68)
1.16(0.98 - 1.8)
0.014
T5
7.02(3.4 - 19.9)
2.92(2.32 - 4.76) 0.039
P3
10.12(7.58- 24.5) 4.48(3.26 - 8.92) 0.014
O1
19.26(5.98- 31.6) 4.56(4.04 - 9.1)
0.012

p<0.05, considered statistical significant; NS=no statistical


significant difference. Fp1-Left prefrontal, Fp2-Right
prefrontal, F3-Left frontal, F4-Right frontal, F7-Left
anterior temporal, F8-Right anterior temporal, T3-Left mid
temporal,T4-Right
mid
temporal,T5-Left
posterior
temporal, T6-Right posterior temporal,C3-Left central,C4Right central,P3-Left parietal,P4-Right parietal,O1-Left
occipital,O2-Right occipital, Fz-Midline frontal,Cz-Midline
central, Pz- midline parietal.
DISCUSSION
In our study, one third of subjects (nine out of thirty)
developed symptoms of drowsiness after cetirizine
administration which contradicts the report that second
generation antihistamines have equivalent therapeutic
effect as classical antihistamines without their undesired
[9]
side effects.
In symptomatic subjects, the EEG extended alpha and beta
activities significantly decreased in cetirizine treated condition
as compared to baseline. Among the extended alpha
activities, the alpha 2 and alpha 3 activities were found
significantly reduced. The decrease in power of EEG
extended alpha activity in our study supported the findings
of previous study that revealed decline in power of EEG

834
Shah Dev et al.,

Int J Med Res Health Sci. 2015;4(4):832-836

alpha activity in the range of 8-13 Hz with neuroleptics


[10]
(sedative/non-sedative), anxiolytics and hypnotics.
The
antihistamine with sedative properties like Ketotifen,
promethazine were associated with decreased EEG alpha
[11,12]
activity.
Thus, decrease in power of extended alpha,
alpha 2 and alpha 3 activity in symptomatic subjects in
our study might be suggestive of sedative properties of
cetirizine. We also found reduced power of EEG beta
activity in symptomatic subjects after cetirizine
administration which supported the previous result that
revealed sedative drugs decrease the power of beta 1 in
[10]
the range of 13-20 Hz.
In asymptomatic subjects, there was significant increase in
power of EEG slow and alpha 1 activities in cetirizine treated
condition as compared to baseline. Sedative and hypnotic
[10]
drugs strongly increases EEG delta/theta ratio.
Sedation has been described as either an annoying
subjective sensation of drowsiness or an actual objective
impairment of cognitive function and psychomotor
[13-15]
performance and even both.
Increased low-voltage
slow-wave activity and decreased alpha activity was
reported with many sedative drugs, and these changes
[16]
are explained as the development of drowsiness.
Gilbert et al found reduced power of EEG slow activity
(delta and theta wave) in subjects after smoking nicotinecontaining cigarettes which was correlated with
[17]
decreased drowsiness.
Thus, increase in power of
EEG slow activity in our study can be correlated with the
sedative effects of cetirizine despite of no symptoms of
drowsiness reported by the subjects. The reasons for
impediments of symptoms despite of positive changes in
electrical activities of central neurons need further
exploration. However, higher threshold for experiencing
the drowsiness in these asymptomatic subjects cannot be
ruled out. Our finding of rise in power of EEG alpha 1
activity in asymptomatic subjects was supported by the
result of Sannita et al who found notably increase in
power of EEG extended alpha (6.5-14 Hz) and its sub
segment alpha 1 (6.5-8 Hz) after administration of
[8]
cetirizine 20 mg to the subjects.
When EEG power of frequency bands between
symptomatic and asymptomatic subjects were compared,
there was significant decrease in EEG alpha 3 activities in
symptomatic subjects at most of the sites like mid-central
(Fz, Cz, &Pz,), left central (C3), prefrontal (Fp1 & Fp2),
frontal (F3 & F4), anterior temporal (F8), middle temporal
(T3 & T4), posterior temporal (T5), parietal (P3 & P4) and
occipital (O1 and O2). The reduction in power of alpha 3
activities in symptomatic subjects can be correlated with
the degree of drowsiness experienced by the subjects.
However, some subjects are particularly susceptible to
the CNS effects of antihistamine, whereas others appear
[1]
to be more resistant.
Therefore, the threshold for
subjective feeling of drowsiness might show individual
variation.
[18]
Sedative side-effect of a drug is dose dependent. Low
incidence of sedative effects of cetirizine is most likely
caused by its diminished potential to cross the blood-brain
barrier and also may be partly the result of its greater
selectivity for H1 receptors, compared with its effect at
[19]
other receptors that may be involved in sedation.
The
large molecular size and relatively lipophobic nature

reduce the potential of second generation antihistamines


to cross the blood-brain barrier readily. In addition their
greater affinity for peripheral H1 receptor also reduce their
[20]
propensity to cause sedation.
Recent studies have
shown that the poorer affinity of these newer
antihistamines for the P-glycoprotein efflux pump at the
blood-brain barrier may also explain their relative lack of
[21,22]
central nervous system (CNS) side effects.
The
incidence of sedation associated with cetirizine at the
recommended adult dose of 10 mg is less than that seen
with first-generation antihistamines but greater than that of
[23]
placebo.
Nevertheless development of drowsiness in
one third of subjects with 10 mg cetirizine in our study
appears to be substantial, especially while prescribing
cetirizine.
CONCLUSION
Our study suggests that EEG power of extended alpha,
alpha 2, alpha 3 and beta activities (i.e. above 8.5 Hz)
reduces in subjects who experience drowsiness after
cetirizine administration. Cetirizine in therapeutic dose also
increases EEG slow and alpha 1 activities (i.e. below 8.5
Hz) despite lack of feeling of drowsiness. Hence our study
concluded that there is change in EEG activity of subjects
after cetirizine intake irrespective of presence or absence of
symptoms of drowsiness. On comparison between
symptomatic and asymptomatic subjects, only EEG alpha3
activity significantly declined in symptomatic subjects and
this finding can be correlated with degree of drowsiness
regardless
of
subjective
threshold.
Hence
a
physician/pharmacist must consider the sedative effect of
cetirizine and counsel patients before delivery of this
drug.
Limitations of the study: The limitation of this study was
that the plasma concentration of drug at the time of EEG
recording could not be measured because of feasibility
reason. Comparison of sedative effect of cetirizine
between healthy subjects and patient on cetirizine can be
one of the future directions of study.
Acknowledgment: We are thankful to all the subjects
who voluntarily participated in the study.
Conflict of interest: There was no conflict of interest
among authors regarding publication of this article.
REFERENCES
1.
2.

3.
4.

5.

Rihoux JP, Donnelly F. CNS effects of histamine H1


antagonists. Clin Exp Allergy. 1999; 29(3):143146.
Mattila MJ, Paakkari I. Variations among nonsedating antihistamines: are there real differences?
Eur J Clin Pharmacol. 1999; 55(2):85-93.
th
Katzung BG (ed).Basic & Clinical Pharmacology. 11
ed. USA: The McGraw-Hill Companies 2004. p. 276.
Spencer CM, Faulds D, Peters DH. Cetirizine. A
reappraisal of its pharmacological properties and
therapeutic use in selected allergic disorders. Drugs.
1993; 46(6):1055-80.
Pal NR, Chuang CY, Ko LW, Chao CF, Jung TP,
Liang SF, et al. EEG-based subject- and sessionindependent drowsiness detection: an unsupervised
approach. EURASIP Journal on Advances in Signal
Processing.
New York:
Hindawi
Publishing
Corporation 2008; id:519480.

835
Shah Dev et al.,

Int J Med Res Health Sci. 2015;4(4):832-836

6.

Rajna P, Veres J. Assessing the sedative (adverse)


effects of antiallergic drugs by quantitative
electroencephalography: effects of setastine a
nonsedating antihistaminic drug. Ther Hung.1994;
42(1):1420.
7. Ghimire N, Paudel BH, Khadka R, Singh PN, Das A.
Electroencephalographic changes during selective
attention. Asian J Med Sci. 2015; 6(2):52-67.
8. Sannita WG, Crimi E, Riela S, Rosadini G, Brusasco
V. Cutaneous antihistaminic action of cetirizine and
dose-related EEG concomitants of sedation in man.
Eur J Pharmacol. 1996; 300(1-2):33-41.
9. Woodward JK. Pharmacology of antihistamines. J
Allergy Clin Immunol. 1990; 86(4 Pt 2):606-12.
10. Niedermeyer
E,
Silva
FH.
EEG
and
Neuropharmacology, In: Electroencephalography:
basic principles, clinical applications, and related
fields. 5th ed. Pennsylvania: Lippincott Williams &
Wilkins publisher.2004; p.695-697.
11. Vollmer R, Matejcek M, Greenwood C, Grisold W,
Jellinger K. Correlation between EEG Changes
Indicative of Sedation and Subjective Responses.
Neuropsychobiol. 1983; 10:249-253.
12. Itil TM (ed.). Psychotropic Drugs and the Human
EEG. Switzerland:Karger; I974. p.377.
13. Gengo FD. Antihistamine selection: Use vs. Side
effects. J S Pharmacist. 1990; 92:5968.
14. Falliers CJ, Brandon ML, Buchman E, Connell JT,
Dockhorn R, Leese PT, et al.
Double-blind comparison of cetirizine and placebo in the
treatment of seasonal rhinitis. Ann Allergy. 1991;
66:25762.
15. Meltzer E, Welch MJ. Adverse effects of H1-receptor
antagonists in the central nervous system. In: F. E. R.
Simons. (ed.) Histamine and H1-receptor antagonists
in allergic disease. New York: Marcel Dekker Inc.
1996; 35781.
16. FII~K M. EEG and Human Psychopharmacology.
Annu. Rev. Pharmacol. 1969; 9:241-258.
17. Gilbert DG, Meliska CJ, Welser R, Estes SL.
Depression, personality, and gender influence EEG,
cortisol, beta-endorphin, heart rate, and subjective
responses to smoking multiple cigarettes.Personality
and individual differences. 1994; 16(2):247-264.
18. Timmerman M. Why are non-sedating antihistamines
non-sedating?Clin Exp Allergy.1999; 29(3):1318.
19. Snowman AM, Snyder SH. Cetirizine: actions on
neurotransmitter receptors. J Allergy Clin Immunol.
1990; 86(6 Pt 2):1025-8.
20. Hindmarch I, Shamsi Z. Antihistamines: models to
assess sedative properties, assessment of sedation,
safety and other side-effects. Clin Exp Allergy. 1999;
29(3):133142.
21. Chishty M, Reichel A, Siva J, Abbott NJ, Begley DJ.
Affinity for the P-glycoprotein efflux pump at the
blood-brain barrier may explain the lack of CNS sideeffects of modern antihistamines. J Drug Target.
2001; 9:223228.
22. Chen C, Hanson E, Watson JW, Lee JS. Pglycoprotein limits the brain penetration of
nonsedating but not sedating H1-antagonists. Drug
MetabDispos. 2003; 31:312318.

23. Dykewicz MS, Fineman S, Skoner DP, Nicklas R,


Lee R, Blessing-Moore J, et al. Diagnosis and
management of rhinitis: complete guidelines of the
Joint Task Force on Practice Parameters in Allergy,
Asthma and Immunology. American Academy of
Allergy, Asthma, and Immunology. Ann Allergy
Asthma Immunol. 1998; 81:478.

836
Shah Dev et al.,

Int J Med Res Health Sci. 2015;4(4):832-836

DOI: 10.5958/2319-5886.2015.00166.6

Available online at: www.ijmrhs.com

Research article

Open Access

THERAPEUTIC IMPORTANCE OF OLDER GENERATION ANTIBIOTICS ON GRAM


NEGATIVE ISOLATES
1

B.Lakshmi , M.Swarajya lakshmi , Rohini

ARTICLE INFO
Received: 05th July 2015
Revised: 10th August 2015
Accepted: 20th Sep 2015
Authors details: 1Associate Professor,
2
Associate Professor, 3M.Sc, Microbiology,
MNR Medical College, Sangareddy
Corresponding author: B. Lakshmi
Associate Professor, Microbiology, MNR
Medical College, Sangareddy
Email: lakshmibapan@gmail.com
Keywords: Antibiogram, Gram negative
isolates, Imipenam, Multi drug resistance,
older generation antibiotics.

ABSTRACT
Introduction: Drug resistance is a serious medical problem. Indiscriminate use of
antibiotics has led to a state where multi drug resistant bacteria have become
increasingly prevalent. Therefore regular surveillance of important pathogens and
their resistant pattern is mandatory. Aim: To find out prevalence of organisms
causing infection and their sensitivity pattern. Material and methods: 676 clinical
samples were screened among which 156 Gram Negative(GN) Isolates were
processed for their antibiotic sensitivity profile against 12 different antibiotics.
Results: Escherichia coli is the most common isolate of 156 gram negative
isolates. Among all antibiotics, ampicillin is least sensitive (22%). Antibiotics with
good sensitivity are Imipenam, Meropenam (100%), Levofloxacin 94%, Amikacin
89% Ciprofloxacin 79%, Gentamycin 77%. Pseudomonas is 100% sensitive to
Amikacin. Conclusion: Antibiotic resistance in our area is still moderate. It is
essential to test for older generation antibiotics before deciding on higher
antibiotics for treatment which will have a tremendous impact on the treatment as
well as cost effectiveness. Regular surveillance helps in implementing better
therapeutic strategies.

INTRODUCTION
Microbiological infection plays a vital role in determining
the outcome as well as cost and duration of hospital stay
[1]
for admitted patients . Gram negative infections were
responsible for more severe infections and case fatality.
Severity of the cases increased by drug-resistant
pathogens in hospitalized patients with serious infections
such as pneumonia, urinary tract infections, skin and skinstructure infections and primary or secondary bacteremia
which is generally ascribed to the widespread use of
antimicrobial agents. In a recent report the Infectious
Diseases society of America specifically addressed three
categories of MDR- Multi Drug Resistant - gram negative
bacilli namely, extended spectrum cephalosporinresistant Escherichia coli and Klebsiella spp., MDR
Pseudomonas aeruginosa, and Carbapenam-resistant
Acinetobacter spp. Moreover there are now a growing
number of reports of cases of infections caused by gram
negative organisms for which no adequate therapeutic
options exist. This return to preantibiotic era has become
[2].
a reality in many parts of the world
So for the
prevention of nosocomial infections a thorough knowledge
of the infection rates and of the source, type and nature of
invading microorganisms along with risk factors
[2,3].
associated with infection is the starting point
Also
knowledge of the resistivity pattern of different clinical
isolates of hospital has been the global necessity for
control of emergence of resistance to antimicrobial
[3]
agents Furthermore this screening would provide a
valuable and critical data that could help physicians in
way of successful treatment in addition to health care
settings policy towards antimicrobial drug programming
and invention of new drugs. Therefore invitro antimicrobial
susceptibility testing has been done by many researchers
as a useful method to identify drug resistance pattern of
clinical isolates. Characterization of bacteria that are

resistant to multiple antimicrobial agents are needed


promptly, timely and locally across all healthcare settings
within a consistent pattern so that such baseline data
could be reliably compared inside and outside the
[4].
country Aim and Objectives: This study is done to
investigate the effect of antibiotics over the isolated
microorganisms from various samples in MNR Hospital.
MATERIALS AND METHODS
In this prospective study, after Institutional ethical
committee approval, clinical samples from all infected
patients attending MNR hospital, Fasalwadi received in
Microbiology lab over a period of 6months are considered.
Total of 676 clinical samples (mid stream urines, blood,
sputum, pus swabs, throat swabs, vaginal swabs,
aspirated fluids from body cavities, CSF) are included in
the study. Samples collected aseptically in sterile
containers are labeled in central lab unit of hospital and
processed within 30min to 1hr of collection.
Inclusion criteria: In this study, only Gram Negative
Bacilli were included.
Exclusive criteria: Gram Positive Bacterial isolates and
fungal isolates were excluded.
Methods: All the above samples are cultured on Blood
o
agar, and Mc Conkey agar plates and incubated at 37 C
for 24-48hrs. Isolates were sub cultured and colonies
were screened for Gram Negative GN isolates.
Identification of isolates was done by Gram staining,
Catalase, Oxidase tests, Triple sugar Iron TSI agar test,
Citrate utilization, Indole test, Methyl Red [MR], Voges
Proskeur [ VP], Urease tests. Result interpretation was
based on conventional methods described in Mackie
[5
McCartney. ].
Antibiotic Susceptibilty Testing
[AST]
done on Muellar Hinton Agar
[ MHA] with Kirby-Bauer
disc diffusion method according to Clinical and Laboratory

837
Lakshmi et al.,

Int J Med Res Health Sci. 2015;4(4):837-840

[6].

Standards Institute [CLSI] guidelines


The antibiotic
discs used were Ampicillin(10g), Pipercillin(100mcg),
Cotrimoxazole(25g), Gentamicin(10g), Amikacin(30g),
Ciprofloxacin(5g), Levofloxacin (5mcg), Ceftazidime(30
g),Ceftriaxone(30g),
Cefoperazone
(75mcg),
Imipinem(10), Meropenam (10mcg) . All these discs
were procured from Hi Media, Mumbai.
RESULTS
A total of 156 Gram negative Bacilli (GNB) were isolated
from various specimens. Highest isolation rate was
observed from pus (33.5%), sputum (27%), urine(20.5%),
blood (12.1% ) and body fluids (4.5% ). Table 1:
Escherichia coli is the most common isolate (64) followed
by Klebsiella (56), Proteus (14), Pseudomonas (13) and
Citrobacter (9). Table 2. Antibiotic sensitivity pattern of 12
different antibiotics were done in the study. All the isolates
are sensitive to Imipenam and Meropenam (100%)
followed by Levofloxacin. Details in Table -3 and Table 4.

Table 1: Total number of gram negative organisms


from different specimens.
Specimen
Urine
Pus
Sputum
Body fluids
Blood
Total

No of samples
312
209
55
67
33
676

Isolates
64
70
15
03
04
156

Table 2: Distribution of Gram negative bacterial


isolates (n=156)
Bacterial Isolates

No of isolates

Percentage %

Esch.coli

64

41

Klebsiella spp

56

36

Proteus

14

Pseudomonas

13

8.3

Citrobacter

09

5.7

Table 3: Antibiotic sensitivity pattern among the isolates.(S - sensitive, R - Resistant)


Antibiotics

Ampicillin

Piperacillin

Cotrimoxazole

Gentamycin

Amikacin

Ciprofloxacin

Levofloxacin

Ceftazidime

Ceftriaxone

Cefaperazone

Imipenam

Meropenam

E.colin = 64

Klebsiella N=56

Proteus N = 14

PseudomonasN = 13

Citrobacter N = 09

5(7.9%)

7 (12.5%)

5 (35.7%)

5 (38.4%)

3 (33.3%)

59 (92.1%)

49 (87.5%)

9 (64.3%)

8 (61.5%)

6 (66.6%)

35 (54.7%)

27 (48.2%)

12 (85.7%)

9 (69.2%)

7 (77.7%)

29 (45.3%)

29 (51.8%)

2 (14.3%)

4 (30.8%)

2 (22.2%)

34 (53.2%)

19 (34%)

3 (21.5%)

6 (46.2%)

4 (44.5%)

30 (46.8%)

37 (66%)

11 (78.5%)

7 (53.8%)

5 (55.5%)

52 (81.3%)

42 (75%)

9 (64.3%)

12 (92.4%)

5 (55.5%)

12 (18.7%)

14 (25%)

5 (35.7%)

1 (7.6%)

4 (44.5%)

60 (93.75%)

49 (87.5%)

11 (78.6%)

13 (100%)

7 (77.7%)

4 (6.25%)

7 (12.5%)

3 (21.4%)

0 0%

2 (22.2%)

46 (72%)

50 (89.3%)

11 (78.6%)

12 (84.6%)

5 (55.5%)

18 (28%)

6 (10.7%)

3 (21.4%)

2 (15.4%)

4 (44.5%)

62 (96.9%)

53 (94.65%)

12 (85.8%)

12 (92.3%)

8 (88.9%)

2 (3.1%)

3 (5.35%)

2 (14.2%)

1 (7.7%)

1 (11.1%)

34 (53.2%)

29 (51.8%)

8 (57.2%)

10 (77.2%)

6 (66.6%)

30 (46.8 %)

27 (48.2%)

6 (42.8%)

3 (23.7%)

3 (33.4%)

34 (53.2%)

38 (67.9%)

10 (71.5%)

10 (77%)

5 (55.5%)

30 (46.8%)

18 (32.1%)

4 (28.5%)

3 (23%)

4 (44.5%)

37 (57.8%)

34 (60.7%)

9 (64.3%)

0-0

6 (66.6%)

27 (42.2%)

22 (39.3%)

5 (35.7%)

13 (100%)

3 (33.4%)

64 (100%)

56 (100%)

14 (100%)

13 (100%)

9 (100%)

00

00

00

00

0-0

64 (100%)

56 (100%)

14 (100%)

13 (100%)

9 (100%)

00

00

00

00

0-0

838
Lakshmi et al.,

Int J Med Res Health Sci. 2015;4(4):837-840

Table 4: Overall resistance to antibiotics


Antibiotic (mcg)
Sensitivity (n=156)

Resistance

the variations in duration and dose of the antibiotics used,


spectrum of antibiotics used, and differing antibiotic
.[3]
policies among different hospitals
Limitations of the study: This study can be further
extended by testing for Extended Spectrum Beta
Lactamases (ESBLs) and Metallo Beta Lactamases
(MBLs).

Ampicillin

35 (22.4%)

131 (84%)

Piperacillin

90 (57.7%)

66 (42.3%)

Cotrimoxazole

66 (42.3%)

90 (57.7%)

Gentamycin

120 (76.9%)

36 (23.1%)

CONCLUSION

Amikacin

140 (89.7%)

16 (10.3%)

Ciprofloxacin

123 (79%)

33 (21%)

Levofloxacin

147 (94.2%)

9 (5.8%)

Ceftazidime

87 (55.8%)

69 (44.2%)

Ceftriaxone

97 (62.2%)

59 (37.8%)

Cefaperazone

86 (55%)

70 (45%)

Imipenam

156 (100%)

0 (0%)

Meropenam

156 (100%)

0 (0%)

This study provides the current trend of drug resistant


GNB among clinical samples so as to keep track of the
resistivity that may arise in future and most important to
know the massive use of particular antibiotics and also
their misuse so that measures could be taken to prevent
.
severe consequences. To conclude, antibiotic resistance
in our area is still moderate with good sensitivity to
Amikacin, Gentamycin, Quinolones, and Carbapenams.
So it is essential to test for older generation antibiotics
before deciding on higher antibiotics which will have a
tremendous impact on the treatment as well as cost
effectiveness. It is recommended that an updated unit
specific antibiograms should be done and provided to
clinicians atleast once in a year to ensure that the data
are current and useful .So that it is of help to them to
devise empiric regimens that have a greater likelihood of
covering the organisms posing risk and at the same time
reduce the unnecessary administration of broad spectrum
antibiotics.

DISCUSSION
Antibiotics when first introduced were considered as a
magic bullet. A single injection of penicillin could eradicate
a life threatening infection. Unfortunately with time due to
malpractices or natural causes, most of the cheaper
antibiotics have lost their efficacy and more and more
expensive and complicated antibiotics were introduced
and marketed to combat simple infection. The microbial
pathogens as well as their antibiotic sensitivity pattern,
[7].
may change from time to time and place to place
Out of 156 Gram Negative bacterial isolates in our study,
Escherichia coli is the most common isolate followed by
[4,8,9].
Klebsiella spp similar to other studies
Most of these isolates are highly resistant to commonly
used antibiotics like ampicillin (84%) which correlated
[2,8]
closely with other studies
High sensitivity was noted to Amikacin (89%) and
Gentamycin (77%) in our study which is in tandem with
[3,4,9]
the work done by other authors
Also Pseudomonas
showed 100% sensitivity to amikacin in our study.
All isolates (100%) were susceptible to Imipenam and
[9,10].
Meropenam
44.23% were resistant to ceftazdime, 37.8% were
resistant to ceftriaxone, 44.87% were resistant to
[1,10].
cefperazone correlated well with other studies
Whereas 70-75% resistance to cephalosporins was
[9]
reported.
Sensitivity to cotrimoxazole (42%) in our work closely
correlates with the work of authors Kala yadav and
.[11,12].
Raminder sandhu
Quinolones were highly effective in our study. Only
21.15% isolates were resistant to ciprofloxacin and 5.8%
isolates were resistant to levofloxacin. Similar to the work
[1].
done by Patel Bhaumik
Contrast to our work, are studies which reported higher
[2,11]
drug resistance to quinolones,
aminoglycosides,
[ 13,14].
cephalosporins
Such variations in the antimicrobial
sensitivity pattern among different studies may be due to

ACKNOWLEDGEMENT
Mr.M. Ravi Varma, Vice chairman, Dr.V.Satya Prasad,
Professor, Department of Anatomy, Dr.G.Shobha Paul,
Professor and HOD Department of Microbiology, Dr. K.
Ambareesha, Department of Physiology, MNR Medical
College and Hospital for giving us the opportunity and
timely guidance.
Conflict of Interest: Nil
REFERENCES
1.

2.

3.

4.

Patel Bhaumik V, Patel Purav G, Raval Payal N,


Patel Mitesh H, Patel Piyush H, Vegad Mahendra M.
Bacteriological profile and Antibiogram of Gram
Negative Organisms isolated from Medical and
Neurology Intensive Care unit with Special reference
to Multi-drug resistant organisms. Nat J Med Res
2012,2 (3) 335-38.
Binit Lamichhane, Chandan Thakur, S.K.Jain.,
Antibiotic Resistance patterns of Gram Negative
isolates in a tertiary care hospital of Nepal. Asian J
Pharm Clin Res. 2014; 7 (3); 30-33.
Kritu Panta, Prakash Ghimire, Shiba Kumar Rai,
Reena Kiran Mukhiya, Ram nath Singh, Ganesh Rai.
Antibiogram typing of Gram Negative isolates in
Different Clinical Samples of a tertiary Hospital. Asian
J Pharm Clin Res. 2013;6(1), 153-56.
Seyedah Afrooz Azmil, Shahram Boroumandi,
Mohammad Rahbar. Prevalence of Drug Resistance
pattern in admitted patients to Pars Hospital, Tehran,
Iran. IJBSCI.2014; 2 (1): 14-21.

839
Lakshmi et al.,

Int J Med Res Health Sci. 2015;4(4):837-840

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Colle, Fraser, Marmion, Simmons. Mackie Mc


th
Cartney - Practical Medical Micribiology. 14 edition.
2006.
Clinical and Laboratory Standards Institute (CLSI).
Analysis and presentation of cumulative antimicrobial
susceptibility test data. 3rd ed. Approved guideline
M39-A3. Wayne PA. CLSI, 2009.
Shamim Mumtaz, Naeem Aktar, Abbas Yayat.
Antibiogram of aerobic pyogenic isolates from
wounds and abscesses of patients at Rawalpind.
Pakistan J Med Res, 2002; 41: 1
C.B.Chikere, B.O.Chikere,V.T.Omani. Antibiogram of
clinical isolates from a hospital in Nigeria. Afr.J
Biotechnol 2008; 7(24): 4359-63.
Jaya Sankarankutty, Soumya Kaup. Distribution and
Antibiogram of Gram Negative isolates from various
Clinical samples at a Teaching Hospital, Tumkur.
Sch.J.App.Med.Sci., 2014; 2 (3): 927-31.
Iraj Alipourfard, Nilufar Yeasam in Nili. Antibiogram of
Extended spectrum Beta-Lactamase producing
Escherichia coli and Klebsiella Pneumoniae isolated
from Hospital sample. Bangladesh J Med Microbiol
2010; 4 (1): 32-36.
Kala Yadav M L, Ashmita Raja. Bacteriological profile
and antibiogram of Gram negative clinical isolates
from a tertiary care centre. Int J Res Health
Sci.2014; 2 (3): 734-9.
Raminder Sandhu, Hema Prakash, RP Nagdawane.
Aerobic bacterial isolates in suppurative infections
and their antibiograms A reflection of Infection
control. www.ijpbsonline.com 2014, 4(2) 186-92.
Mohammadi-mehr M, Feizabadi MM. Antimicrobial
resistance pattern of Gram negative bacilli isolated
from patients at ICUs of Army hospitals in Iran. Iran J
Microbiol. 2011;(1): 26-30.
Gunserena, Mamikoglua L, Ozturkb S, Yucesoy M,
Biberogluc K, Yulugc N. A surveillance study of
Antimicrobial resistance of Gram negative bacilli
isolated from patients at Intensive Care Units in eight
hospitals n Turkey. J.Antimicrib. Chemother. 1999;
43 (3): 373-78.

840
Lakshmi et al.,

Int J Med Res Health Sci. 2015;4(4):837-840

DOI: 10.5958/2319-5886.2015.00167.8
Open Access

Available online at: www.ijmrhs.com


Research article

EFFECT OF DIAPHRAGMATIC AND COSTAL MANIPULATION ON PULMONARY


FUNCTION AND FUNCTIONAL CAPACITY IN CHRONIC OBSTRUCTIVE PULMONARY
DISEASE PATIENTS: RANDOMIZED CONTROLLED STUDY
1

Abdelaal Ashraf AM , Ali Mohamed MI , Hegazy Ibrahim M

ARTICLE INFO
Received: 6th Jul 2015
Revised: 5th Sep 2015
Accepted: 18th Sep 2015
Authors details: 1Department of
Physical Therapy for Cardiovascular/
Respiratory Disorder and Geriatrics,
Faculty of Physical Therapy, Cairo
University, Egypt
2
Department of Physical Therapy for
Musculoskeletal Disorders, Faculty of
Physical Therapy, Cairo University,
Egypt
3
Ph.D. in Physical Therapy for
Musculoskeletal
Disorders,
Cairo
University Hospitals, Egypt
Corresponding
author:
Abdelaal
Ashraf AM, Faculty of Physical Therapy,
Cairo University, Egypt
E-mail: drashraf_pt79@yahoo.com
Keywords:
Diaphragm
&
Costal
Manipulation,
COPD,
Pulmonary
Function, Functional Capacity.

ABSTRACT
Background: Many manual procedures have long been involved in the
management of chronic obstructive pulmonary disease (COPD). Few
literatures evaluated the COPD responses to individual or multiple
manipulative techniques, so effects are unclear and poorly understood.
Aim: to explore ventilatory functions (VF) and functional capacity (FC)
responses to diaphragmatic or costal manipulation or both in COPD
patients. Methods: 195 male patients were randomly assigned into
diaphragmatic manipulation group (group-A; n= 46), rib raising group
(group-B; n= 53), both procedures group (group-C; n= 50) and control group
(group-D; n= 46). Treatment regimens were applied twice weekly for 12
weeks. Forced vital capacity (FVC), forced expiratory volume in one second
(FEV1) and FC (by 6 minute walk test "6MWT") were evaluated before and
after the study. Results: At the end of the study; FVC, FEV1 and 6MWT
mean values and percentages of increases were [3.63 0.56 (4.52%), 2.46
0.51 (14.42 %), 416.35 28.62 (3.82 %)], [3.56 0.38 (5.97 %), 2.43
0.48 (16.63), 415.28 37.81 (3.04 5)] and [3.930.54 (16.92), 2.86 0.5
(33.44 %), 433.03 46.76 (6.9 %)] for group-A, B and C respectively (P <
0.05). There were also significant differences in FVC, FEV1 and 6MWT
mean values between groups at the end of the study but in favor of group-C
(P< 0.05).Conclusions: Diaphragmatic and costal manipulative procedures
are effective therapeutic tools in improving VF and FC in COPD patients
especially if applied together.

INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a
common treatable disorder with progressive, partially
[1,2]
reversible airflow limitation. COPD is characterized by a
[3]
gradual worsening of lung functions and health status.
Globally; COPD is associated with considerable morbidity
and mortality proportion, it is the fifth leading cause of
death in the world; with its mortality rate is expected to
[4]
increase more than 30% during the next 10 years. Even
with recent treatment advances; COPD continues as a
severely debilitating condition that is usually undiagnosed
[5]
until clinical symptoms become apparent. Exercise and
activity intolerance are the two main characteristic features
of COPD patients. Pulmonary, cardiovascular as well as
skeletal muscles dysfunctions are the main underlying
elements in limiting exercise capacity of COPD
[6]
patients. Although patients with COPD can greatly benefit
from exercise training in improving functional capacity (FC)
[7]
for satisfactory long periods, but presence of airflow
limitations and early breathlessness that may limit their FC
[8]
and exercise performance and may be clearly apparent
during low and moderate exercise intensities or even at
rest, directed researchers to seek alternative and
complementary procedures that can effectively and safely
benefit COPD patients. Therapeutic intervention designed
to counteract COPD changes and increase chest wall

compliance (as stretching of the respiratory muscles)can


improve chest wall mobility, improve vital capacity and
[9]
reduce dyspnea. A variety of manual techniques were
introduced to improve pulmonary function (PF),these
techniques are targeting neuronal, lymphatic and
musculoskeletal components of pulmonary system.
Although variety of COPD-related manipulative procedures
are not newly established treatment, but it didn't receive
[10]
adequate attention in the biomedical community section.
Functional capacity and PF were previously used variables
when evaluating the effects of manipulative treatment in
variety of communities, and results were controversial.
Furthermore; the chronic effects of individual manipulative
technique remains unclear. Understanding such effects
could lead to establishment of proper treatment protocols.
Because presence of few studies reporting the influence of
manipulative procedures on COPD; so little information is
available about COPD patients' responses to manipulative
treatment. Furthermore; and up to our knowledge and
available literature - none of them investigated or
compared effects of single and commutative manipulative
procedures on PF and FC in COPD patients. This study
was a trial to explore and compare the responses of the VF
and FC to either diaphragmatic manipulation or rib rising or
both procedures in patients with moderate COPD.

841
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

METERIALS & METHODS


Study design: Experimental (Randomized controlled
study).
Study place: The study was conducted during May 2013
to August 2014 from Sadr Al-Abasia hospital, Egypt.
Ethics approval: This study was conducted in accordance
with Helsinki Declaration principles 1975, revised in 2000
[12]
, was approved by the departmental council and was in
compliance withthe ethics committee's principles of the
Faculty of Physical Therapy, Cairo University. All patients
had a history of smoking but all had stopped smoking. All
patients were initially fully informed about the purpose,
procedures and risks of the study and so an informed
consent was obtained from each patient agreed for
participation and publication of the study results.
Inclusion criteria: Age ranged from 45-65 years, with
moderate COPD (50 % <Forced expiratory volume in first
second "FEV1"<80, Forced expiratory volume in first
second per forced vital capacity FEV1/FVC <70% of
predicted values) and partially reversible airway
obstruction), no clinical evidence of obvious exerciselimiting cardiovascular or neuromuscular diseases. All
participants were sedentary and not involved in previous
rehabilitation program at least 4 months prior to the study,
and had no recent infectious exacerbations for the 2
months preceding the study, with no history of psychiatry
or psychological disorders. Initial medical screening was
performed for each patient prior to the study.
Exclusion criteria: Patients were excluded if they had
significant or unstable cardiac, musculoskeletal or
psychological problems or medication that could affect or
interfere with their performance or affect their safe
participation, any known abdominal pathologies, history of
gastroesophageal reflux of any degree, persistent hiccups
within previous three months, a history of serious injury to
the spine or thorax, including costal or spinal fractures or
history of diaphragm surgery, bronchial asthma or
restrictive lung disease or receiving long-term oxygen
therapy.
Sample size: To avoid type II error, a preliminary power
analysis (power (1- error probability)) = 0.95, = 0.05,
effect size = 0.31) determined a sample size of 184 for this
study to yield realistic results. In this study, included
sample size was 195. To avoid bias; patient randomization
was processed through two stages, first; all patients
fulfilled the inclusion criteria were reported by Three
volunteer physical therapists, they had no other role in the
study.
Grouping: After medical counseling; patients were
randomly assigned into one of the four groups through
opening an opaque envelope prepared by an independent
person-who had no further participation in the study-with
random number generation.
Patients were randomly divided into four groups:
Diaphragmatic manipulation group (group-A; n=46), Rib
rising group (group-B; n=53), Diaphragmatic manipulation
plus rib rising group (group-C; n=50), and Control group
(group-D; n=46).

Subjects: All participants were asked to continue their


drug therapies, regular diet and normal daily activities
throughout the study.
Patients in group-A received diaphragmatic manipulation.
Patients in group-B received rib rising manipulation.
Patients in group-C received both maneuvers. Patients in
group-D underwent evaluations without participation in any
manipulative techniques. The study was conducted during
May to August 2013 and 2014.
Outcome measures: All participants underwent an
identical battery of tests. The evaluated parameters
included FVC in liter, FEV1 in liter and distance covered by
the patient in 6 minutes' walk test (6MWT) in meters.
Evaluations were performed at the beginning and after the
end of the study (after 12 weeks). The assessors were
blinded to the participants treatment assignments and
groups' allocation throughout the study. All subjects' data
were collected using standard laboratory procedures. Body
weight was measured in light indoor clothes to the nearest
0.1 kg and patient standing height without shoes was
measured to the nearest 0.1 cm using calibrated clinical
weight scale and stadiometer. Body mass index (BMI) was
calculated as the weight (kg) divided by the height squared
2
(m ).
Pulmonary Functions Test (PFT) : Ventilatory function
(FVC and FEV1) were evaluated for each patient using
computerized electronic spirometer (ZAN-GP12.00, made
in Germany) while patients were standing. Data were
expressed as a percentage of the predicted values for age,
height, and sex. Full explanation of test procedures was
done for each patient individually in simple terms, with
emphasize on the need for maximum effort from the
participant to gain the best results. All patients were
previously instructed to avoid any kind of stress or heavy
meals prior to the test. Inhalation of bronchodilators
treatment was withheld for at least 12 hours before PF
testing. Spirometry was performed before and 20 minutes
after inhalation of two puffs of 200g salbutamol. The PFT
apparatus was continuously calibrated daily using a 3 liter
syringe. After recording patients' data (name, age, weight,
height, race and sex) in the PFT apparatus, and release of
any tight clothing; the patient stands with thorax in a nearly
vertical way; with the chin elevated slightly and then
connected to flow sensor through a mouth piece that was
held by subject's teeth and firmly enclosed by his lips, then
nose clips was placed around patient's nose. The patient's
then breathe normally for several cycles, then performed a
slow maximal inspiration, followed by a maximum forced
exhalation as much as he can. FVC and FEV1 evaluating
maneuvers were repeated trice, and then the best one was
selected.
Functional capacity evaluation (6MWT): The 6MWT was
conducted according to a standardized protocol.
[13]
Patients were asked to walk at their own maximal pace
from end to end of a 40 meter flat straight corridor marked
every one meter by colored tape on the floor, in order to
cover as much ground as possible while maintaining a
steady pace without running during the allowed time. No
encouragement was given, and subjects were informed
each 2 minutes of the remaining time. The patients were
allowed to stop, but they could start again, if possible,
within the 6 minutes. Distance covered in 6 minutes was
recorded in meter. For patient safety; heart rate were

842
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

monitored during the 6MWT by pulse oximeter (3301; BCI


International Co, Waukesha, WI, USA) as the test was to
be terminate if the patient reaches 85% of their predicted
maximal heart rate "HR max"(220-age). No adverse events
were recorded.
Interventions (Manipulative treatment protocols):
In the study groups-A, B and C; manipulative treatments
were regularly held on a frequency of two sessions per
week between 9 and 11 am. Either diaphragmatic or costal
manipulative procedures were repeated in form of 3 sets of
4 repetitions per each session, with 2 minutes rest between
sets. All patients were directed to maintain deep and quiet
breathing pattern as possible throughout the sessions,
closely monitored during the treatment sessions to exclude
any signs that may interfere with the continuity of the study.
No adverse events or withdrawals were recorded during
the study. All participants completed their prescribed
treatment regimens.
1Diaphragmatic
manipulation:
Diaphragmatic
manipulative procedures were applied in the following
sequences:
1.a- Diaphragmatic release; supine: While the patient
was supine on bed; therapist's fingers' pads applied slow
and steady cephalic pressure on the inferior surface of the
right dome of the diaphragm below the costal arch.
Pressure was maintained throughout the deep and quiet
breathing cycle so that inhalation was resisted "but not
restricted", a slow, gentle upward pressure was applied at
the end of expiration for several cycles. Therapists other
hand was placed on the lower anterior rib cage to stabilize
it. The procedure was applied on one side at a time, and
then repeated on the other side.
1.b- Diaphragmatic release; sitting: The patient was
seated facing a mirror, while the therapist stood behind;
therapist's fingers' pads applied bilateral slow and steady
cephalic pressure on the inferior surfaces of both domes of
the diaphragm below the costal arches throughout the
deep and quiet breathing cycle. Inhalation was resisted
and exhalation was followed by slow, gentle upward
pressure.
1.c- Re-Doming of the diaphragm; supine: While the
patient was supine, therapist stood beside the patient at his
waist level. Therapist's hands were placed antro-laterlly on
either side of patient's lower costal cage, applying bilateral,
simultaneous gentle resistance to thoracic motion while the
patient breathe deeply and quietly. Slow, gentle upward
pressure was done at the end of expiration.
2- Costal/ Rib manipulation: Costal manipulation
procedures were applied in the following sequences:
2.a- Rib rising; supine-i: While the patient was supine on
the bed, maintaining deep and quiet breathing pattern as
possible, therapist stand beside the patient; with his hands
placed under the patient's rib cage (at thoraco-lumber
area). Lateral traction was applied by fingers' pads that
contact posteriorly medial to the ribs' angles; lifting the rib
cage by pushing down on the forearms which were used
as a fulcrum. The procedure was applied on one side, and
then repeated on the other side.
2.b.i- Rib Rising; Sitting: The patient was seated with his
arms extended over the therapist's shoulders who stands
facing him, maintaining deep and quiet breathing pattern
as possible. Lateral pull was applied on the rib cage
bilaterally by therapist's fingers' pads that were articulated

posteriorly medial to the ribs' angles, pulling the patient


forward.
2.b.ii- Rib rising-supine: The patient was supine on the
bed, encouraged to inhale quietly deeply and slowly.
Therapist stand beside the patient at his rib cage level,
stretching the patient's intercostal muscles through
applying passive, gentle raising of patient's arm in a
cephalic direction with one hand while the other therapist's
hand stabilizing the lower antro-lateral aspect of the rib
cage on the same side. The procedure was repeated on
one side, and then repeated on the other side.
3- Control group (D): Forty-six patients underwent
evaluations without participation in any manipulative
program, but were required to lie quietly under the same
circumstances for about 30 minutes, nearly the same
length of time it took to apply the manipulative techniques
to the other groups.
Statistical analysis: Raw data were explored for normality
using the Shapiro-Wilk statistic and measures of skewness
and kurtosis. Statistical analyses were performed using
SPSS software (version 16.0). Data are presented as
mean SD. Mean changes in ventilatory functions and
functional capacity within each group before and after the
study were analyzed using paired t-test. Between-groups
differences were analyzed using analysis of variance
(ANOVA).Percent changes in evaluated variables before
and after interventions were calculated in each group, ChiSquare test was used for comparison of proportions. The
level of significance was set at p < 0.05.
RESULTS
At the pre-study evaluation; there were non-significant
differences in age, body weight, height, BMI,FVC, FEV1
and 6MWT between the four groups (p > 0.05) (Table I).
Data collected from the four groups pre and posttreatments were compared within and between groups.
Forced Vital Capacity (FVC; L): Within-group comparison
revealed that there were significant increase in FVC mean
values between the pre and post-study evaluations by 4.52
2.25 %, 5.97 2.51% and 16.92 10.71% for group A, B
and C respectively (P<0.05), while there was significant
decrease in FVC mean value for group-D (-3.14- 1.27 %)
-19
between the same evaluation points (P=1.2 ) (Table 2).
Between-groups comparison revealed that there were
statistically significant differences in FVC mean values
-9
-38
(P=1.42 ) and FVC mean percent changes (P= 1.1 )
between groups at the post-study evaluations; but in favor
of the group-C, additionally; there was non-significant
difference between group-A and B in FVC mean values
(P= 0.47) and mean percent changes (P= 0.21) (Table 3),
FEV1 (L): Within-group comparison revealed that there
were significant increase in FVC mean values between the
pre and post-study evaluations by 14.42 15.74%, 16.63
0.49% and 33.44 4.31% for group A, B and C
respectively (P<0.05), while there was significant decrease
in FEV1 mean value for group-D (-1.18 2.1-%) between
-4
the same evaluation points (P= 4.85 )(Table 2). Betweengroups comparison revealed that there were statistically
-11
significant differences in FEV1 mean values (P=4.71 )
-49
and FEV1 mean percent changes (P=2.04 ) between
groups at the post-study evaluations; but in favor of the
group-C, furthermore; there was non-significant difference

843
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

between group-A and B in FEV1 mean values (P= 0.75)

and FEV1 mean percent changes (P= 0.17) (Table 3).

Table1: The demographic characteristics of participants


Diaphragmatic
Both
Rib Rising
Character
Manipulation
Procedures
(Group-B)
(Group-A)
(Group-C)
Age (year)
52.52 5.51
53.94 5.57
53.24 5.71
Weight (Kg)
70.3 3.02
69.59 2.89
69.3 3.19
Height(meter)
1.69 0.72
1.68 0.73
1.69 0.05
2
BMI (kg/m )
24.85 2.47
24.25 2.341
24.25 1.54
FVC-Pre (Liter)
3.48 0.55
3.36 0.37
3.38 0.47
FEV1-Pre (Liter)
2.17 0.44
2.09 0.42
2.15 0.38
6MWT-Pre(meter)
401.11 28.4 403.13 37.95
405.06 43.71
FVC/FEV1-Pre(%)
65.85 10.21 62.13 10.81
63.53 6.6
Level of significance at P<0.05. = significant

Control group
(Group-D)

F-Value

P-Value

54.64 5.8
68.93 2.91
1.70 0.63
23.84 1.96
3.36 0.43
2.15 0.38
402.8 39.62
64.12 7.97

1.21
0.09
0.81
2.12
0.7
0.42
0.088
3.84

0.31
0.17
0.49
0.1
0.56
0.74
0.97
1.0

Table 2: Within groups comparison of FVC, FEV1, MVV and 6MWT mean value for the four groups (pre-posttest)
Both
Character
Diaphragmatic
Rib
Rising
Control group
Procedures
Manipulation (Group-A) (Group-B)
(Group-D)
(Group-C)
T-Value
-15-17.84-12.0315.7
FVC (Liter)
-19
-24
-16
-19
4.02
8.01
3.09
1.2
P-Value
T-Value
-5.64-38-36.65-3.77FEV1 (Liter)
-6
-39
-37
-4
1.06
1.31
2.84
4.85
P-Value
T-Value
-60.72-54.54-64.5318.33
6MWT (meter)
-45
-47
-49
-22
8
1.43
4.61
3.23
P-Value
Level of significance at P<0.05. = significant
Table 3: Post-hoc multiple comparisons mean percent changes (between groups) (P value).
Variable
Group
Group-A
Group-B
Group-C
Means
%
Means
%
Means
%
-40
FVC,
Group-B
0.47
0.21
4.703
-21
-4
-18
(FVC %)
Group-C
0.002
7.43
1
2.88
-4
-9
-13
-11
(P value)
Group-D
1.87
1.39
0.001
3.24
4.37
-51
FEV1,
Group-B
0.75
0.17
2.54
-5
-24
-6
-21
(FEV1 %)
Group-C
4.99
7.88
6.98
5.88
-17
-22
-12
(P value)
Group-D
0.001
4.43
0.002
6.71
1.57
-18
-164
6MWT,
Group-B
0.89
1.05
3.6
-92
-111
(6MWT %)
Group-C
0.04
3.23
0.02
1.14
-122
-111
-5
(P Value)
Group-D
0.04
2.1
0.04
3.58
3.3
Level of significance at P<0.05.
in group-D by (0.9 0.3 %) between the same evaluation
-22
points (P= 3.23 ) (Table 2). Between-groups comparison
revealed that there were statistically significant differences
in 6MWT mean values (P=0.001) and 6MWT mean
-162
percent changes (P=2.33 ) between groups at the poststudy evaluations; but in favor of the group-C, furthermore;
there was non-significant difference between group-A and
B in 6MWT mean values (P= 0.892) and 6MWT mean
percent changes (P= 0.08) (Table 3, Figure 1).
DISCUSSION

Fig 1: Percentages of change in FVC, FEV1, and 6MWT


in all groups.
6MWT (m): Within-group comparison revealed that there
were significant increase in 6MWT mean values between
the pre and post-study evaluations by 3.82 0.49%, 3.04 0.52- % and -6.90 0.08- % for group A, B and C
respectively (P<0.05), while there was significant decrease

The purpose of this study was to investigate the effect of


12-weekdiaphragmatic, rib manipulation therapy or both
procedures together on VF and FC in patients with
moderate COPD. The main outcome of this study was that
although COPD patient can significantly benefit from either
diaphragm or rib manipulative treatment, but combined
application of both procedures yielded more beneficial
increase in VF and FC in COPD patients. Results also
clarified that there were non-significant differences in FVC,

844
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

FEV1 and 6MWT mean values between group-A and B at


the end of the study.
Impaired exercise capacity (EC) and reduced health
related quality of life are common features of COPD
[14]
patients. Assessment of FC has gained importance in
understanding the impact of disease and establishment of
COPD-management procedures. The development of
valid and reliable measures of EC in COPD patients
reflects the growing perception of the importance of
monitoring
and
maintaining
EC
in
COPD
[15]
patients. Proper ventilation and functional performance
of the pulmonary system depends mainly on -and is tightly
linked to- the ability of respiratory muscles to respond
[16]
adequately to a given metabolic stress. Many literatures
handled the relationship between good breathing pattern
[17,18, 19, 20, 21]
and health maintenance.
The diaphragm plays
an important role in maintaining efficient quiet breathing
[21]
pattern,
with the normal diaphragmatic contribution to
tidal volume is about two-thirds and three-fourths during
[23]
erect and supine positions.
COPD manifests itself in reduced diaphragm mobility, as
investigated by Yamaguti et al, who objectively evaluated
diaphragm displacement in COPD patients using
ultrasound and found significant reduction in diaphragm
mobility
compared
with
normal
healthy
[24]
subjects. Diaphragm and internal intercostal muscles
abnormalities and hypertonicity are commonly observed
[25]
musculoskeletal changes in COPD patients, resulting in
disturbed
and
dysfunctional
breathing
[17]
pattern. Pathologically increased workload in COPD
[10,17]
results in dysfunction of the diaphragm and rib cage.
Flattening of diaphragm seen in COPD can decrease the
movement of the lower ribs and reduce the efficiency of
respiration, thereby reducing ventilation of the lungs;
[26]
finally producing undesirable health consequences.
Manipulative therapy of the diaphragm increases its
excursion
and
hence
improves
breathing
[22]
mechanics, facilitates bronchial tree lymphatic flow and
[27]
so reduces airways congestion
and beneficially reduce
the hypertonicity of the diaphragm shown in COPD by
[28]
stretching it, so increasing its efficacy during inspiration
[29]
as well as in expiration. Manipulative treatment is
effective in health as well as in disease. Manipulative
treatment significantly improves FVC and FEV1 in normal
[30]
individuals. Manipulative techniques for COPD can
increase thoracic cage and ribs mobility, mobilize thoracic
[31]
spine and so can improve PF; not only in adults but also
[32]
[33]
in pediatrics and postoperative patients. Influences of
manipulative procedures were further evaluated in other
pathological cases, manipulative treatments significantly
improve respiratory parameters in patients with idiopathic
[34]
Parkinson's syndrome.
Studies evaluating the effect of manipulative treatment on
PF in COPD patients have produced variable results.
There were so many published studies in the field of
COPD management; however few studies reported
manipulative treatment as an important and useful
[35]
modality for COPD patients. Majority of available studies
focuses mainly on measuring acute effects of applied
[36]
[37,38,39]
treatment on health
or disease.
Majority of
published studies on the field of utilizing manipulative
procedures in COPD treatment focused on evaluating
acute or immediate effects of either single or multiple

manipulative procedures and results of these studies are


confusing. Reported acute effects floated from no change
[36]
on PF, to symptomatic improvement with mild worsening
[37]
of many lung function parameters, to positive noticeable
[38]
effect in other studies. These conflicting results may be
attributed to study design, different treatment protocols,
small sample size, and over-manipulation. Unfortunately,
the established benefits of manipulative treatment
procedures are relatively marginal and primarily affect
[40]
symptomatic aspects.
In a small sample and short duration study; Miller reported
that manipulative procedures improved FC in COPD
patients, manifested in increased walking distance,
reducing dyspnea after treatment. On the other hand;
there was a worsening of patients residual volume and
[41]
total lung capacity. COPD patients treated with
manipulative procedures can gain significant improvement
in forced expiratory flow at 25%-50% of vital capacity and
at the mid-expiratory phase. Worsening of residual volume
and total lung capacity can be attributed to overmanipulation, utilization of "thoracic lymphatic pump
technique" that resulted in rapid lungs inflation while
COPD patients were not able to fully exhale because of
[38]
the underlying pathology. COPD patients' responses to
sequential manipulation sessions of four weeks interval
were evaluated by Noll et al., and results revealed an
easing of symptoms, worsened PF and increased residual
[39]
volume.
COPD patients benefit greatly from thoracic
spine and chest cage manipulation through reduction in
COPD
symptoms
and
increases
oxygen
[42]
saturation. Beneficial effects of manipulative therapy in
COPD can be also explained on the basis of improvement
of primary and accessory respiratory muscles' fibers, that
in turn can be reflected on better functioning small and
[43]
medium airways.
Few longer duration studies evaluated the effects of
[44,
manipulative treatment and reported beneficial effects.
45]
One can conclude that the length of the study is an
important factor that affects treatment outcomes. Sufficient
time course of manipulative treatment was correlated with
significant improvement in arterial blood gases and PF in
[45]
COPD cases.
Adding to that; the efficacy of
manipulative treatment may be enhanced by using
manipulative procedures in combination, where one
procedure works synergistically with another to achieve
[10]
overall therapeutic effect. The principal limitation of a
multi-technique manipulative treatment is that the
contribution of each technique to the final result is
[37]
unknown;
furthermore; none of these studies clarified
the long-term impact of manipulative treatment on COPD
[40]
patients.
CONCLUSIONS
Functional outcomes of COPD patients may be limited by
pulmonary, musculoskeletal constraints and low functional
capacity. Diaphragmatic or costal manipulation procedures
yielded significant benefits on both pulmonary function and
functional capacity in patients with moderate COPD.
Furthermore; results reported better responses of
pulmonary function and functional capacity to combined
application of both procedures.

845
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

Limitations: Although chronic effects of manipulative


procedures on COPD were evaluated, but still there are a
lack in our knowledge regarding to how extent these
effects will persist. Male gender was another limiting
factor. Further studies are needed to cover areas of
deficiencies in this study. Future studies should include
both genders and to be conducted on a long follow-up
basis.
ACKNOWLEDGMENT: The authors would like to express
their appreciation to all patients for their participation and
cooperation in this study. The authors would like to thank
all the stuff members of the chest and physiotherapy
departments; Sadr Al-Abasia hospital; Cairo; Egypt.
Conflict of Interest: Nil
REFERENCES
1.

Barnes PJ. Chronic obstructive pulmonary disease. N


Engl J Med. 2000; 343:269-280.
2. Global Initiative for Chronic Obstructive Pulmonary
Disease (GOLD). Global Strategy for Diagnosis,
Management
and
Prevention
of
COPD
2014.www.goldcopd.org/uploads/users/files/GOLD_R
eport2014_Feb07.pdf.Accessed November 14, 2014.
3. Shankar PS. Recent Advances in the assessment
and management of chronic obstructive pulmonary
disease: Review article. The Indian Journal of Chest
Diseases & Allied Sciences 2008; 50: 79-88.
4. World Health Organization (WHO), Global status
report on non-communicable diseases 2010. www.
who. int/nmh/ publications/ ncd_report_full_en.pdf.
Accessed November 14, 2014.
5. The American Osteopathic Association. Osteopathic
Physicians' Guide: COPD. USA: Boehringer
Ingelheim Pharmaceuticals Inc.; 2011.
6. Mohamed AA, Mousa GS. Effect of exercise therapy
on blood gases and ventilatory functions in chronic
obstructive pulmonary disease Patients: Randomized
Control Study. J Am Sci. 2012; 8(10):738-746.
7. Rochester CL. Exercise training in chronic obstructive
pulmonary disease. Journal of Rehabilitation
Research and Development 2003; 40(5 Suppl. 2): 5980.
8. Puente-Maestu L, Garcia G, Martinez-Abad Y, Ruiz
JM, Liorente D, Cubillo JM. Dyspnea, ventilatory
system, and changes in dynamic hyperinflation
related to the intensity of constant work rate exercise
in COPD. Chest 2005; 128:651-656.
9. Kakizaki F, Shibuya M, Yamazaki T, Yamada M,
Suzuki H, Homma I. Preliminary report on the effects
of respiratory muscle stretch gymnastics on chest wall
mobility in patients with chronic obstructive pulmonary
disease. Respir Care 1999; 44:409-414.
10. Kuchera
ML,
Kuchera
WA.
Osteopathic
considerations in systemic dysfunction. Dayton, Ohio,
Greyden Press; 1994: 33-52, 198-204.
11. Global Initiative for Chronic Obstructive Lung Disease
(GOLD), 2010. Global strategy for the diagnosis,
management and prevention of chronic obstructive
pulmonary disease. www.goldcopd. org/uploads/
users/files/ GOLD Report_April112011.pdf. Accessed
November 14, 2014.

12. Carlson RV, Boyd KM, Webb DJ. The revision of the
Declaration of Helsinki: past, present and future.
British Journal of Clinical Pharmacology 2004; 75(6):
695-713.
13. Rabinovich RA, Vilar J, Roca J. Evaluation Exercise
Tolerance in COPD Patients: the 6-Minute Walking
Test. Arch Bronconeumol 2004, 40(2): 80-85.
14. Puhan MA1, Bsching G, VanOort E, Zaugg C,
Schnemann HJ, Frey M. Interval exercise versus
continuous exercise in patients with moderate to
severe chronic obstructive pulmonary disease--study
protocol
for
a
randomized
controlled
trial
[ISRCTN11611768]. BMC Pulmonary Medicine 2004;
4: 5-16.
15. Carter R, Holiday DB, Nwasuruba C, Stocks J,
Grothues C, Tiep B. 6-minute walk work for
assessment of functional capacity in patients with
COPD. CHEST 2003; 123:1408-1415.
16. Neder JA, Andreoni S, Lerario MC, Nery LE.
Reference values for lung function tests. II. Maximal
respiratory pressures and voluntary ventilation.
Brazilian Journal of Medical and Biological Research
1999; 32(6): 719-727.
17. Courtney R. The functions of breathing and its
dysfunctions and their relationship to breathing
therapy. International Journal Osteopathic Medicine
2009; 12(3): 78-85.
18. Thomas M, McKinley RK, Freeman E, Foy C.
Prevalence of dysfunctional breathing in patients
treated for asthma in primary care: cross sectional
survey. BMJ 2001; 322:1098-1100.
19. Thomas M, McKinley RK, Freeman E, Foy C, Prodger
P, Price D. Breathing retraining for dysfunctional
breathing in asthma: A randomized controlled trial.
Thorax 2003; 58: 110-5.
20. Chaitow L, Bradley D, Gilbert C. Multidisciplinary
approaches to breathing pattern disorders. London;
Churchill Livingstone; 2002: 51-86.
21. Bartley J, Clifton-Smith T. Breathing Matters: a New
Zealand guide. Auckland: Random House New
Zealand; 2006: 52-56.
22. Hruby RJ. The rib cage. In, Foundations for
nd
osteopathic medicine; Ward RC. 2 edition; 719-720;
London, Lippincott Williams & Wilkins; 2003.
23. Campbell EJ, Agostoni E, Davis JN. The Respiratory
Muscles. Philadelphia, PA, WB Saunders Co; 1970.
24. Yamaguti WP, Paulin E, Shibao S, Chammas MC,
Salge JM, Ribeiro M, et al. Air trapping: The major
factor limiting diaphragm mobility in chronic
obstructive pulmonary disease patients. Respirology
2008; 13(1), 138-144.
25. Sammut EA, Searle-Barnes P. Osteopathic diagnosis.
nd
Great Britain: Antony Rowe Ltd Press; 2002. 2 ed.
26. Ettlinger H. Treatment of the acutely Ill hospitalized
patient. In Ward RC (ed.), Foundations for
nd
osteopathic medicine, 2 ed, 1129. London: Lippincott
Williams & Wilkins, 2003.
27. Degenhardt BF, Kuchera ML. Update on osteopathic
medical concepts and the lymphatic system. Journal
American Osteopathic Association 1996; 96(2): 97100.

846
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

28. Digiovanna FL. Section II: Osteopathic Manipulation;


75-83, Digiovanna F L, Rivera-Martinez S. Section XI:
Systemic consideration; Pulmonary applications; 618624, In DiGiovanna EL, Schiowitz S, Dowling DJ (ed).
An osteopathic approach to diagnosis and treatment,
rd
3 edition, USA, Lippincott Williams & Wilkins, 2005.
29. Wallace E, McPartland JM, Jones JM, Kuchera WA,
Buser BR. Lymphatic system: Lymphatic manipulative
techniques. In Ward RC (ed.), Foundations for
nd
osteopathic medicine, 2
ed., 1056-1077. London:
Lippincott Williams & Wilkins, 2003.
30. Engel RM, Vemulpad S. The effect of combining
manual therapy with exercise on the respiratory
function of normal individuals: a randomized control
trial. J Manipulative PhysiolTher, 2007; 30(7), 509513.
31. Allen TW, D'Alonzo GE. Investigating the role of
osteopathic manipulation in the treatment of asthma.
Journal American Osteopathic Association 1993;
93(6), 654-659.
32. Guiney PA, Chou R, Vianna A, Lovenheim J. Effects
of osteopathic manipulative treatment on pediatric
patients with asthma: a randomized controlled trial.
Journal American Osteopathic Association 2005;
105(1): 7-12.
33. Sleszynski SL, Kelso AF. Comparison of thoracic
manipulation with incentive spirometry in preventing
postoperative atelectasis. J Am Osteopath Assoc.
1993; 93: 834-845.
34. Yao SC, Hart AD, Terzella MJ. An evidence-based
osteopathic approach to Parkinson disease.
Osteopathic Family Physician 2013; 5: 96-101.
35. Seffinger MA, King HH, Ward RC, Jones JM, Rogers
FJ, Patterson MM. Osteopathic philosophy. In Chila
AG, Foundations of Osteopathic Medicine, Wolters
rd
Kluwer Lippincott Wiliams & Wilkins Press; 2011; 3
edition: 3-23. 1.
36. Ortley GR, Sarnwick RD, Dahle RE, Roode TD, Zink
JG, Kilmore MA. Recording of physiologic changes
associated with manipulation in healthy subjects. J
Am Osteopath Assoc. 1980; 80:228-229.
37. Noll DR, Degenhardt BF, Johnson JC, Burt SA.
Immediate Effects of osteopathic manipulative
treatment in elderly patients with chronic obstructive
pulmonary disease. J Am Osteopath Assoc. 2008;
108:251-259.
38. Noll DR, Degenhardt BF, Fossum C, Hensel K.
Clinical and research protocol for osteopathic
manipulative treatment of elderly patients with
pneumonia. J Am Osteopath Assoc. 2008; 108:508516.
39. Noll DR, Johnson JC, Baer RW, Snider EJ. The
immediate effect of individual manipulation techniques
on pulmonary function measures in persons with
chronic obstructive pulmonary disease. Osteopath
Med Prim Care. 2009; 3: 9. http://www.ompc.com/content/3/1/9
40. Miller SJ. Osteopathic principles and practice in
chronic
obstructive
pulmonary
disease.
In
Osteopathic Physicians Guide; COPD; 23- 27;

American
Osteopathic
Association;
USA;
BoehringerIngelheim Pharmaceuticals Inc, 2011.
http://www.osteopathic.org/copd-guide. Miller WD.
Treatment of visceral disorders by manipulative
therapy. In: The Research Status of Spinal
Manipulative Therapy [monograph]. National Institute
of Neurological and Communication Disorders and
Stroke (NINDS), Bethesda, Md. 1975; No.15: 295301.
41. Howell RK, Kappler RE. The influence of osteopathic
manipulative therapy on a patient with advanced
cardiopulmonary disease. J Am Osteopath Assoc.
1973; 73 (4):322-327.
42. Cosmai S. Osteopathic treatment collaborating with
medical therapy to improve the respiratory function of
patients
suffering
from
chronic
obstructive
bronchopneumopathy.
Ph.D
diss.,
Milano:
IstitutoSuperiore
di
Osteopatia,
2003.
http://www.osteopathicresearch.com/paper_pdf/cosm
ai.pdf
43. Zanotti E, Berardinelli P, Bizzarri C, Civardi A,
Manstretta A, Rossetti S, Fracchia C. Osteopathic
manipulative treatment effectiveness in severe
chronic obstructive pulmonary disease: A pilot study.
Complementary Therapies in Medicine 2012; 20: 1622.
44. Howell RK, Allen TW, Kappler RE. The influence of
osteopathic manipulative therapy in the management
of patients with chronic obstructive lung disease. J
Am Osteopath Assoc 1975; 74:757-760.

847
Ashraf et al.,

Int J Med Res Health Sci. 2015;4(4):841-847

Available online at: www.ijmrhs.com

DOI: 10.5958/2319-5886.2015.00168.X

Research article

Open Access

A STUDY ON NEW PATTERNS OF CERVICAL DEGENERATIVE DISEASE AT A


UNIVERSITY HOSPITAL IN WESTERN REGION OF SAUDI ARABIA
1

Mohammed Bangash , Fawaz Almutairi

ABSTRACT

ARTICLE INFO
th

Received: 7 July 2015


Revised: 4th Sep 2015
Accepted: 21st Sep 2015
Author details: 1Associate Professor,
Section
of
Neurological
Surgery,
Department of Surgery, King Abdulaziz
University, P.O Box 42806 Jeddah
21551, Saudi Arabia
2
Medical
student,
Department
of
Surgery, King Abdulaziz University,
Jeddah 21551, Saudi Arabia
Corresponding author: Mohammed
Bangash, Associate Professor, Section
of Neurological Surgery, Department of
Surgery, King Abdulaziz University, P.O
Box 42806 Jeddah 21551, Saudi Arabia
Email: mbangash@kau.edu.sa
Keywords:
Cervical,
Degenerative, Jeddah

Spine,

Introduction: Degenerative cervical spine disorders are referred to one or more of


the following process: decrease in signal intensity of disc, posterior disc protrusion,
anterior compression of spinal cord and dura, disc space narrowing, foraminal
stenosis or osteophytosis. They are asymptomatic in most of the cases. However,
the symptoms may vary between different populations. The aim of this study is to
find out the pattern of degenerative cervical spine disease at King Abdulaziz
university hospital. Material and Method: This was a Retrospective study From
January 2005 to December 2010, the medical files of the patients were reviewed
for demographic data (age and gender), clinical presentation, duration of
symptoms, physical examination and progression of disease, radiological
examinations with evidence of degenerative cervical. The results were presented
in mean standard deviation; the correlation between variables was calculated by
using Spearman's formula for the nonparametric values. Results: A total of 120
cases were reviewed. 63 (52.5%) were females and 57 (47.5%) were males. The
mean age was 55.2 12.8 years. The most common degenerative cervical spine
changes were found at C 5-6 levels. The younger patients tended to have higher
cervical spine level involvement P=0.0. The mean duration of symptoms was
41months. The younger patients tended to present more with the weakness and
numbness p = 0.002, p = 0.005, respectively. 35 (29.1%) of patients found to have
lost reflexes and 17 (14.1%) had exaggerated reflexes. Conclusion: Younger age
group presents with more numbness, weakness and higher level in the cervical
spine involvement. May be the new life style with more use of handheld devices
and bad flexion posture of the neck plays a role in this aspect Further
biomechamical studies need to be conducted to explore the effect of head posture
on the cervical spine. The mean duration of symptoms prior to presentation was 41
months seems to be long, an education campaign need to be conducted to the
community about the degenerative cervical disease risk factors, prevention and
early recognition.

INTRODUCTION
Degenerative cervical spine disorders are referred to one
or more of the following process: decrease in signal
intensity of disc, posterior disc protrusion, anterior
compression of spinal cord and dura, disc space
[1]
narrowing, foraminal stenosis
or osteophytosis. Aging
process plays a significant role in the pathogenesis of
[1]
cervical spine degeneration . They are asymptomatic in
[3]
most of the cases . It can be hereditary in 73% of cases
[2]
[3;4]
, or sport related
,
The pathophysiology of cervical degenerative disease may
be multifactorial with both dynamic factors and static
factors that will lead to stenosis resulting in repetitive injury
[5]
to the spinal cord .
In United States a population study at Rochester, Minn,
shows the annual incidence of cervical radiculopathy for
men and women from all causes is 107.3 and 63.5 cases
[6]
per 100,000 populations, respectively . Another study
from Italy in 1996 reported a prevalence of cervical
radiculopathy from spondylosis as 3.5 cases per 1000
[7]
people .
In this study, we aim to study patterns of cervical
degenerative disease at King Abdulaziz University

hospital (KAUH) in Western region of Saudi Arabia as


we found that there is a lack of studies regarding this
subject in Middle east and Saudi Arabia.
MATERIAL & METHOD
Study design: We conducted a retrospective descriptive
study.
Ethical approval: The research ethics committee at King
Abdulaziz University approved the research project.
Places of study: The study was done at King Abdulaziz
University hospital between January 2005 to December
2010.
Inclusion criteria: All included patients were presented at
our hospital with cervical degenerative disease.
Exclusion criteria: Patients with cervical spine trauma,
infection or neoplasm were excluded.
Methodology: The Patients' demographic data (age and
gender), clinical presentation, duration of symptoms,
physical examination and progression of disease were
reviewed, radiological examinations with evidence of
degenerative cervical diseases (such as disc bulge,
protrusion or herniation, osteophyte formation, cervical
stenosis, spondylolisthesis, facet arthropathy and

848
Bangash et al.,

Int J Med Res Health sci. 2015;4(4):848-851

spondylosis) were studied. A total of 120 samples were


eligible for the study. All cervical spines MRI were reported
by a KAUH neuroradiologist. The treatment and outcome
were beyond the scope of this study.
Statistical analysis: The results were presented in mean
standard deviation; the correlation between variables
was calculated by using Spearman's formula for the
nonparametric values. The results were presented with
the P value significance and the 95% confidence interval.
A P value of < 0.05 was considered significant. All the
statistical analysis was performed using IBM Corp. SPSS
Statistics for Windows, Version 21.0.
RESULTS
A total of 120 patients were included, 63 (52.5%) were
females and 57 (47.5%) were males.
Age: The mean age was M= 55.212.8 years. The mean
age for females was 58.8912.65 years. The mean age for
males was 51.1611.87 years. There is a significant
correlation between the gender and age r = 0.254, n =
120, p = 0.005. (Figure 1)
The level involves: The most common level involved was
C5-6 39 (32.5%) with a mean age of 5611.6 years,
followed by C6-7 level 30 (25%) with mean of age involved
for this level of 56.913.6 years. There was a significant
correlation between the patients' age and the level
involved r = 0.222, n = 75, p = 0.05 (figure 2), where the
younger patients tended to have higher cervical spine level
involvement. (Table 1)
There was no significant correlation between the gender
and the level involved r = 0.076, n = 75, p = 0.516
Duration of symptoms: The mean duration of symptoms
prior to presentation was 41 25.6(5,180) months. (Fig 3)
There was a significant correlation between the level
involved and the duration of symptoms prior to
presentation r = 0.34, n = 63, p = 0.006. Where the higher
levels involved in the cervical spine tended to present later
than the lower levels.
Laterality: 21 (17.5%) patients had their symptoms on the
right side, 12 (10%) had their symptoms on the left side
and 48 (40%) involved bilateral sides. There was no
significant gender correlation with the laterality of the
degenerative disease r = 0.092, n = 81, p = 0.414.
Pain and radiation: All patients were presented with neck
pain, 84(70%) patients were presented with radiation.
Weakness: the number of patients presented with history
of weakness was 48(40%), there was a significant
correlation between the age and the weakness r = 0.339, n
= 81, p = 0.002, where the younger patients tended to
present more with the weakness.
Numbness: There were 57(47.5%) patients presented
with limb(s) numbness. There was a significant correlation
between the age and the presentation with numbness r =
0.254, n = 120, p = 0.005, the younger patients presented
more with numbness.
History of chronic illness: The total number of patients
had diabetes mellitus (DM) was 30 (24.8%). There was a
positive correlation between the history of DM and the
history of numbness r = 0.43, n = 84, p = 0.001, weakness
r = 0.233, n = 78, p = 0.04 and finding out the abnormal
reflexes r = 0.21, n = 93, p = 0.044.

The total number of patients gave history of hypertension


(HTN) was 45 (37.2%). There was a positive correlation
between the history of HTN and the history of radiating
pain r = 0.289, n = 105, p = 0.003, numbness r = 0.33, n =
87, p = 0.002, weakness r = 0.386, n = 81, p = 0.001 and
finding out the abnormal reflexes r = 0.353, n = 96, p =
0.001. There was no correlation between the gender and
the DM (p = 0.196) or HTN (p = 0.131).
Power: With regard the examination of power, 36(30%)
patients were found to have weakness of muscle power.
There was no significant correlation between the muscle
weakness on the examination and the age (P= 0.572),
gender (P= 0.185), level of the cervical spine involved (P=
0.927) or duration of symptoms (P= 0.702).
Abnormal sensory examination: 30(25%) patients were
found to have abnormal sensation.
There was no significant correlation between the abnormal
sensation on the examination and the age (P= 0.457),
gender (P= 0.411), level of the cervical spine involved (P=
0.579) or duration of symptoms (P= 0.152).
Abnormal reflexes: The number of patients found to have
normal reflexes on the examination was 57 (47.1%). The
number of patients found to have lost reflexes was 35
(29.1%) and exaggerated reflexes 17 (14.1%). There was
no significant correlation between the gender and the
abnormal reflexes p = 0.8. While there was a correlation
between the age and the abnormal reflexes p = 0.004, the
older age (>70 years) tended to have hyperreflexia more
than the younger age group.
Table1: The correlation between different studied
factors with the corresponding significance
Factor A

Age

Gender
level
involved

Factor B

r value

P value

Gender

0.254

120

0.005

level involved
history of
weakness
history of
numbness

0.222

75

0.05

0.339

81

0.002

0.254

120

0.005

level involved
Abnormal
reflexes
duration of
symptoms

0.076

75

0.516

0.26

96

0.01

0.34

63

0.006

Fig1: the mean age in relation to the gender

849
Bangash et al.,

Int J Med Res Health sci. 2015;4(4):848-851

Fig 2: the mean age with the corresponding involved


level

Fig 3: the duration of symptoms in months for all


patients
DISCUSSION
The prevalence and incidence of cervical disease due to
degeneration of the spine are estimated at a minimum of
605 and 41 per million in North America, respectively.
Incidence of cervical spondylotic myelopathy-related
hospitalizations has been estimated at 4.04/100,000
[8]
person-years, This cervical degenerative disease usually
produces intermittent neck pain in middle-aged and elderly
[9]
patients
. The clinical presentation of the cervical
degenerative disc disease can be easily grouped into axial
[10]
pain, radiculopathy and myelopathy . The axial neck pain
is the most common presenting symptoms that is proven in
this article where all the patients presented with this type
of pain. The radiculoapthy refers to the compression of the
nerve root that results in radiating pain in the shoulder and
upper extremity. This can be associated with sensory and
motor changes in the affected limb. Cervical myelopathy
refers to compression of cervical spinal cord with the
resultant pain and upper motor neuron lesion below the
level of the compression. The current article focuses on
the common clinical features among patients presenting to
King Abdulaziz University Hospital as an initial step to find
out the people at risk in order to prevent this problem in
the population, From the age prospective, the mean
distribution of age is 52.2 years with greater females
involvement that is in line with other studies showing the
[11;12]
same findings
. One of the striking feature of this
study is the presentation of younger age group with more
numbness, weakness and higher level in the cervical spine
involvement. Can this be explained by the new life style

with more use of handheld devices and bad flexion


posture of the neck? A few studies published about this
point that could be a significant contributor to the
development of degenerative cervical disease in the future
[13-16]
. Further biomechamical studies need to be
conducted to explore the effect of head posture on the
cervical spine. Another explanation on younger age
involvement with numbness and weakness can be related
to more medical education level for this age group with
early recognition of warning symptoms and thus seeking
medical advices, this concept is recognized in oncology
[17],
however, it can be the case in symptomatic
degenerative cervical disease. The level of the
populations knowledge about degenerative cervical
disease need to be studied in the future.
The higher levels involved in the cervical spine tend to
present later than the lower levels, this can be related to
decreasing diameter of the cervical spinal canal going from
[18]
higher to lower levels , so, the presence of degenerative
changes will produce symptoms faster than the higher
level where the canal can accommodate extra masses
prior to compressing the neural element.
The mean duration of symptoms prior to presentation was
41 months seems to be long, however, it is similar to the
[19]
duration of symptoms reported before
. To avoid long
[20]
term poor outcome , an education campaign need to be
conducted to the community about the degenerative
cervical disease risk factors, prevention and early
recognition. The most common level involved was C5-6
[21;22]
has been reported before in other studies
.
The limitations of this study are: the retrospective design,
relative small sample and single center experience. A
prospective and multicenter study is needed in the future.
CONCLUSION
Younger age group presents with more numbness,
weakness and higher level in the cervical spine
involvement. May be the new life style with more use of
handheld devices and bad flexion posture of the neck
plays a role in this aspect Further biomechamical studies
need to be conducted to explore the effect of head posture
on the cervical spine. The mean duration of symptoms
prior to presentation was 41 months seems to be long, an
education campaign need to be conducted to the
community about the degenerative cervical disease risk
factors, prevention and early recognition.
Conflict of interest: The authors declare no actual or
potential conflict of interest including any financial,
personal or other relationships with other people or
organizations that could inappropriately influence, or be
perceived to influence, their work.
Acknowledgement: The authors would like to thank Mrs.
Maha Daffa in medical records for her great help in
collecting the data for this article.
REFERENCES
1.
2.

Lestini WF, Wiesel SW. The pathogenesis of cervical


spondylosis. Clin Orthop Relat Res. 1989;(239):69-93
Sambrook PN, MacGregor AJ, Spector TD. Genetic
influences on cervical and lumbar disc degeneration:

850
Bangash et al.,

Int J Med Res Health sci. 2015;4(4):848-851

3.

4.

5.

6.

7.

8.

9.
10.

11.

12.

13.

14.

15.

16.

17.

18.

a magnetic resonance imaging study in twins. Arthritis


Rheum. 1999;42(2):366-72
Kartal A, Yildiran I, Senkoylu A, Korkusuz F. Soccer
causes degenerative changes in the cervical spine.
Eur Spine J. 2004;13(1):76-82
Triantafillou KM, Lauerman W, Kalantar SB.
Degenerative disease of the cervical spine and its
relationship to athletes. Clin Sports
Med.
2012;31(3):509-20
Lebl DR, Hughes A, Cammisa FP, Jr., O'Leary PF.
Cervical spondylotic myelopathy: pathophysiology,
clinical presentation, and treatment. HSS J. 2011
Jul;7(2):170-8
Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland
LT. Epidemiology of cervical radiculopathy. A
population-based study from Rochester, Minnesota,
1976 through 1990. Brain. 1994;117 ( Pt 2):325-35
Salemi G, Savettieri G, Meneghini F, Di Benedetto
ME, Ragonese P, Morgante L, et al. Prevalence of
cervical spondylotic radiculopathy: a door-to-door
survey in a Sicilian municipality. Acta Neurol Scand.
1996 Feb;93(2-3):184-8
Nouri A, Tetreault L, Singh A, Karadimas SK, Fehlings
MG.
Degenerative
Cervical
Myelopathy:
Epidemiology, Genetics, and Pathogenesis. Spine
(Phila Pa 1976 ). 2015 Jun 15;40(12):E675-E693
McCormack BM, Weinstein PR. Cervical spondylosis.
An update. West J Med 1996 Jul;165(1-2):43-51.
Rao R. Neck pain, cervical radiculopathy, and cervical
myelopathy: pathophysiology, natural history, and
clinical evaluation. Instr Course Lect. 2003;52:479-88
Fay LY, Huang WC, Wu JC, Chang HK, Tsai TY, Ko
CC, et al. Arthroplasty for cervical spondylotic
myelopathy: similar results to patients with only
radiculopathy at 3 years' follow-up. J Neurosurg
Spine. 2014 Sep;21(3):400-10
Landriel FA, Hem S, Goldschmidt E, Ajler P, Vecchi E,
Carrizo A. Polyetheretherketone interbody cages
versus autogenous iliac crest bone grafts with anterior
fixation for cervical disc disease. J Spinal Disord
Tech. 2013 Apr;26(2):61-7
Hansraj KK. Assessment of stresses in the cervical
spine caused by posture and position of the head.
Surg Technol Int. 2014 Nov;25:277-9
Newell RS, Siegmund GP, Blouin JS, Street J, Cripton
PA. Cervical vertebral realignment when voluntarily
adopting a protective neck posture. Spine (Phila Pa
1976 ). 2014 Jul 1;39(15):E885-E893
Zemp R, Taylor WR, Lorenzetti S. In vivo spinal
posture during upright and reclined sitting in an office
chair. Biomed Res Int. 2013;2013:916045
Visscher CM, de BW, Naeije M. The relationship
between posture and curvature of the cervical spine. J
Manipulative Physiol Ther. 1998 Jul;21(6):388-91
Mor V, Masterson-Allen S, Goldberg R, Guadagnoli E,
Wool MS. Pre-diagnostic symptom recognition and
help seeking among cancer patients. J Community
Health. 1990 Aug;15(4):253-66
Yukawa Y, Kato F, Suda K, Yamagata M, Ueta T.
Age-related changes in osseous anatomy, alignment,
and range of motion of the cervical spine. Part I:

19.

20.

21.

22.

Radiographic data from over 1,200 asymptomatic


subjects. Eur Spine J. 2012 Aug;21(8):1492-8
Sadasivan KK, Reddy RP, Albright JA. The natural
history of cervical spondylotic myelopathy. Yale J Biol
Med. 1993 May;66(3):235-42
Machino M, Yukawa Y, Ito K, Inoue T, Kobayakawa A,
Matsumoto T, et al. Risk factors for poor outcome of
cervical laminoplasty for cervical spondylotic
myelopathy in patients with diabetes. J Bone Joint
Surg Am. 2014 Dec 17;96(24):2049-55
Park DH, Ramakrishnan P, Cho TH, Lorenz E, Eck
JC, Humphreys SC, et al. Effect of lower two-level
anterior cervical fusion on the superior adjacent level.
J Neurosurg Spine. 2007 Sep;7(3):336-40
Peterson CK, Humphreys BK, Pringle TC. Prevalence
of modic degenerative marrow changes in the cervical
spine. J Manipulative Physiol Ther. 2007 Jan;30(1):510

851
Bangash et al.,

Int J Med Res Health sci. 2015;4(4):848-851

Available online at: www.ijmrhs.com

DOI: 10.5958/2319-5886.2015.00169.1

Research article

Open Access

CORRELATION BETWEEN ANTHROPOMETRY, BIOCHEMICAL MARKERS AND


SUBJECTIVE GLOBAL ASSESSMENT DIALYSIS MALNUTRITION SCORE AS
PREDICTORS OF NUTRITIONAL STATUS OF THE MAINTENANCE
HEMODIALYSIS PATIENTS
1

Vanitha Rani N , S. Kavimani , Soundararajan P , Chamundeeswari D , Kannan Gopal

ARTICLE INFO
th

Received: 12 July 2015


th
Revised: 30 Aug 2015
th
Accepted: 27 Sep 2015
Authors details:
1
Lecturer, Department of Pharmacy Practice,
4
Principal,
Faculty
of
Pharmacy,
Sri
Ramachandra University Chennai, Tamilnadu,
India
2
Professor
&
Head,
Department
of
Pharmacology, Mother Theresa Post Graduate
and Research Institute of Health Sciences,
Pondicherry.
3
Professor & Head, Department of Nephrology,
Sri Ramachandra Medical Center, Chennai
5
Professor & Head, Department of Pharmacy
Practice, Saastra College of Pharmaceutical
Education and Research, Nellore
Corresponding author: N. Vanitha Rani
1
Lecturer, Department of Pharmacy Practice,
Faculty of Pharmacy, Sri Ramachandra
University. Chennai, Tamilnadu, India
Email: vanithak9@rediffmail.com
Keywords:
SGA-DMS,
Anthropometry,
Nutritional status, Hemodialysis, Iron, Ferritin,
Transferrin, Albumin

ABSTRACT
Background: Protein energy malnutrition is the major cause of poor prognostic
outcome in patients on maintenance hemodialysis (MHD). The assessment of
nutritional status in patients on maintenance hemodialysis should be done both
subjectively and objectively by integrating clinical, biochemical and anthropometric
measurements. A study was conducted to assess the possible correlations
between the subjective global assessment-dialysis malnutrition score (SGA-DMS),
anthropometric measurements, and biochemical parameters in hemodialysis
patients. Methods: The study included 90 patients (55 males and 35 females; age
range of 25 to 73 years; mean age 52.62 11.7 years) undergoing twice/thrice
weekly maintenance hemodialysis for six months and above in the dialysis unit of
a tertiary care teaching hospital. The MHD patients were assessed by SGA -DMS,
anthropometry and biochemical indicators (serum albumin, iron, ferritin and
transferrin) of nutritional status. Results: According to the SGA-DMS 54.4 % were
moderate to severely malnourished, 31% were mild to moderately nourished and
14.4% were well nourished. There was a highly significant negative correlation
between SGA DMS and serum albumin, iron, transferrin; positive correlation
between SGA-DMS and ferritin (P<0.0001). Body mass index, upper arm
circumferences, and skin fold thickness had a highly significant negative
correlation with SGA-DMS (P<0.001), where as the lean body mass, total body
water and the fat free mass had a significant negative correlation (P<0.05).
Conclusion: SGA-DMS correlated with anthropometric and biochemical
parameters that are indicative of nutritional status. SGA DMS used in
conjunction with other objective nutritional assessment methods may be of greater
impact in determining nutritional status of hemodialysis patients.

INTRODUCTION
Protein energy malnutrition (PEM) is highly prevalent in
patients on maintenance hemodialysis (MHD) and is
strongly associated with poor clinical outcomes in these
[1]
patients. Dietary restriction, increased protein catabolism
due to inflammatory cytokines, anorexia, uremic toxins and
metabolic acidosis as well as a decrease in anabolic
hormones, contribute to malnutrition in chronic
[2]
hemodialysis patients. Assessment of nutritional status is
often ignored in many dialysis centers while periodical
assessment of the nutritional status by simple methods
could have a beneficial impact on the patients. Hence it
should be part of the follow-up of dialysis patients, and is
fundamental for preventing, diagnosing and treating PEM.
Early detection and management of PEM plays a pivotal
role in reducing complications and mortality in patients on
[3]
MHD.
According
to
the
National
Kidney
Foundation/Dialysis Outcome Quality Initiative Guidelines
(National Kidney Foundation, 2002), the assessment of
nutritional status in CKD patients on MHD should be made
by integrating clinical, biochemical and anthropometric
[4]
parameters. The anthropometric measurements includes
measurement of body mass index, lean body mass, skin
fold thickness, mid arm circumference (MAC) and mid arm
[5,6]
muscle circumference (MAMC).

Subjective global assessment Dialysis malnutrition score


(SGA-DMS) is a fully quantitative reproducible instrument
[7, 8]
for assessing the nutritional status of dialysis patients.
Among the biochemical markers serum albumin and
transferrin have been proved to be useful indicators of
[9]
PEM. Several factors, such as altered protein synthesis,
over
hydration,
reduced
protein
intake,
bowel
malabsorption and protein losses (as during nephrotic
syndrome) influence plasma albumin concentrations, thus
making hypoalbuminemia a marker of PEM. Transferrin,
with a half-life of 7 8 days, rises in iron deficiency, whilst
its decrease indicates iron overload or inflammation.
Compared to serum albumin, serum transferrin is a more
sensitive marker (due to its short half life) of nutritional
[10]
status, and of the visceral protein pool.
Serum ferritin is frequently used as a marker of iron status
in patients on hemodialysis. According to National Kidney
Foundation (NKF) Kidney Disease and Dialysis Outcome
Quality Initiative guidelines, serum ferritin level >800ng/ml
in MHD patients may reflect iron overload. However, serum
ferritin is an acute phase reactant and a better indicator of
inflammation which is closely related to PEM in dialysis
[11, 12]
patients.
This study was conducted to determine the
prevalence of PEM in MHD patients using the SGA-DMS
and to analyze possible correlations between SGA-DMS

852
Vanitha et al.,

Int J Med Res Health Sci. 2015;4(4):852-856

and different indicators of nutritional status including the


anthropometric measurements and biochemical markers of
malnutrition.
MATERIALS AND METHODS
A cross-sectional study was conducted in 90 patients,
aged above 18 years, diagnosed with stage V Chronic
Kidney Disease,
undergoing twice or thrice weekly
maintenance hemodialysis for 6 months and above in the
dialysis unit of a tertiary care teaching hospital, after
obtaining the approval of the Institutional Ethics Committee
and the informed consent of the patients. Patients with
inflammatory diseases, smoking history, acute illness, long
term therapy with steroids and immunosuppressant, known
malignancies, patients on once weekly maintenance
hemodialysis (MHD) and patients on enteral or parenteral
nutrition were excluded from the study. On initiation, data
including demographics, medical history and duration of
dialysis was obtained from patients cases records and
direct history interview of the patients. The assessment of
nutritional status was done by Subjective Global
Assessment-Dialysis Malnutrition score (SGA-DMS).
SGA-DMS is a fully quantitative scoring system consisting
of seven features: weight change, dietary intake,
gastrointestinal symptoms, functional capacity, co
morbidity, subcutaneous fat and signs of muscle wasting.
Each component has a score from 1(normal) to 5 (very
severe). Thus the malnutrition score (sum of all seven
components) is a number between 7(normal) to 35
(severely malnourished). A lower score denotes normal
nutritional status and a higher score is an indicator of the
presence of malnutrition elements, that is the higher the
SGA-DMS the stronger the tendency towards protein
[7]
energy malnutrition.
Anthropometric Indices:
The following measurements were performed between 1020 minutes after termination of dialysis session.
2 [13]
1. Body mass index (dry body weight in kg/ height in m )
Dry body weight is the weight obtained by the end of
dialysis without causing hypotension and /or cramps.
2. Mid arm circumference (MAC) was measured with a
plastic tape on the non dialysis access arm for three times
and average result of the three measurements was taken
[14]
as final measurement
3. Triceps skin fold thickness (TSF) was measured with a
conventional skinfold caliper (Harpenden caliper) on the
non-dialysis access arm using standard techniques for
three times and average result of the three measurements
[15]
was taken as final measurement
4. Mid arm muscle circumference (MAMC) is a measure for
muscle mass in the body measured together with the
triceps skinfold assuming that the measured muscle
circumference is representative for the rest of the body. It
[15]
was calculated using the following equation
MAMC (cm)
= MAC -3.1415 triceps skin fold thickness
5. Mid arm muscle area (MAMA) is an estimation of the
area of the bone and muscle portions of the upper arm. It
[16]
was calculated using the formula

MAMA = [Mid arm circumference (cm) (3.14 TSF cm)]


- 10 (males) or - 6.5 (females)
4
6. Mid arm fat area (MAFA) [16]:
2
MAFA = (MAC TSF)/2 (TSF) /4
7. Lean body mass (LBM) is an estimation of difference
between the total body mass (weight in kg) and weight
[17]
of the body fat. LBM was obtained using the formula
LBM in kgs (men) = (1.10 Weight (kg)) 128 (Weight
2
2
/ (100 Height (m)) )
LBM in kgs (women) = (1.07 Weight (kg)) 148
2
2
(Weight / (100 Height (m)) )
8. Ideal Body weight (IBW) was calculated using Devine
[18]
formula
IBW in kgs (men) = 50 kg + 2.3 kg * (Height (in) - 60)
IBW in kgs (women) = 45.5 kg + 2.3 kg *(Height (in) 60)
9. Total body water (TBW) gives the Urea volume of
distribution. It is calculated from the formula by Watson
[19]

Male TBW (liters) =2.447 - (0.09156 x age) + (0.1074 x


height) + (0.3362 x weight)
Female TBW (liters) = - 2.097 + (0.1069 x height) +
(0.2466 x weight)
The biochemical parameters estimated for the study
population after the dialysis session included serum
albumin, iron, ferritin and transferrin by routine laboratory
methods.
Statistical Analysis:
The analysis was performed using SPSS 16.0 version.
Categorical variables were expressed as frequency and
percentage and Continuous variables were expressed as
mean standard deviation. The statistical analysis of
differences in the anthropometric indices and the
biochemical markers of the case population with respect to
their nutritional status as per SGA-DMS were done using
One way ANOVA with Tukey's Post-Hoc test. Pearsons
correlation was done to assess the strength of association
between the anthropometric indices, biochemical
parameters and the SGA-DMS. A P value of < 0.05 was
considered statistically significant.
RESULTS
The study was conducted in 90 patients (55(61%) males
and 35(39%) females) undergoing twice/thrice weekly
maintenance hemodialysis. The age range of the study
population was 18 to 73 years and the mean age was 52.62
11.7 years. Majority of the patients were in the age range
of 46 to 55 (39%) and above 55 years (42%). The mean
dialysis vintage of the study population was found to be
20.99 12.08 months. The primary causes of renal disease
in the study population were diabetic nephropathy in 43.3%
patients, hypertensive nephropathy in 30%, polycystic
kidney disease in 12.2 %, glomerulonephritis in 10%
pyelonephritis in 3.4% and neurogenic bladder in 1.1%
patients.
The overall mean SGA-DMS score was found to be 19.71
7.5. Based on the SGA-DMS, 49 (54.4 %) patients were
moderate to severely malnourished with a score range of

853
Vanitha et al.,

Int J Med Res Health Sci. 2015;4(4):852-856

21 to 35 (mean score 25.55 3.8), 28 (31%) patients were


mild to moderately malnourished with a score range of 11
to 20 (mean score 14.50 3.23) and 13 (14.4%) patients
were well nourished with a score range of 7 to 10 (mean
score 8.92 1.15) .
The mean values of the anthropometric indices and the
biochemical markers of the nutritional status of the study
population based on the SGA-DMS are expressed in Table
1. There was a statistically significant difference in the
mean body mass index, triceps skin fold thickness, mid arm
circumference, mid arm muscle circumference, mid arm
muscle area and mid arm fat area of the study population
based on their nutritional status as per the SGADMS(P<0.05). The mean body mass index, dry body
weight, lean body mass, ideal body mass, total body water,
fat free mass and the total body fat were also found to be
higher in well nourished patients than the moderately and
severely malnourished patients but the differences were not

statistically significant. The mean values of serum albumin,


iron and transferrin were found to decrease with respect to
the increase in the SGA-DMS (P<0.001). The serum ferritin
levels were found to increase with an increase in the SGADMS (P<0.001) reflecting the inflammatory status in
malnourished patients.
There was a significant negative correlation between the
anthropometric indices BMI, triceps skinfold thickness, mid
arm circumference, mid arm muscle circumference, mid
arm muscle area, mid arm fat area, lean body mass, fat
free mass and the mean SGA - DMS. The anthropometric
parameters were significantly lower for the patients with
higher SGA-DMS values. The mean ideal body mass, total
body water and total body fat had no correlation with the
SGA - DMS. Serum albumin, iron and transferrin had a
statistically significant negative correlation with SGA-DMS
and serum ferritin had a highly significant positive
correlation with SGA-DMS (P<0.001) (Table 2).

TABLE 1 - ANTHROPOMETRY AND BIOCHEMICAL MARKERS OF NUTRITIONAL STATUS AS PER SGA-DMS


Parameters
Mean SD
Significance
P
Well
Mild
to
Moderately Moderate
to
Severely
nourished
malnourished
malnourished
(n=13)
(n=28)
(n=49)
Dry body weight (kg)

55.06 8.02

51.87 11.89

0.157

Body Mass Index (kg/m )

57.71

10.03
23.34 3.39

22.11 2.59

20.63 3.59

0.02*

Mid arm circumference (cm)

22.25 2.27

21.49 1.94

18. 65 4.27

< 0.0001**

Mid
arm
muscle
circumference (cm)
Triceps skin fold thickness
(mm)
2
Mid arm muscle area (cm )

18.46 1.53

18.05 1.47

15.82 3.23

< 0.0001**

12.01 2.67

10.96 1.92

9.27 3.47

0.004*

27.35 4.5

26.09 4.18

20.59 8.23

< 0.0001**

Mid arm fat area (cm )

12.42 3.89

10.99 2.78

8.56 4.79

0.004*

Lean Body mass (kg)

46.85 6.31

45.68 6.97

42.27 9.17

0.141

Ideal body mass (kg)

55.04 8.43

54.38 9.33

53.71 6.49

0.782

Total body water (L)

31.92 3.87

31.89 4.41

30.44 5.46

0.381

Fat free mass (kg/m )

44.33 5.37

44.29 6.17

42.27 7.58

0.385

Total body fat (kg)

10.36 3.42

9.46 2.18

8.24 2.37

0.261

Serum albumin (g/dL)

3.44 0.562

3.66 0.34

3.26 0.431

< 0.0001**

64.84 17.78

0.002**

374 .19 186. 08

0.003*

170.16 39.09

< 0.0001**

88.92
75.43 24.40
32.72
261.36
277.5 70.43
Serum ferritin (ng/mL)
72.95
237.69
202. 29 35.93
Serum transferrin (mg/dL)
35.16
** P<0.001- highly significant; *P<0.05- significant
Serum iron (g/dL)

854
Vanitha et al.,

Int J Med Res Health Sci. 2015;4(4):852-856

TABLE 2- CORRELATION BETWEEN SGA-DMS AND


ANTHROPOMETRY BIOCHEMICAL MARKERS OF
NUTRITIONAL STATUS
Variable
Pearson
P value
Correlation (r)
Body
Mass
Index -0.463
<0.001**
2
(kg/m )
Mid arm circumference -0.597
<0.001**
(cm)
Mid
arm
muscle -0.585
<0.001**
circumference (cm)
Triceps
Skin
fold -0.518
<0.001**
thickness (mm)
Mid arm muscle area -0.586
<0.001**
2
(cm )
2
Mid arm fat area (cm )
-0.529
<0.001**
Lean Body mass (kg)
-0.318
0.002*
Ideal body mass (kg)
0.059
0.58
Total body water (L)
-0.204
0.054
2
Fat free mass (kg/m )
-0.210
0.047*
Total body fat (kg)
-0.164
0.12
Serum albumin (g/dL)
-0.435
<
0.001**
-0.428
<
Serum iron (g/dL)
0.001**
0.618
<
Serum ferritin (ng/mL)
0.001**
- 0.486
<
Serum
transferrin
0.001**
(mg/dL)
** P<0.001 - highly significant; *P<0.05 - significant

severe malnutrition and the albumin levels negatively


correlated with the SGA-DMS. The systemic inflammatory
response can present as an important cause of protein
wasting in chronic renal disease by causing anorexia and
[22-26]
increase protein catabolism.
Most biochemical markers such as serum albumin or
transferrin are useful in identifying patients with
deteriorating nutritional state. Kalantar Zadeh et al, also
suggested that transferrin values are superior to other
biochemical markers in assessing nutrition and will
supplement SGA criteria. They also suggested that serum
ferritin may be useful as a predictor of inflammation
[26]
associated PEM.
There are multiple causes of
malnutrition in HD patients. An ideal protocol for early
diagnosis of PEM in these patients has not yet been
formed. Hence, a combination of valid complementary
measures is to be adopted to assess the nutritional status
in maintenance dialysis patients rather than any single
measure alone to obtain a better clinical outcome.
Limitations of the study: Small sample size and cross
sectional study design.
CONCLUSION
Patients on maintenance hemodialysis have moderate to
severe protein energy malnutrition. The present study
showed the correlation between SGA-DMS and some
biochemical and anthropometric indices of malnutrition.
Therefore, we conclude that SGA- DMS when used with
objective methods may be of greater significance in
determining nutritional status of hemodialysis patients.
ACKNOWLEDGMENT

DISCUSSION
Nutritional assessment is a vital function of healthcare
providers. The nutritional status of hospitalized patients can
be assessed by a variety of methods. Subjective Global
Assessment Dialysis Malnutrition Score (SGA -DMS) is a
fully quantitative nutritional status assessment tool which is
widely used in patients on maintenance hemodialysis both
in clinical practice and in research.
In the present study, based on the SGA-DMS, 31.1% of the
patients were mild to moderately and 54.4% were moderate
to severely malnourished. A study conducted by Janardhan
et al, reported that 91% of patients on MHD were mild to
[20]
moderately malnourished.
Similarity Faintuch et al, also
reported severe malnutrition in 13% of their study
[21]
population.
In this study, SGA-DMS negatively correlated with
anthropometric measurements such as body weight, body
mass index, TSF and MAC and biochemical parameters
such as serum albumin, iron and transferrin. KalantarZadeh et al, found that SGA-DMS was significantly
correlated with anthropometric parameters like MAMC,
MAC, BMI, TSF and TIBC. A study done by Janardhan et
[20]
al, also reported the same.
Serum albumin has frequently been used as a marker of
nutritional status. In the present study, like many other
studies a statistically significant lower level of serum
albumin was observed in HD patients with moderate to

The authors wish to thank Mrs. B. Kundhala, Lecturer,


Department of Clinical Nutrition, Sri Ramachandra
University, Chennai, for her guidance in anthropometric
assessments and SGA-DMS interpretations.
Conflict of Interest: Nil
REFERENCES
1.

2.

3.

4.

5.

Bonanni A, Mannucci I, Verzola D, Sofia A, Saffioti S,


Gianetta E, et al. Protein-energy wasting and mortality
in chronic kidney disease. Int J Environ Res Public
Health 2011;8:1631-54
Ekim M, Ikinciogullari A, Ulukol B, Bakkaloglu SA,
Ozkaya N, Kendirli T, et al. Evaluation of nutritional
status and factors related to malnutrition in children on
CAPD. Perit Dial Int 2003;23:557-62.
Locatelli F, Fouque D, Heimburger O. Nutritional status
in dialysis patients: A European consensus. Nephrol
Dial Transplant 2002;17:563-72.
National Kidney Foundation. K/DOQI clinical practice
guidelines for chronic kidney disease: evaluation,
classification, and stratification. Am J Kidney Dis 2002;
39:Suppl. 1, S1266.
Chumlea WC. Anthropometric and body composition
assessment in dialysis patients. Seminars in Dialysis
2004;17(6):466-70.

855
Vanitha et al.,

Int J Med Res Health Sci. 2015;4(4):852-856

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Stenvinkel P, Barany P, Chung SH, Lindholm B,


Heimbrger O. A comparative analysis of nutritional
parameters as predictors of outcome in male and
female ESRD patients. Nephrol Dial Transplant
2002;17(7):1266-74.
Kalantar-Zadeh K. Kleiner M, Dunne E, Lee GH, Luft
FC. A modified quantitative subjective global
assessment of nutrition for dialysis patients. Nephrol
Dial Transplant 1999;14: 1732-38.
Kalantar-Zadeh K, Kopple JD, Block G, Humphreys
MH. A malnutrition-inflammation score is correlated
with morbidity and mortality in maintenance
hemodialysis
patients.
Am
J
Kidney
Dis
2001;38(6):1251-63.
Lowrie EG, Lew NL. Death risk in hemodialysis
patients:the predictive value of commonly measured
variables and an evaluation of death rate differences
between facilities. American Journal of Kidney
Diseases 1999; 15:45882.
Memoli B, Guida B, Saravo MT, Nastasi A, Trio R,
Liberti R, et al. Predictive and diagnostic factors of
malnutrition in hemodialysis patients. G Ital
Nefrol. 2002;19(4):456-66.
National Kidney Foundation. Kidney-Dialysis Outcome
Quality Initiative. K/DOQI clinical practice guidelines:
anemia. Am J Kidney Dis 2001; 37; 1
Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM,
Kopple
JD.
Malnutrition-inflammation
complex
syndrome in dialysis patients: causes and
consequences. Am J Kidney Dis 2003;42(5):864-81.
Must A, Dallal GE, Dietz WH. Reference data for
th
obesity: 85 percentiles of body mass index (wh/ht2)
and triceps skin fold thickness. Am J Clin Nutr
1991;53:839-46.
Heymsfied SM, McManus C, Smith J, Stevens V,
Nixon DW. Anthropometric measurements of muscle
mass: revised equations for calculating bone-free arm
muscle area. Am J Clin Nutr 1982; 36: 68090.
Frisancho A. new norms of upper limb fat and muscle
areas for assessment of nutritional status. Am J Clin
Nutr 1981;34:2540-45.
Frisancho AR. (Ed) In: Anthropometric Standards for
the Assessment of Growth and nutritional Status.
University of Michigan Press, 1990.
Hallynck TH, Soep HH, Thomis JA, Boelaert J,
Daneels R, Dettli L, et al. Should clearance be
normalized to body surface or to lean body mass ?. Br
J Clin Pharmacol 1981;11:523-6.
Halls MD. "About Arithmatic Formulas Calculating Ideal
Body Weight". Available at: http://halls.md/ideal-weightformulas-broca-devine/ (Retrieved 2014-02-15).
Watson PE, Watson ID, Batt RD. Total body water
volumes for adult males and females estimated from
simple anthropometric measurements. Am J Clin Nutr
1980;33:27-39.
Janardhan, V, Soundararajan P, Rani NV, Kannan G,
Thennarasu P, Chacko R A, Reddy C U M. Prediction
of Malnutrition Using Modified Subjective Global
Assessment-dialysis Malnutrition Score in Patients on
Hemodialysis. Indian J Pharm Sci 2011; 73(1):3845.

21. Faintuch J, Morais AAC, Silva MAT, Vidigal EJ, Costa


RA, Lyrio DC, et al. Nutritional profile & inflammatory
status of haemodialysis patients. Renal Failure
2006;28:295-301.
22. Kaysen GA, Don BR. Factors that affect albumin
concentration in dialysis patients and their relationship
to vascular disease. Kidney Int (suppl) 2003;84:94-7.
23. Suliman ME, Qureshi AR, Stenvinkel P, Pecoits-Filho
R, Barany P, Heimburger O. Inflammation contributes
to low plasma amino acid concentrations in patients
with chronic kidney disease. Am J Clin Nutr
2005;82(2):342-9.
24. Rasic-Milutinovic R, Perunicic G, Pljesa S, Gluvic Z,
Ilic M, Stoki E. Metabolic syndrome in HD patients:
association with body composition, nutritional status,
inflammation
and
serum
iron.
Intern
Med
2007;46(13):945-51.
25. Kaysen GA. Inflammation, nutritional state and
outcome in end stage renal disease. Miner Electrolyte
Metabol 1999;25:242-50.
26. Kalantar-Zadeh, Kleiner M, Dunne E, Ahern K, Nelson
M, Koslowe R, et al. Total iron-binding capacityestimated transferrin correlates with the nutritional
subjective global assessment in hemodialysis patients.
Am J Kidney Dis 1998;31(2):263-72.

856
Vanitha et al.,

Int J Med Res Health Sci. 2015;4(4):852-856

Available online at: www.ijmrhs.com

DOI: 10.5958/2319-5886.2015.00170.8

Research article

Open Access

EFFECT OF WEEKLY IRON SUPPLEMENTATION ON IRON INDICES IN


PREGNANT WOMEN
1

Bagchi Sipra , Sah Shanti , Alwadhi Kimmi , Goel J.K.

ARTICLE INFO
Received: 14th July 2015
Revised: 24th Aug 2015
Accepted: 30thSep 2015
1
Authors
details:
MD, Assistant
2
Professor; MS, Assistant Professor;
3
MS, Senior Resident; 4MS, Professor &
Head
Dept.
of
Obstetrics
and
Gynaecology, SRMS Institute of Medical
Sciences, Bareilly, Uttar Pradesh, India

Corresponding author: Bagchi Sipra


MD, Assistant Professor, Dept. of
Obstetrics and Gynaecology, SRMS
Institute of Medical Sciences, Bareilly,
Uttar Pradesh, India
Email: drsiprabagchi@gmail.com
Keywords: Iron deficiency anaemia,

Weekly iron supplementation, Iron


indices

ABSTRACT
Introduction: The serum iron and ferritin concentrations decline after
midpregnancy. The amount of dietary iron, together with that mobilized from
stores, will be insufficient to meet the average demands imposed by
pregnancy. Without supplementation, the haemoglobin concentration and
hematocrit fall appreciably as the blood volume increases leading to iron
deficiency anaemia (IDA). Aims & objectives: To compare effectiveness of
weekly supplementation of 200 mg elemental iron with daily supplementation
of 100 mg elemental iron on iron indices along with haemoglobin and
hematocrit values in pregnant women. Materials & Methods: A prospective
randomised longitudinal study was conducted at a tertiary care teaching
hospital. Study included 100 pregnant women randomly allocated to two
groups. Group I (n=50) received daily iron and group II (n=50) received
weekly iron supplementation. During follow-up haemoglobin and hematocrit
values were estimated at 4, 8 , 12 and 16 weeks of iron supplementation. Iron
indices: serum iron, total iron binding capacity (TIBC) and serum ferritin were
estimated before and after 12 and 16 weeks of iron supplementation.
Results: Significant increase in haemoglobin, hematocrit and serum iron
levels was ovserved in both the groups (p < 0.001) but on intergroup
comparison it was significantly higher in group I than group II (p < 0.001).
Serum ferritin improved in both the groups but improvement was not
significant in weekly supplemented group. Compliance was better and sideeffects were less in group II as compared to group I (11.36% versus 39.9%).
Conclusion: The weekly supplementation with 200 mg of elemental iron of
pregnant women had desired effect on iron indices except for the serum
ferritin level which can be overcome by extending the supplementation to the
post-partum period.

INTRODUCTION
Iron deficiency anemia is one of the most common
nutritional disorders and presents as a widespread public
health problem in the world and especially in developing
[1]
countries including India . In India 62-88% pregnant
[2,3]
women suffer from anaemia
. Approximately 80% of all
[4]
anemias in pregnancy occur due to iron deficiency .
[5,6]
Anemia is associated with poor pregnancy outcome , in
the form of preterm birth, low birth weight, inability to
tolerate haemorrhage during labour leading to increase
incidence of infection etc.
In India despite the effort of the National anemia
prophylaxis programme since 1970 to supplement all
pregnant women with daily iron and folic acid, anaemia
[2,3]
still continues unabated . The reasons for the limited
success of iron supplementation are unclear but poor
compliance because of the related gastrointestinal side
effects of medicinal iron is commonly cited as an important
constraint.
In recent years, oral iron supplementation program has
been focused from daily doses to intermittent doses (once
or twice weekly). Many studies have been conducted in
various parts of world and most of the studies showed that
the increase in hemoglobin level were similar to daily
supplementation.
The hypothesis behind intermittent iron supplementation
has been based on mucosal block theory of iron

[7]

absorption . The gut has a mechanism to prevent entry of


excess iron in the body. The mucosal cells absorb iron on
the basis of iron requirement of the body. The iron
reaching inside the mucosal cell is either transported to
plasma or oxidized to ferric form and complexed with
apoferritin to form ferritin. This ferritin generally remains
stored in the mucosal cells and is lost when they are shed
(gut mucosal turnover rate 3-4 days). This is called the
[4]
ferritin curtain
. The iron status of body and
erythropoietic activity govern the balance between these
two processes.
Though iron requirement during the first trimester is
reduced but in the second and third trimesters it rises to
[8]
between 4 and 6 mg, respectively . During the last 6-8
weeks of pregnancy the iron requirement may rise up to
10 mg/d because of significant change in the red blood
[
cell mass that starts in the middle of the second trimester
9- 11]
.
The phenomenon of hemodilution during pregnancy
results in reduced hemoglobin concentration. As a result
of increased requirement during pregnancy both serum
iron and ferritin concentrations decrease and TIBC
[12-14]
increases
.
There is a moderate drop in the concentration of serum
[15]
iron that stabilizes in the middle of pregnancy
.
However there is steady rise in total iron-binding capacity

857
Bagchi et al.,

Int J Med Res Health Sci. 2015;4(4):857-860

during pregnancy to approximately 50% above normal.


There is some evidence that serum ferritin rises modestly
early in pregnancy, presumably because of reduced
[9,15]
erythropoietic activity; thus, iron is diverted to store
.
Thereafter, however, the serum ferritin concentration
drops steadily to approximately 50% of normal at midterm.
These changes reflect hemodilution and the mobilization
of iron from stores to meet the increased demands of
pregnancy.
The present study was conducted to determine and
compare the effects of daily versus weekly iron
supplementation on iron indices at different duration of
supplementation.
MATERIALS AND METHODS
Study design: This was a randomized prospective
longitudinal study.
Ethical approval: Study was conducted in the department
of Obstetrics and Gynaecology for one year duration; it
was approved by ethical committee of research
department of our institution. Inform consent was taken
from the participants.
Inclusion criteria: apparently healthy pregnant women of
16 to 22 weeks of gestation with haemoglobin level
between 9.0 g/dl to 11.0 g/dl were included in the study.
Exclusion criteria: Women with multiple pregnancy,
haemoglobin level < 9.0 g/dl or > 11.0 g/dl, with chronic
systemic disorder or with any high risk factor were
excluded.
Grouping: A total of hundred women were recruited and
randomly allocated to two groups: Group I (Daily iron
Supplementation, n=50) and Group II (Weekly iron
Supplementation, n=50).
Methodology: All the subjects were matched for age,
parity, socioeconomic status and baseline anthropometry
i.e. height, weight and BMI (body mass index). A detailed
history was obtained and complete physical examination
done on all the women.
group I were given daily dose of 100 mg elemental iron
and 1.5 mg folic acid and group II received once a week
200 mg of elemental iron and 3.0 mg folic acid . Subjects
were provided iron tablets every month according to group
allocated. All women were advised to show empty blister
packs before issuing the drug for next month to ensure
proper compliance.
They were subjected to routine antenatal investigations
along with baseline complete haemogram and iron indices
(serum iron, total iron binding capacity, serum ferritin).
Serum iron was measured using bathophenanthroline
[16]
method
Estimation of Total Iron Binding Capacity
(TIBC) was done using magnesium carbonate. Serum
ferritin was measured using enzyme immunoassay
method (Mfg. by Syntron Bioresearch Inc. USA).
All the women were given antihelminthics. Subjects in
Haemoglobin & hematocrit values were estimated 4
weekly upto 16 weeks of iron supplementation. Iron
indices were estimated after 12 weeks and 16 weeks of
iron supplementation. On every visit subjects were asked
about any side effects related to iron intake, like heart
burn, nausea, vomiting, diarrhoea, constipation etc.
Statistical analysis: For comparing difference in a
variable at two different time intervals paired 't' test was

used. For comparing the proportions Chi-square ( ) test


was used.
A difference between two groups was
considered significant for ' p' value <0.05.
RESULTS
Initially 100 women were enrolled, 50 in each group.
However complete data were available for 89 women; 45
in group I and 44 in group II. Majority of subjects belonged
to 16-18 weeks, 19-21 weeks of gestational age and few
patients of 22-24 weeks of gestation.
The base line haematological values including iron indices
did not have any statistically significant difference in both
the groups. Intergroup 'p' values for serum iron, TIBC,
serum ferritin were 0.815, 0.724 and 0.333 respectively.
The haemoglobin (Hb) level increased to a significant level
(Table 1) in weekly supplemented group after 12 weeks of
supplementation (p=0.0015) and also at the end of
supplementation i.e. After 16 weeks of supplementation
(p<0.001). Though the increase in haemoglobin levels in
daily supplemented group was significantly more than
weekly group (p=0.008). The improved levels in weekly
supplemented group could not be ignored.
The hematocrit (Hct) values increased in weekly group to
a significant level as in daily group. Upto 12 weeks of
supplementation there was no significant difference in
both groups ('p' value 0.20) but after 16 weeks of
supplementation, the increase in daily group was
significantly higher than weekly group('p' value <0.001).
This pattern depicts the effect of hemodilution on
hematocrit values and inference is that even after iron
supplementation the hematocrit values remained almost
same (Group II) or there was slight increase (Group I).
The serum iron values have no significant difference
(p=0.067) in both groups after 12 weeks of
supplementation but after 16 weeks of supplementation
there was significant difference (p<0.001) in Group I and
Group II showing more increase in Group I.TIBC values
increased after 12 weeks of supplementation in both
groups. As TIBC increases when there is more iron
demand than the amount of iron absorbed. Thereafter
there was fall in both Group I and Group II after 16 weeks
of supplementation. But the fall was more in Group I
indicating more improvement in iron status of patients. As
Table 2 shows, there was significant difference in TIBC
values after 16 weeks of supplementation in both Group I
(p=0.0004) and Group II (p=0.038).
Though there was increase in S. ferritin levels in both
Group I and Group II but it was more in Group I and the
difference was statistically significant both after 12 weeks
of supplementation (p<0.001) and after 16 weeks of
supplementation (p<0.001). Serum ferritin values
increased to a significant level (p<0.001) only in Group I,
there was no significant increase in Serum ferritin values
in Group II (p value 0.0661).
Side effects and compliance was also tested in this study
and it was found that 40% of patients in daily group
experienced negative side effects like nausea/vomiting,
diarrhoea, constipation and heart burn; contrary to only
11.36% in weekly group. The difference was significant
(p=0.002).

858
Bagchi et al.,

Int J Med Res Health Sci. 2015;4(4):857-860

Table 1: Hematological values at the beginning and after 12 weeks and 16 weeks of supplementation period
Study groups

Baseline

12 weeks of
supplementation

16 weeks of
supplementation

Difference*

't' value*

'P'
value*

Group I (n=45)
GroupII (n=44)

10.22+0.59
10.29+0.71

11.04+0.45
10.76+0.69

11.45+0.55
11.07+0.64

1.23
0.78

9.76
5.064

<0.001
<0.001

Group I (n=45)

32.19+2.04

35.87+2.30

37.58+2.34

5.39

11.211

<0.001

GroupII (n=44)
32.94+2.46 34.81+1.76
* difference is between initial and 16 weeks values

35.63+1.99

2.69

5.244

<0.001

Hb
(g/dL)
Hct
(%)

Table 2: Iron indices at the beginning and after 12 weeks and 16 weeks of supplementation period
Study groups

Baseline

12 weeks of
supplementation

16 weeks of
supplementation

Difference*

t' value*

'P'
value*

Serum iron
(g/dL)

Group I (n=45)

79.06+33.55

105.16+25.01

134.50+19.37

55.44

9.599

<0.001

Group II (n=44)

77.85+35.79

93.43+34.13

107.01+29.98

29.16

4.143

<0.001

TIBC
(g/dL)

Group I (n=45)

549.33+166.33

608.11+119.05

440.91+105.32

-108.42

3.6943

0.0004

Group II (n=44)

528.75+146.98

629.85+175.37

464.54+139.52

-64.21

2.102

0.038

Serum
ferritin
(g/dL)

Group I (n=45)

50.05+29.68

82.42+30.09

117.44+20.22

67.39

12.588

<0.001

Group II (n=44)

58.82+36.36

58.92+26.49

70.70+24.08

12.21

1.861

0.0661

* difference is between initial and 16 weeks values


[20]

DISCUSSION
The present study aimed to evaluate the effect of weekly
compared with daily iron supplementation on iron indices
along with haemoglobin and hematocrit values in
pregnant women who attended the antenatal clinic, at our
hospital.
Though in our study the haemoglobin rise was more
significant in daily group, it increased to a significant level
[Table 1 (p<0.001)] in weekly group too and was
[17]
maintained to a safe level. In study by Mumtaz et al.
too, the hemoglobin rose to a significant level in weekly
group (p=0.0037).
The serum iron values increased to a significant level in
both groups but increase in daily group was significantly
more than weekly group (p<0.001). Similarly the TIBC
values increased up to 12 weeks of supplementation
thereafter there was fall in TIBC values which was
significant in both groups but in daily group the change
was significantly more than weekly group (p<0.001).
Serum ferritin value which is a sensitive indicator of iron
storage did not increase to a significant level (p=0.0661)
in weekly group but in daily group the increase was
significant (p<0.001). Similar results were found in the
[17]
study by Mumtaz et al.
where the serum ferritin level
increased to a significant level in daily group (p<0.001)
whereas in weekly group it did not change (p=0.16). In the
[18]
study by Sunil Gomber et al.
the ferritin values
continued to be remain low during pregnancy irrespective
of supplementation (p=0.63 within groups and p=0.40
between groups). In the study by A. Mukhopadhyay et al.
[19]
the baseline S. ferritin values were significantly
different in both groups (p=0.027) with a lower value in
weekly groups. There was no significant increase in S.
ferritin values in both daily (p=0.477) and weekly group
(p=0.680). Intergroup p values was 0.10. In study by

Ridwan et al.
, there were no significant within group
changes in serum ferritin concentrations. But a small
decrease in the weekly group together with a small
increase in the daily group, however caused a small but
significant difference between groups in treatment effect
[21]
(p=0.049). In study by SMZ Hyder et al. the baseline S.
ferritin values were higher in weekly group (p=0.06).
There was no significant difference in S. ferritin values at
6 weeks post-partum in both the groups. But in anaemic
subset of women a significantly (p<0.01) larger increment
in the daily regimen was observed than in the weekly at 6
weeks post-partum (Table-3).
Table 3: S. Ferritin levels in the two intervention
groups in different studies
Daily supplementation
Study

A.
Mukhopad
hyay et
al.18
Sunil
Gomber et
al.17*
Ridwan et
al.19
Mumtaz
etal.16
SMJ Hyder
et al.20**
Present
study

Initial
S.ferritin
(g/dl)

Final
S.ferritin
(g/dl)

18.41+21.9 27.7+19.8

Weekly
supplementation
Initial
Final
S.ferritin
S.ferritin
(g/dl)
(g/dl)
23.2+20.5

20.5+16.9

2.93

2.84

2.69

2.67

28.0+19.2

27.7+19.8

23.2+20.5

20.5+16.9

23.8+29.7

41.6+34.9

23.0+33.7

27.6+31.5

12.4

57.6

20.3

57.3

50.0+29.7

117.4+20.

58.82+36.4

71.04+24

* The data in this study was provided after logarithmic


conversion
** Final values were taken at 6 weeks postpartum
So, we can say that though Hb raised to a significant level
in weekly supplemented group in most of the studies but
S. ferritin values showed a variable change. S. Ferritin

859
Bagchi et al.,

Int J Med Res Health Sci. 2015;4(4):857-860

values increased to a significant level in the daily group in


[18]
most of the studies (except study of Sunil Gomber et al.
[20]
and Ridwan et al. ) but in weekly supplemented group
it either did not change or decreased.
Though, under experimental conditions (as discussed
earlier), the increase in haemoglobin or serum ferritin
levels was lower with weekly supplementation than with
daily supplementation, the positive implication for largescale intervention may compensate for this.

10.
11.

12.

CONCLUSION
It can be concluded from this study that supplementation
of pregnant women once per week with 200 mg of
elemental iron is an effective option for prophylaxis in mild
anaemic or non-anaemic pregnant women in terms of
hematologic response
including iron indices under
conditions resembling routine antenatal care. Although
iron stores as indicated by S. ferritin were improved but
the improvement was not significant in weekly
supplemented group. This was probably because of
increased demands during pregnancy which outstripped
the supply. This can be overcome by extending the
supplementation to the post-partum period.
ACKNOWLEDGEMENT

13.

14.
15.

16.

17.

Authors appreciate and thank the department of patholgy


and the lab staff for their help and immense support. We
are also grateful to all those authors whose articles are
cited and included in references of this manuscript.
18.
REFERENCES
1.

2.

3.

4.

5.

6.

7.
8.

9.

Galloway R, McGuire J. Determinants of compliance


with iron supplementation: supplies, side effects or
psychology? Soc. Sci. Med. 1994; 39: 381-90.
Indian Council of Medical Research: Evaluation of the
National Nutritional Anemia prophylaxis program.
New Delhi, ICMR, 1989.
Indian Council of Medical Research Supplementation
trial in pregnant women with 60 mg, 120 mg and 180
mg iron with 500 g of folic acid. New Delhi, ICMR,
1992; 641.
The World Health Report: Conquering suffering,
enriching humanity 1998 WHO Geneva: World Health
Organization;1997
Scholl TO,Hediger ML,Fischer RL,Shearer JW.
Anaemia vs. iron deficiency: increased risk of preterm
delivery in a prospective study. American J Clin Nutr.
1992; 55: 985-8.
Murphy JF, Newcombe RG, O'Riordan J, Colis EC,
Pearson JF. Relation of hemoglobin levels in first and
second trimesters to outcome of pregnancy. Lancet
1986; 1: 992-4.
A. Jacobs. Iron absorption . J Clin Pathol Suppl (R
Coll Pathol). 1971; 5: 5559
FAO. 1988.Requirements of vitamin A, iron, folate
and vitamin B12. FAO Food and Nutrition Series No.
23, Rome, Food and Agriculture Organization.
Hallberg L, Hulten L. Iron requirements, iron balance
and iron deficiency in menstruating and pregnant

19.

20.

21.

women. In: Hallberg L, Asp N-G eds. Iron Nutrition in


health and disease, London, George Libbey, 1996;
165-82.
Lund CJ, Donovan JC. Blood volume in pregnancy.
Am J Obstet Gynecol 1967; 98: 393-03.
Hallberg L. Iron balance in pregnancy and lactation.
In: Foman SJ, Zlotkin S Eds. Nutritional anemias.
New York, Raven Press, 1992; 13-28.
Svanberg B, Arvidsson B, Norrby A, Rybo G, Slvell
L. Absorption of supplemental iron during pregnancy
a longitudinal study with repeated bone marrow
studies and absorption measurements. Acta Obstet
Gynecol Scand Suppl. 1975; 48: 87-08.
DeLeeuw NK, Lowenstein L, Hsieh YS. Iron
deficiency and hydremia in normal pregnancy.
Medicine(Baltimore) 1966 Jul; 45: 291-15.
Fenton V, Cavill I, Fisher J. Iron stores in pregnancy.
Br J Haematol. 1977; 37: 145-9.
Kaufer M, Casanueva E. Relation of prepregnancy
serum ferritin levels to haemoglobin levels throughout
pregnancy. Eur J Clin Nutr 1990; 44: 709-15.
Peters,T.,T.J.Giovanniello,
L.APT,
and
J.F.Ross.1956b.A simple improved method for the
determination
of
serum
iron,PartII.Lab.Clin.Med.48:280-88.
Zubia Mumtaz, Saqib Shahab, Naila Butt, M Abdur
Rab and Aime De Muynik. Daily iron supplementation
is more effective than twice weekly iron
supplementation in pregnant women in Pakistan in a
randomized double-blind clinical trial. Journal of
Nutrition 2000; 130: 2697-02.
Sunil Gomber, KN Agarwal, Charu Mahajan and N
Agarwal. Impact of daily versus weekly hematinic
supplementation on Anemia in pregnant women.
Indian Pediatrics 2002; 39: 339-46.
Mukhopadhyay A, Bhatla Neerja, Kriplani Alka,
Pandey RM, Saxena R. Daily versus intermittent iron
supplementation in pregnant women : Hematological
and pregnancy outcome. Journal of Obstetrics &
Gynaecology Research Dec. 2004; 30 (6):409-17.
Ridwan E, Schultink W, Dillon D, Gross R. Effects of
weekly iron supplementation on pregnant Indonesian
women are similar to those of daily supplementation.
Am J Clin Nutr 1996; 63: 884-90.
Ziauddin Hyder SM, Persson LA, AMR Chowdhury,
BO Lnnerdal and Eva-Charlotte Ekstrm. Impact of
daily and weekly iron supplementation to women in
pregnancy and pueperium on hemoglobin and iron
status six weeks post-partum: results from a
community based study in Bangladesh. Scandinavian
Journal of Nutrition 2003; 47(1): 19-25

860
Bagchi et al.,

Int J Med Res Health Sci. 2015;4(4):857-860

Available online at: www.ijmrhs.com


Research article

DOI: 10.5958/2319-5886.2015.00171.X
Open Access

ETIOLOGY AND TREATMENT OUTCOME OF PEDESTRIANS WITH TRAUMATIC


BRAIN INJURIES FROM ROAD TRAFFIC CRASHES
1

Nnadi, Mathias O N FWACS, FMCS, Bankole, Olufemi B FWACS, Fente Beleudanyo G FWACS, FMCS
2

ARTICLE INFO
Received: 26th Jul 2015
Revised: 10th Sep 2015
Accepted: 29th Sep 2015
Authors details:
1
Division of Neurosurgery, Department
of Surgery, University of Calabar
Teaching Hospital, Calabar, Nigeria.
2
Neurosurgical Unit, Department of
Surgery, Lagos University Teaching
Hospital, Lagos, Nigeria
3
Department of Surgery, Niger Delta
University Teaching Hospital, Okolobiri,
Bayelsa State, Nigeria
Institution the work is credited:
Division of Neurosurgery, Department of
Surgery, University of Calabar Teaching
Hospital, Calabar, Cross River State,
Nigeria.
Corresponding
author:
Nnadi,
Mathias, Division of Neurosurgery,
Department of Surgery, University of
Calabar Teaching Hospital, Calabar,
Nigeria.

Email: nnadimon@yahoo.com

ABSTRACT

Context: That unconscious man on the road being taken into the
ambulance was knocked down by a vehicle. The energy he absorbed from
the impact was proportional to the weight of the vehicle with its occupants,
and to the square of the velocity of the vehicle. That is a regular scenario
for the most unprotected and the most vulnerable road user, the pedestrian.
The need to know about him and protect him cannot be overemphasized.
Objective: To determine the etiologies, severity of traumatic brain injuries
and treatment outcome in pedestrians involved in road traffic accident.
Methods: It was a prospective, cross-sectional study involving pedestrians
with traumatic brain injuries from road traffic accidents managed in our
center over a four year period. Data were collected using structured
proforma which was component of our prospective data bank that was
approved by our hospital research and ethics committee. The analysis was
done using Environmental Performance Index (EPI) info 7 software. Result:
Seventy three patients were studied. There were 48 males. The mean age
was 25.08 years. Elderly patients were three. Fifty five patients had
vehicular accident. Twenty two patients were injured between 6AM and
10AM. Thirty two patients had mild head injuries. Favorable functional
outcome was seen in 82.19%, while mortality was 17.81%. Severity of
injury significantly affected the outcome. Conclusion: Our study showed
that the commonest cause of traumatic brain injuries in pedestrians was
vehicular accident. The mortality from traumatic brain injuries among
pedestrians was high. Severity of injury significantly affected the outcome.

Keywords: Pedestrian, road traffic

accident, Treatment outcome


INTRODUCTION
Road traffic accident is one of the leading causes of
mortality and morbidity in the world with an estimated
mortality of 1.2 million and morbidity of 5million people
[1,2]
yearly all over the world.
Human factor has been the
most prevalent contributing factor for road traffic
[3,4]
accident.
Crashes between vehicles and pedestrian
had been documented to be responsible for over a third of
[5]
all traffic-related deaths and injuries worldwide. The
commonest cause of death among pedestrian was
[6]
traumatic brain injury. We studied pedestrians with
traumatic brain injuries from road traffic accidents
managed in our center over a four year period.
METHODS
Study design: It was a descriptive prospective, crosssectional study
Ethical approval & inform consent: It was component of
our prospective data bank that was approved by our
Research and Ethics Committee.
Inclusion criteria: Pedestrians with traumatic brain
injuries managed in our neurosurgical center.
Exclusion criteria: Patients we could not ascertain the
etiology, especially those picked up along the roads by

security agents in the night, were excluded from the study.


Those discharged against medical advice were also
excluded.
Sample size: Sample size was calculated using Fishers
2
2
formulae: n=Z pq/d and nf = n/1+n/N. With prevalence of
23%, the calculated sample size was 72.
Research work place & duration: The study was done at
st
University of Calabar Teaching Hospital, Calabar from 1
st
August, 2010 to 31 July, 2014.
Methodology:
The patients were managed using our unit protocols:
Patients were managed in accident and emergency using
Advanced Trauma Life Support (ATLS) protocols, primary
and secondary surveys. In primary surveys, patients were
resuscitated ensuring patent airways and Oxygen
saturation of 95% and above. We used Normal saline to
maintain blood volume aiming at euvolemia and
normotension. We gave adequate analgesia, antiepileptic
drugs in post-traumatic seizures, and calm aggressive
patients with Chlorpromazine. Quick checks of other organ
injuries that could be life threatening to patients were
made. In secondary survey, we took detailed history and
physical examinations. Glasgow Coma Scores after
resuscitation were assessed. Appropriate investigations
were carried out based on need and affordability.

861
Nnadi Mathias et al.,

Int J Med Res Health Sci. 2015;4(4):861-864

Patients who had mild, moderate, and severe head


injuries with CT scan lesions not requiring surgery, and
those unable to do CT scan were managed nonoperatively. We gave broad spectrum antibiotics (to those
who had open tissue injuries), multivitamins, high energy
and high protein diets constituted thus: 500ml pap, 2
tablespoonful powdered milk, 1 tablespoonful red oil, 2
tablespoonful soya bean powder and 1 tablespoonful
crayfish powder. The diet was given 5-6 times daily via
naso-gastric tubes or orally. Their daily fluid requirements
were calculated and factored into the fluid content of the
diet. We used locally prepared diet because most of our
patients could not afford Complan or Casilan, and there
was no functional dietetic unit in the hospital.
Patients with lesions requiring surgery such as extradural,
subdural, and intracerebral hematomas/contusions, and
depressed skull fractures had surgical care. Surgical
procedures included craniotomy for acute extradural,
acute subdural and intracerebral hematomas/contusions,
Burr hole for sub-acute and chronic subdural hematomas,
and craniectomy with primary bone fragment replacement
or elevation for depressed skull fractures. Superficial
temporal artery pseudoaneurysm had excision.
Associated injuries were managed by appropriate
specialist units. After their discharge, we followed them up
in out-patient clinic. Data were collected using structured
proforma which was component of our unit prospective
data bank that was approved by our hospitals research
and ethics committee. In accident and emergency, the
demographic data, history, including time and etiology of
accidents, and the physical signs were documented. The
Glasgow Coma Scores were assessed and documented
after resuscitation. CT scan findings were documented
once it was done. The progress of the patients was
documented in ICU, wards and out-patient clinic. Glasgow
[7]
Outcome Score was used to determine the outcome. It
classifies patient into 5 categories: 1 death, 2 vegetative
state, 3 severe disability, 4 moderate disability, and 5
normal recovery. The scores were documented three
months post-injury as it had been documented that
outcome score three months post-injury predicted long
[8]
term outcome.
Statistical analysis: The data were analyzed using
Environmental Performance Index (EPI) info 7 software
(CDC Atlanta, Georgia, USA, EPI info 7 version 7.0.8.0 of
2011). We used visual band method of analysis. In the
analytical gadgets we used frequency, mean and
MXN/2X2 with its advanced option if need be. At 95%
confidence interval, P 0.05 was considered significant.
RESULTS
There were seventy three patients in the study. Males
were forty eight, while females were twenty five. Their
ages ranged from a year and six months to seventy years
with a mean of 25.08 years. There were only three elderly
patients, table 1. Highest numbers of patients were
involved in crashes between 6AM and 10AM, table 2.
There was no significant relationship between age group
and period of accident, P = 0.1297. The commonest
etiology was vehicle, but there was no significant

difference among the etiological agents in terms of injury


severity, P = 0.1213, table 3.
Thirty one patients did CT scan of the brain. Among extraaxial lesions seen, there were seven subdural hematoma,
three extradural hematoma, and two subarachnoid
hemorrhages. Fourteen patients had skull fractures. The
commonest cerebral injury was contusion/intracerebral
hemorrhages, but no significant difference among the
causative etiologies, P = 0.5737, table 4. Twenty six
patients had major organ associated injuries. Fifteen
(57.58%) of them were musculoskeletal injuries, mainly
fractures of limb bones. There was no significant
association of major organ injuries with outcome, P =
0.6994.
Sixty four patients were managed conservatively, while
nine had surgery. One patient had surgery for extradural
hematoma, 4 for subdural hematoma, 3 for depressed
skull fractures, and one for superficial temporal artery
pseudoaneurysm.
Favorable functional outcome (4) was seen in 82.19% of
patients, while the mortality was 17.81%. One of the three
elderly patients died. Two patients died among those that
did CT scan, while 11patients died among those that could
not afford CT scan. The severity of injury significantly
affected the outcome, P = 0.00, table 5. Etiology did not
have any significant effect on the outcome, P = 0.7897,
table 6.
Table 1: Age group frequency
Age group
Number
Children
35
Adult
35
Elderly
3
Total
73

Percent (%)
47.95
47.95
4.11
100

Table 2: Accident period frequency


Accident period
Number
>6AM 10AM
22
>10AM 2PM
12
>2PM 6PM
20
>6PM 10PM
17
>10PM 6AM
2
Total
73

Percent (%)
30.14
16.44
27.40
23.29
2.74
100

Table 3: Etiology vs Severity


Etiology
Mild (%)
Moderate (%)
Motorcycle 9 (60.00)
3 (20.00)
Tricycle
3 (100)
0 (0.00)
Vehicle
20 (36.36) 11 (20.00)
Total
32 (43.84) 14 (19.18)
P = 0.1213

Severe (%)
3 (20.00)
0 (0.00)
24 (43.64)
27 (36.99)

Table 4: Etiology vs Cerebral injury


Etiology

Motorcycle
Tricycle
Vehicle
Total
P = 0.5737

Contusion/he
morrhage
4
1
8
13

Diffuse
axonaI
injury
0
0
7
7

Edema

0
0
1
1

None

2
0
8
10

862
Nnadi Mathias et al.,

Int J Med Res Health Sci. 2015;4(4):861-864

Table 5: Severity vs Glasgow Outcome Score


Severity
1 (%)
4 (%)
5 (%)
4 (%)
Mild
1 (3.13) 0 (0.00) 31 (96.88) 31 (96.88)
Moderate 1 (7.14) 1 (7.14) 12 (85.71) 13 (92.85)
Severe
11 (40.7) 6(22.22) 10 (37.04) 16 (59.26)
Total
13(17.81) 7 (9.59) 53 (72.60) 60 (82.19)
P = 0.00
Table 6: Etiology vs GOS
Etiology
1 (%)
4 (%)
Motorcycle 2 (13.33) 2 (13.3)
Tricycle
0 (0.00) 0 (0.00)
Vehicle
11 (20) 5 (9.09)
Total
13(17.81) 7 (9.59)
P = 0.7897

5 (%)
4 (%)
11(73.33) 13 (86.67)
3 (100)
3 (100)
39(70.91)
44 (80)
53(72.60) 60 (82.2)

DISCUSSION
In this study, there were more males (65.75%) than
[9]
females. In Bangalore, India, Pruthi et al in their study of
529 pedestrians with traumatic brain injuries, found 70.3%
males. The high incidence in males was due to males
being more active in search of means of livelihood for the
families. High percentage of males with traumatic brain
injuries from road traffic accident had been documented by
[10-12]
other authors.
There were only three (4.11%) elderly
patients in this study, while the rest were 35 children and
35 adults. The low percentage of elderly is a reflection of
life expectancy in developing countries like ours. High
percentage of elderly were seen in developed countries
[13,14]
where life expectancy are high.
High number of
pedestrian with traumatic brain injuries mirrors poverty
level in our society where the poor trek their ways to
[15]
school and work. Dandona et al
found that children of
highest household income were significantly less likely to
sustain pedestrian injury when compared to children from
low household incomes.
Majority of the patients were injured between 6AM and
10AM, and between 2PM and 6PM (57.53%). These are
peaks hours when people go to school and work, and
when they come back home after school and work. These
are the two major periods we experience traffic hold-ups in
our city. During these periods pedestrians and commuters
movement at T-junctions appear chaotic, trying to avoid
one another. In places with traffic light, the same scenario
occur because the lights do not have pedestrian phase.
The same thing is seen near schools, where children cross
roads at random, competing with vehicles. In few places
with Zebra-crossings, majority of the children as well as
majority of the drivers do not understand the meaning. In
few places where we have footbridges, iron barriers were
built under them, stretching up to two meters on both sides
to encourage pedestrians to use the bridges, still they trek
to the end of the barriers to run across the roads. Another
high incidence was between 6PM and 10PM. This could
be explained by high social life in our city. There is high
level of clubbing in the night with periods ranging from
6PM to early hours of the morning. Most of the excluded
patients were picked up on the roads during this period.
These people, under the influence of alcohol tried to cross
the roads and were knocked down. Lack of street lights

makes it difficult for the drivers to see them, especially


[13]
those wearing dark clothes. McElroy et al in Wisconsin,
USA, found highest incidence between 6PM and midnight.
[9]
Pruthi et al in India, found highest incidence during peak
traffic hours, between 4PM and 9PM. Other studies also
[16, 17]
found highest frequency between 6PM and midnight.
They were attributed to peak hours in their areas. The
commonest etiology was vehicular crashes. In London,
[18]
Baldwin et al
found that 74% of all pedestrian injuries
[19]
involved either a bus or a car. Umaru et al
in Azare,
Nigeria, found motorcycle crashes as the commonest
etiology. The similarity and difference in above findings
was the banning of commercial motorcycles in our city
before our study started. Pedestrians had been
documented as very highly vulnerable group among motor
[20]
vehicular trauma patients with very high mortality. There
are three force transmissions in vehicular/pedestrian
crash: the impact by the bumper to the limbs; the wrapping
of the body around the vehicle with hitting of the head on
the windscreen or hood; the impact on falling to the
[5,21]
ground.
Only 31(42.47%) patients afforded CT scan of the brain.
This showed that many of the patients were poor. Among
those who afforded CT scan 2 patients died, while those
who could not afford CT scan (42), 11 patients died. The
cause of death might have been operable lesions such as
hematomas. Among those who afforded CT scan, the
commonest cerebral lesion was contusion/intracerebral
[9]
hemorrhage (41.94%). Pruthi et al in their study also
found contusion commonest (47.2%). The commonest
major organ associated injuries were in musculoskeletal
system (20.55%). This is because vehicular crashes
formed the commonest etiology and first impact site in
most cases occur in the lower limbs.
In this study, 82.19% had favorable functional outcome but
the mortality was 17.81%. The high mortality in
pedestrians depicts the triple impact mechanism of injury
[14]
discussed above. Tokdemir et al
in their study found
mortality of 18.3% among pedestrian with traumatic brain
[22]
injury. In Nepal, Mandal et al
found 12.5% mortality
among pedestrians with traumatic brain injuries. Highest
mortality among pedestrian with traumatic brain injury was
seen among the elderly. In this study 33.33% (1/3) of our
elderly patients died. This is due to the frail nature of
[23]
patients in this age group. Munivenkatappa et al in their
study found mortality of 22.8% among elderly pedestrians
with traumatic brain injuries. Severity of injury was the only
significant factor that determined the outcome. Like in
many series of traumatic brain injuries, severity of injuries
[24had been key significant factor in determining outcome
28].

CONCLUSION
Majority of patients in this study were males and vehicle
was the commonest etiology. Peak hours for commuters
were when the majority of patients were injured. Less than
50% could do CT scan of the brain, and the commonest
cerebral lesion was contusion/intracerebral hemorrhage.
Favorable functional outcome was 82.19% while mortality
was 17.81%. Severity of the injury significantly affected
outcome.

863
Nnadi Mathias et al.,

Int J Med Res Health Sci. 2015;4(4):861-864

Recommendations: Traffic lights without pedestrian


phasing currently in our city should be replaced with those
with exclusive pedestrian phasing. Sidewalks, pedestrian
refuge islands, underpasses, and footbridges should be
provided in areas with heavy traffics. Increased intensity
roadway lighting is essential. Flyovers and single lane
roundabouts will also help reduce crashes in our city.
Provision of zebra crossings in roads adjacent to schools
cannot be overemphasized. In designing vehicles,
tricycles, and motorcycles, safety of the pedestrian should
be taken into consideration. Most importantly, education of
road users is essential in their understanding of the safety
measures. These measures had been found to be
effective by some authors.
Conflict of interest: Authors have no conflict of interest.
Financial support: There was no source of financial
support.

13.

14.

15.

16.

REFERENCES
1.

Liu B, Ivers R, Norton R, Boufous S, Blows S, Lo SK.


Helmets for preventing injury in motorcycle riders.
Cochrane Database Syst Rev 2008;1:CD004333.
2. World Health Organization. Global status report on
road safety: time for action.2009. Available at:
www.who.int/violence_injury_prevention/road_safety_
status/2009.
3. Lewin I. Driver training: a perpetual motor skill
approach. Ergonomics 1982;25:917-24.
4. Evan L. A new traffic safety vision for the United
States. Am J Public Health 2003;9:1384-6.
5. Crandall JR, Bhalla KS, Madley J. Designing road
vehicles for pedestrian protection. Br Med J
2002;324:1145-8.
6. Markogiannakis H, Sanidas E, Koutentakis D,
Messaris E, Alpantaki K, Kafetzakis A, et al. Motor
vehicle trauma: analysis of injury profiles by road user
category. Emerg Med J 2006;23:27-31.
7. Jennet B, Bond M. Assessment of outcome after
severe brain damage. Lancet 1975;1:480-4.
8. King JT, Carlier PM, Marion WD. Glasgow outcome
scale scores predict long-term functional outcome in
patients with severe traumatic brain injury. J
Neurotrauma 2005;22:947-54.
9. Pruthi N, Munivenkatappa A, Shiva KV, Jhavar K,
Somanna S, Devi BI. Magnitude of pedestrian head
injuries and fatalities in Bangalore, South India: a
retrospective study from an apex neurotrauma center.
Indian J Med Res 2012;136:1039-43.
10. Majdan M, Mauritz W, Brazinova A, Rusnack M,
Leitgeb J, Janciak I, et al. Severity and outcome of
traumatic brain injuries with different causes of injury.
Brain Injury 2011;25:797-805.
11. Younis R, Younis M, Hamidi S, Musmar M, Mawson
AR. Causes of traumatic brain injury in patients
admitted to Rafida, Al-Ittihad and the specialized Arab
hospitals, Palestine. Brain Injury2011;25:282-91.
12. Leijdesdorff HA, van Dijck TJM, Keijnen P, VleggeertLankamp CIM, Schippar IB on behalf of the Regional
Trauma Center West-Netherlands Research Group.
Injury pattern, hospital triage, and mortality of 1250

17.
18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

patients with severe traumatic brain injury caused by


road traffic accidents. J Neurotrauma 2014;31:459-65.
McElroy LM, Juern JJ, Bertlesin A, Xiang Q, Szabo A,
Weigettt J. A single center experience with adult
pedestrians struck by motor vehicles. WMJ
2013;112:117-23.
Tokdemir M, Kafadar H, Turkoglu A, Deveci SE,
Colak C. Comparison of the severity of traumatic brain
injuries in pedestrians and occupants of motor
vehicles admitted to Firat health center: a five year
series in an Eastern Turkish city. Med Sci Monit
2009;15:p11-4.
Dandona R, Anil KG, Ameratunga S, Dandona L.
Road use pattern and risk factors for non-fatal road
traffic injuries among children in urban India. Injury
2011;42:97-103.
Brainard BJ, Slauterbeck J, Benjamin JB, Hagaman
RM, Higie S. Injury profiles in pedestrian motor
vehicle trauma. Ann Emerg Med 1989;18:881-3.
Vestrup JA. A profile of urban pedestrian trauma. J
Trauma 1989;29:741-5.
Baldwin A, Harris T, Davis G. Look right a
retrospective study of pedestrian accidents involving
overseas visitors to London. Emerg Med J
2008;25:843-6.
Umaru H, Ahidjo A, Dogo H. Pedestrian injuries
resulting from road traffic accidents: the Azare
experience. Niger J Med 2007;16:169-72.
Peng RY, Bongard FS. Pedestrian versus motor
vehicle accidents: an analysis of 5000 patients. J Am
Coll Surg 1999;189:343-8.
McLaughlin TF, Zuby DS, Elias JC, Tanner CB.
Vehicle interaction with pedestrians, Springer-Verlag,
New York, 1993;539-66.
Mandal BK, Yadav BN. Pattern and distribution of
pedestrian injuries in fatal road traffic accident cases
in Dharan, Nepal. Journal of Natural Science, Biology
and Medicine 2014;5:320-3.
Munivenkatappa A, Pruthi N, Phillip M, Devi BI,
Somamma S. Elderly pedestrian neurotrauma: a
descriptive study from a premier neurotrauma center
in India. J Neurosci Rural Pract 2013;4:29-32.
Yusuf AS, Odebode TO, Adeniran JO, Salaudeen AG,
Adeleke NB, Alimi MF. Pattern and outcome of
motorcyclists head injury in Ilorin, Nigeria. Nigerian
Journal of Basic Clinical Sciences 2014;11:80-4.
Agrawal S, Agrawal CS, Kumar A, Lewis O, Malla G,
Khatiwada R, et al. Epidemiology and management of
pediatric head injury in Eastern Nepal. African J
Pediatr Surg 2008;5:15-18.
Kwan I, Mapstone J. Interventions for increasing
pedestrian and cyclist visibility for the prevention of
death and injuries. Cochrane Database Syst Rev
2006;CD003438.
Retting RA, Ferguson SA, McCartt AT. A review of
evidence-based
traffic
engineering
measures
designed to reduce pedestrian-motor vehicle crashes.
Am J Public Health 2003;93:1456-63
Duprrex O, Roberts I, Bunn F. Safety education of
pedestrian.
Cochrane
Database
Syst
Rev
2002;CD001531

864
Nnadi Mathias et al.,

Int J Med Res Health Sci. 2015;4(4):861-864

Available online at: www.ijmrhs.com


Research article

DOI: 10.5958/2319-5886.2015.00173.3
Open Access

KNOWLEDGE AND AWARENESS REGARDING HIV/AIDS AMONG FIRST YEAR


MEDICAL UNDERGRADUATES: A CROSS SECTIONAL STUDY
1

Sharma Panchsheel , Khan Mohammad Shibly

ARTICLE INFO
th

Received: 5 Aug 2015


th
Revised: 10 Aug 2015
th
Accepted: 16 Aug 2015
1,2

Authors
details:
Assistant
Professor, Department of Community
Medicine, F.H. Medical College,
Tundla, Firozabad, Uattar Pradesh,
India
*Corresponding author: Sharma
Panchsheel
Assistant Professor, Department of
Community Medicine, F.H. Medical
College, Tundla, Firozabad, Uattar
Pradesh, India
Email: drpanchsheelsharma@yahoo.co.in

Keywords:
Awareness

HIV/AIDS,

Knowledge,

ABSTRACT
Background: HIV/AIDS affects the most productive age group, the
knowledge of which is clouded with many myths and misconceptions.
Objective: To determine the knowledge and awareness about various
aspects of HIV/AIDS among the students of MBBS first year. Methodology:
The students were asked to fill a pre-designed, structured, semi open ended
questionnaire. All efforts were made to ensure the originality of the
responses. Statistical Analysis: The data collected so, was analysed,
tabulated and presented in the forms of percentages and proportions.
Appropriate statistical tests applied, wherever applicable. Results: Among
the total of 122 respondents, all of them have heard about HIV/AIDS and
that it is caused by a virus. About 43.4% students believed that HIV infection
means AIDS. The place where HIV testing is done, was known to about
78%. Knowledge about the routes of spread included; through infected
injections (100%), through blood transfusion (98%), Unprotected Sexual
contact (97.5%), Infected Mother to child (86%). The respondents were
aware that it doesnt spread through touching/hand shaking (99.2%),
sharing food (93.4%), using common cups/glasses (89%), used
clothes/towels/soap (88.5%). About 80% responded to have discussed about
HIV/AIDS ever with anybody, while about 82% considered safe working with
a patient of HIV/AIDS. Conclusion: Most of students were aware about the
basic knowledge while they also had a misconception which implies that the
students should be equipped more, especially since the beginning of their
career.

INTRODUCTION
AIDS was recognised as an emerging disease in the
early 80s but has spread its tentacles throughout the
world, responsible for millions of the deaths within less
than twenty years. It affects the most productive age
group and causing premature deaths thereby. According
to the annual report of National Aids Control
Organization India has the third highest number of
estimated people living with HIV in the world as per the
HIV estimations 2012, with the estimated number of
[1]
people living with HIV/AIDS in India to be 20.89 lakh .
Also, India has worlds largest youth population with
people in the age group of 15-29 years comprising
almost 25 percent of the countrys population and
[2]
account for around 31% of HIV/AIDS burden
.
Moreover, still there are many myths and misconceptions
prevalent in the society regarding HIV/AIDS. For
instance, in a study conducted among the general public
in Karnataka (southern state of India), about one third of
the respondents thought it to be spread it just by
[3]
touching a patient who is HIV positive
Many studies have been conducted among the youth
population belonging to different streams such as
[4, 5]
[6,7]
students of high school
, senior secondary school
,
[8]
[9]
college students , nursing students , medical students
[10]
etc. These studies reflect varied knowledge and
awareness regarding this subject. The Medical students
constitute an important stakeholder as far the prevention
of AIDS is concerned, both in terms of being at the risk

of contracting this deadly infection during their hospital


training (and in their professional carrier afterwards) as
well as by virtue of being a future doctor and educator.
So, they need to be inculcated on the basic human
values along with the medical skills. Attitude of the health
care provider towards the patient, be he is a doctor or
paramedic, has a tremendous impact on the patients
perceptions of their own health. Very few studies have
been conducted on the knowledge, awareness of
HIV/AIDS among medical students. Present study is one
time cross sectional survey based study conducted
among the students of MBBS first year in a private
medical college in western Uttar Pradesh.
Aims & Objectives: To determine the knowledge and
awareness about various aspects of HIV/AIDS among
the first year medical students.
MATERIALS & METHODS
Study design: This study is a cross-sectional survey
based study
Ethical Consideration: Ethical approval taken from the
institutional ethics committee. Confidentiality was
assured and a health education session on HIV/AIDS
was conducted after completing the survey.
Inclusion criteria: The first year medical students (both
sex) at FH Medical College, Tundla, Firozabad. Only

868
Sharma et al.,

Int J Med Res Health Sci. 2015;4(4):868-871

those students were included into the study who were


present in the class.
Sample size: A total of 122 subjects were included into
the study out of the total strength of 150.
Methodology:
The students were asked to fill a semi open ended
questionnaire,
which
was
self-designed.
The
questionnaire was pre-tested before the data collection.
The nature and purpose of the study was explained to
students. All of the study participants were to complete
the questionnaire in a single sitting in the lecture theatre.
To ensure the originality of the responses, the staff of
community medicine department was present in the
lecture theatre, invigilating the session. The students
were emphasised on to put/mark their original
responses, and no subsequent survey was done among
the students who were left due to possibility of questions
being leaked out thereby responses might be biased.
Statistical analysis: The data collected so, was
analysed, tabulated and presented in the forms of
percentages and proportions. Appropriate statistical tests
applied, wherever applicable.
RESULTS
A total of 122 students took part in the study comprising
of 76 (62.3%) males and 46 (37.7%) females. All of them
(100%) had heard about HIV/AIDS and that it is caused
by a virus while the source of information being from
multiple sources. About 43.4% (i.e. 53) students believed
that HIV infection means AIDS. The place where HIV
testing is done, was known to about 78% (96).
Knowledge about four classical modes of
transmission: The participants were asked to mention
the classical modes of transmission in the form of open
ended questions. Only about 9% (11) students could
reproduce/mention all the four classical modes of spread
(i.e. sexual, infected needles & syringes, infected blood
transfusion and mother to child). Majority of the
respondents i.e. around 36.9% could mention only two
modes of transmission, while 27% and 13.9%
respondents could be able to mention three and one
route of spread, respectively (table 1). No significant
difference was observed between knowledge of these
classical routes of transmission and gender of the
respondents.

Knowledge about other routes of transmission: In


this part the students were asked about the routes of
transmission in the form of a closed ended questions.
The knowledge about various routes was as follows (as
shown in table 2); through infected injections (100%),
through blood transfusion (98%), Unprotected Sexual
contact (97.5%), Infected Mother to child (86%). As far
as awareness regarding non-spread is concerned then
the respondents were aware that it doesnt spread
through touching/hand shaking (99.2%), sharing food
(93.4%), using common cups/glasses (89%), used
clothes/towels/soap (88.5%). Regarding other routes the
participants responses included- spread through breast
feeding (26.2%), oral sex (32.8%), kissing (23%) and
mosquito bite (23%). As many as 34% and 68% believed
it to not spread through surgery and tooth extraction
while around 18% responded it to be spread through
coughing.
Knowledge about High Risk Groups: The awareness
about existence of high risk groups for HIV/AIDS was
found to be as follows (table 3); female sex worker
(70.5%), Clients of Female Sex Workers (59.8%),
patients suffering from sexually Transmitted Diseases
(56.6%), recipients of repeated blood transfusion
(54.1%), intra venous drug users (45.9%), truck drivers
(34.4%), men having sex with men (29.4%). There was
no significant difference observed between the
awareness of high risk groups among boys and girls
(p>0.05)
Knowledge about prevention & treatment and
Attitude towards HIV/AIDS: Among all of the study
participants about 34% believed that HIV means AIDS.
As shown in table 4, about 3.3% respondents believed
that there is a permanent cure available for HIV/AIDS,
the availability of any drug effective against this virus
was known to only 36.9%. About 80% (about 82%
females and 78.9% males) respondents admitted to have
discussed about HIV/AIDS ever with anybody, while
about 82% considered safe to working with a patient of
HIV/AIDS. Significantly higher percentage of females
(97.8%) than males (84.2%) believed that the HIV/AIDS
patient should not be excluded from the society. The
percentage of respondents who admitted to have no
problem in sharing room with a patient of HIV was 64%
which was significantly higher (p<0.05) among females
(78.3%)
than
males
(56.6%).

Table 1: Knowledge about four classical modes of transmission*


Male (n=76)
Knowledge about modes of spread
All four routes* reproduced/mentioned
6 (7.9%)
Only 3 routes reproduced/mentioned
19 (25%)
Only 2 routes reproduced/mentioned
33 (43.4%)
Only 1 route reproduced/mentioned
11 (14.5%)
None or none correctly reproduced/mentioned
7 (9.2%)
2
=6.715, d.f.=8, p value=0.568, Not Significant
* participants were asked to mention routes of
transmission in the form of open ended question (the
correct response taken to be 1.unsafe sexual contact, 2.

Sharma et al.,

Female(n=46)

Total (N=122)

5 (10.9%)
14 (30.4%)
12 (26.0%)
6 (13.0%)
9 (19.6%)

11 (9%)
33 (27.0%)
45 (36.9%)
17 (13.9%)
16 (13.1%)

from infected mother to child, 3. transfusion of infected


blood and 4. through infected needle and syringes)

869
Int J Med Res Health Sci. 2015;4(4):868-871

Table 2: Knowledge/Awareness about other routes of transmission (N=122)


Spreads throughYes
Injections
122 (100%)
Infected Blood Transfusion
120 (98.4%)
Unprotected Sexual contact
119 (97.5%)
Infected Mother to child
105 (86.1%)
Tattooing or ear piercing
86 (70.5%)
Breast Feeding
32 (26.2%)
Oral Sex
40 (32.8%)
Kissing
28 (23%)
Mosquito Bite
28 (23%)
During surgery
73 (59.8%)
During Tooth Extraction
22 (18%)
Coughing
23 (18.9%)
Touching/hand shaking
00 (00)
Sharing Food
06 (4.9%)
Using common cups/glasses
11(9%)
Used clothes/towels/soap
10 (8.2%)
Table 3: Knowledge/awareness about High Risk Groups
Male (n=76)
Knowledge about High Risk Groups

Female(n=46)

No
00 (00%)
02 (1.6%)
03 (2.5%)
10 (8.2%)
26 (21.3%)
72 (50.0%)
58 (47.5%)
91 (74.5%)
81 (66.4%)
42 (34.4%)
83 (68%)
89 (73%)
121 (99.2%)
114 (93.4%)
109 (89.3%)
108 (88.5%)

Total (N=122)

Dont Know
00 (00%)
00 (00%)
00 (0%)
7 (5.7%)
10 (8.2%)
18 (14.8%)
24 (19.7%)
03 (2.5%)
13 (10.7%)
7 (5.7%)
17 (14%)
10 (8.1%)
01 (0.8%)
02 (1.6 %)
02 (1.6%)
04 (3.3%)

P value*

Truck Drivers

28 (36.8%)

14 (30.4%)

42 (34.4%)

>0.05

Female Sex worker (FSW)

49 (64.5%)

37 (80.4%)

86 (70.5%)

>0.05

Patients suffering from STDs

42 (55.3%)

27 (58.9%)

69 (56.6%)

>0.05

Intra Venous Drug Users


Men Having Sex with Men

33 (43.4%)
21 (27.6%)

23 (50.0%)
10 (21.7%)

56 (45.9%)
31 (29.4%)

>0.05
>0.05

Clients of FSWs
44 (57.9%)
29 (63.0%)
73 (59.8%)
Recipients of repeated Blood transfusion
38 (50.0%)
28 (60.9%)
66 (54.1%)
*p>0.05 Non significant, p<0.05 Significant
Table 4: Knowledge/ Awareness about prevention & treatment and Attitude towards HIV/AIDS
Variables concerned
Male (n=76)
Female(n=46)
Total
(N=122)
HIV positive means patient is having AIDS
33 (43.4%)
20 (43.5%)
53 (43.4%)
Availability of any drug against HIV
31 (40.8%)
14 (30.4%)
45 (36.9%)
Permanent cure for HIV/AIDS available
2 (2.6%)
2 (4.3%)
4 (3.3%)
Ever discussed HIV/AIDS with anybody
60 (78.9%)
38 (82.6%)
98 (80.3%)
Working with a patient of HIV/AIDS is safe
60 (78.9%)
41 (89.1%)
101 (82.8%)
HIV patient should not be excluded from society
64 (84.2%)
45 (97.8%)
109 (89.3%)
No problem in sharing room with a patient of HIV
43 (56.6%)
36 (78.3%)
79 (64.8%)

>0.05
>0.05

P
value
>0.05
>0.05
>0.05
>0.05
>0.05
<0.05
<0.05

DISCUSSION
Present study was conducted among the first year
students of MBBS, who have spent just 3 months in the
medical curriculum, at the time of survey. As far as the
basic knowledge about HIV/AIDS is concerned, then all
of the respondents were aware about the viral aetiology,
most of the students were aware about the routes of
transmission. This is similar to a study conducted among
first year medical students in Karnataka in which most of
[10]
the students were aware about routes of transmission .
In our study no significant difference was observed
between the knowledge of transmission among male and
[11]
female student, similar to Joshi et al .
Most of the students were aware that it doesnt spread
through touching/hand shaking. In a study conducted
among general population in Karnataka, about one third
of the respondents thought it to be spread it just by

Sharma et al.,

touching a patient who is HIV positive. Some


misconception were also revealed in our study such as,
up to 36% students believed it to be spread through
mosquito bite, 18.9% students believed it to be spread by
coughing and 9% believed it to be spread by using
common utensils. The misconception of spread through
mosquito bite has also been reported among medical
[12]
students by Joshi et al and Basavayya
. In a study
conducted among young college student 6.3%
participants believed that it can be transmitted by
[8]
mosquito bite .
Knowledge and awareness regarding high risk groups
was varied in our study, on one hand as much as 70%
considered the female sex workers to be a risk group the
awareness went on to decrease up to the level that only
29.4% considered the MSMs to be a high risk group. In a

870
Int J Med Res Health Sci. 2015;4(4):868-871

study conducted among the college students, only 47%


[11]
were aware that STDs are at high risk of AIDS .
In our study only 3.3% participants believed that there is
a permanent cure available for HIV/AIDS, while in a study
conducted among the college students 10% believed so
[8]
whereas 45% students in Kerala were aware that AIDS
[11]
is non-curable at present time .
In our study as many as 89% believed that HIV patients
should not be excluded from the society, while 64%
reported to be having no problem in sharing room with a
HIV patient. About 74% college students in another study
[8]
in Lucknow, agreed to share a room with a HIV patient .
CONCLUSION
In our study the knowledge and awareness about
HIV/AIDS among first year medical students was found to
be variable. On one hand most of students were aware
about the basic knowledge while on another hand they
had misconceptions similar to non-medico students.
Considerable percentages of students were having
misconceptions related to transmission such as through
mosquito bite, coughing and sharing utensils. The
awareness regarding the high risk groups for HIV/AIDS
was also found to be very low.
Recommendations: The medical students should be
equipped more especially since the beginning of their
career. The students should also be engaged in the
health education session whereby they can learn by
doing, once they start explaining to the community,
automatically their hidden potentials of the learning will
eventually unfold.
Limitations: The questionnaire used was not a standard
questionnaire but was self-designed, thereby there remains
chances of missing many aspects so this may be counted
as a limitation of the study

4. Pramanik S, Chartier M, Koopman C. HIV/AIDS


Stigma and Knowledge among Predominantly
Middle-Class High School Students in New Delhi,
India. J. Commun. Dis. 2006, 38 (1):57-69.
5. Kumar P, Pore P, Patil U. HIV/AIDS Related KAP
among High-School Students of Municipal
Corporation School in Pune. - An Interventional
Study. National Journal of Community Medicine
2012; 3(1):74-79.
6. Gupta P, Anjum F, Bhardwaj P, Srivastav JP, Zaidi
ZH. Knowledge about HIV/AIDS among secondary
school students. North Am J Med Sci 2013;5: 11923.
7. Lal P, Nath A, Badhan S, Ingle GK. A study of
awareness about HIV/AIDS among senior secondary
school children of Delhi. Indian J Community Med
2008,33:190-2.
8. Dubey A, Sonker A, Chaudhary RK. Knowledge,
attitude, and beliefs of young, college student blood
donors about Human immunodeficiency virus. Asian
J Transfus Sci 2014; 8:39-42.
9. Kumar A, Lal P, Walia M, Arora R, Gulati N.
AIDS
awareness among nursing students of Delhi.
J Commun Dis. 1996; 28(1):207.
10. Joshi AV, Nikam K, Hungund BR, Viveki RG, Nikam
SV, et al. Knowledge about and attitude towards
HIV/AIDS among first year medical students: A
cross-sectional study. J Sci Soc 2013; 40:155-8.
11. Lal SS, Vasan RS, Sharma PS, Thankappan KR.
Knowledge and attitude of college students in
Kerala towards HIV/AIDS, sexually transmitted
diseases and sexuality. Natl Med J India 2000;
13:231-6.
12. Basa vayya GS. Awareness of HIV/AIDS among
medical students. Indian J Public Health
2005;49:31-2

ACKNOWLEDGMENT
The authors are thankful to the students who participated
in the study and the staff of department of community
medicine who actively participated in the data collection
of the study.
Conflict of interest: Nil
REFRENCES
1. Department of AIDS control. Annual Report 2013-14.
Ministry of Health & Family Welfare, Government of
India.
www.naco.gov.in/
upload/2014%20mslns/NACO_English%20201314.pdf
2. National AIDS Control Organization. Ministry of
Health & Family Welfare, Government of
India.http://www.naco.gov.in/NACO/Quick_Links/You
th
3. Unnikrishnan B, Mithra PP, Rekha T, Reshmi B.
Awareness and attitude of the general public toward
HIV/AIDS in coastal Karnataka. Indian J Community
Med 2010;35:142-46.

871
Sharma et al.,

Int J Med Res Health Sci. 2015;4(4):868-871

Available online at: www.ijmrhs.com


Research article

DOI: 10.5958/2319-5886.2015.00173.3
Open Access

KNOWLEDGE AND AWARENESS REGARDING HIV/AIDS AMONG FIRST YEAR


MEDICAL UNDERGRADUATES: A CROSS SECTIONAL STUDY
1

Sharma Panchsheel , Khan Mohammad Shibly

ARTICLE INFO
th

Received: 5 Aug 2015


th
Revised: 10 Aug 2015
th
Accepted: 16 Aug 2015
1,2

Authors
details:
Assistant
Professor, Department of Community
Medicine, F.H. Medical College,
Tundla, Firozabad, Uattar Pradesh,
India
*Corresponding author: Sharma
Panchsheel
Assistant Professor, Department of
Community Medicine, F.H. Medical
College, Tundla, Firozabad, Uattar
Pradesh, India
Email: drpanchsheelsharma@yahoo.co.in

Keywords:
Awareness

HIV/AIDS,

Knowledge,

ABSTRACT
Background: HIV/AIDS affects the most productive age group, the
knowledge of which is clouded with many myths and misconceptions.
Objective: To determine the knowledge and awareness about various
aspects of HIV/AIDS among the students of MBBS first year. Methodology:
The students were asked to fill a pre-designed, structured, semi open ended
questionnaire. All efforts were made to ensure the originality of the
responses. Statistical Analysis: The data collected so, was analysed,
tabulated and presented in the forms of percentages and proportions.
Appropriate statistical tests applied, wherever applicable. Results: Among
the total of 122 respondents, all of them have heard about HIV/AIDS and
that it is caused by a virus. About 43.4% students believed that HIV infection
means AIDS. The place where HIV testing is done, was known to about
78%. Knowledge about the routes of spread included; through infected
injections (100%), through blood transfusion (98%), Unprotected Sexual
contact (97.5%), Infected Mother to child (86%). The respondents were
aware that it doesnt spread through touching/hand shaking (99.2%),
sharing food (93.4%), using common cups/glasses (89%), used
clothes/towels/soap (88.5%). About 80% responded to have discussed about
HIV/AIDS ever with anybody, while about 82% considered safe working with
a patient of HIV/AIDS. Conclusion: Most of students were aware about the
basic knowledge while they also had a misconception which implies that the
students should be equipped more, especially since the beginning of their
career.

INTRODUCTION
AIDS was recognised as an emerging disease in the
early 80s but has spread its tentacles throughout the
world, responsible for millions of the deaths within less
than twenty years. It affects the most productive age
group and causing premature deaths thereby. According
to the annual report of National Aids Control
Organization India has the third highest number of
estimated people living with HIV in the world as per the
HIV estimations 2012, with the estimated number of
[1]
people living with HIV/AIDS in India to be 20.89 lakh .
Also, India has worlds largest youth population with
people in the age group of 15-29 years comprising
almost 25 percent of the countrys population and
[2]
account for around 31% of HIV/AIDS burden
.
Moreover, still there are many myths and misconceptions
prevalent in the society regarding HIV/AIDS. For
instance, in a study conducted among the general public
in Karnataka (southern state of India), about one third of
the respondents thought it to be spread it just by
[3]
touching a patient who is HIV positive
Many studies have been conducted among the youth
population belonging to different streams such as
[4, 5]
[6,7]
students of high school
, senior secondary school
,
[8]
[9]
college students , nursing students , medical students
[10]
etc. These studies reflect varied knowledge and
awareness regarding this subject. The Medical students
constitute an important stakeholder as far the prevention
of AIDS is concerned, both in terms of being at the risk

of contracting this deadly infection during their hospital


training (and in their professional carrier afterwards) as
well as by virtue of being a future doctor and educator.
So, they need to be inculcated on the basic human
values along with the medical skills. Attitude of the health
care provider towards the patient, be he is a doctor or
paramedic, has a tremendous impact on the patients
perceptions of their own health. Very few studies have
been conducted on the knowledge, awareness of
HIV/AIDS among medical students. Present study is one
time cross sectional survey based study conducted
among the students of MBBS first year in a private
medical college in western Uttar Pradesh.
Aims & Objectives: To determine the knowledge and
awareness about various aspects of HIV/AIDS among
the first year medical students.
MATERIALS & METHODS
Study design: This study is a cross-sectional survey
based study
Ethical Consideration: Ethical approval taken from the
institutional ethics committee. Confidentiality was
assured and a health education session on HIV/AIDS
was conducted after completing the survey.
Inclusion criteria: The first year medical students (both
sex) at FH Medical College, Tundla, Firozabad. Only

868
Sharma et al.,

Int J Med Res Health Sci. 2015;4(4):868-871

those students were included into the study who were


present in the class.
Sample size: A total of 122 subjects were included into
the study out of the total strength of 150.
Methodology:
The students were asked to fill a semi open ended
questionnaire,
which
was
self-designed.
The
questionnaire was pre-tested before the data collection.
The nature and purpose of the study was explained to
students. All of the study participants were to complete
the questionnaire in a single sitting in the lecture theatre.
To ensure the originality of the responses, the staff of
community medicine department was present in the
lecture theatre, invigilating the session. The students
were emphasised on to put/mark their original
responses, and no subsequent survey was done among
the students who were left due to possibility of questions
being leaked out thereby responses might be biased.
Statistical analysis: The data collected so, was
analysed, tabulated and presented in the forms of
percentages and proportions. Appropriate statistical tests
applied, wherever applicable.
RESULTS
A total of 122 students took part in the study comprising
of 76 (62.3%) males and 46 (37.7%) females. All of them
(100%) had heard about HIV/AIDS and that it is caused
by a virus while the source of information being from
multiple sources. About 43.4% (i.e. 53) students believed
that HIV infection means AIDS. The place where HIV
testing is done, was known to about 78% (96).
Knowledge about four classical modes of
transmission: The participants were asked to mention
the classical modes of transmission in the form of open
ended questions. Only about 9% (11) students could
reproduce/mention all the four classical modes of spread
(i.e. sexual, infected needles & syringes, infected blood
transfusion and mother to child). Majority of the
respondents i.e. around 36.9% could mention only two
modes of transmission, while 27% and 13.9%
respondents could be able to mention three and one
route of spread, respectively (table 1). No significant
difference was observed between knowledge of these
classical routes of transmission and gender of the
respondents.

Knowledge about other routes of transmission: In


this part the students were asked about the routes of
transmission in the form of a closed ended questions.
The knowledge about various routes was as follows (as
shown in table 2); through infected injections (100%),
through blood transfusion (98%), Unprotected Sexual
contact (97.5%), Infected Mother to child (86%). As far
as awareness regarding non-spread is concerned then
the respondents were aware that it doesnt spread
through touching/hand shaking (99.2%), sharing food
(93.4%), using common cups/glasses (89%), used
clothes/towels/soap (88.5%). Regarding other routes the
participants responses included- spread through breast
feeding (26.2%), oral sex (32.8%), kissing (23%) and
mosquito bite (23%). As many as 34% and 68% believed
it to not spread through surgery and tooth extraction
while around 18% responded it to be spread through
coughing.
Knowledge about High Risk Groups: The awareness
about existence of high risk groups for HIV/AIDS was
found to be as follows (table 3); female sex worker
(70.5%), Clients of Female Sex Workers (59.8%),
patients suffering from sexually Transmitted Diseases
(56.6%), recipients of repeated blood transfusion
(54.1%), intra venous drug users (45.9%), truck drivers
(34.4%), men having sex with men (29.4%). There was
no significant difference observed between the
awareness of high risk groups among boys and girls
(p>0.05)
Knowledge about prevention & treatment and
Attitude towards HIV/AIDS: Among all of the study
participants about 34% believed that HIV means AIDS.
As shown in table 4, about 3.3% respondents believed
that there is a permanent cure available for HIV/AIDS,
the availability of any drug effective against this virus
was known to only 36.9%. About 80% (about 82%
females and 78.9% males) respondents admitted to have
discussed about HIV/AIDS ever with anybody, while
about 82% considered safe to working with a patient of
HIV/AIDS. Significantly higher percentage of females
(97.8%) than males (84.2%) believed that the HIV/AIDS
patient should not be excluded from the society. The
percentage of respondents who admitted to have no
problem in sharing room with a patient of HIV was 64%
which was significantly higher (p<0.05) among females
(78.3%)
than
males
(56.6%).

Table 1: Knowledge about four classical modes of transmission*


Male (n=76)
Knowledge about modes of spread
All four routes* reproduced/mentioned
6 (7.9%)
Only 3 routes reproduced/mentioned
19 (25%)
Only 2 routes reproduced/mentioned
33 (43.4%)
Only 1 route reproduced/mentioned
11 (14.5%)
None or none correctly reproduced/mentioned
7 (9.2%)
2
=6.715, d.f.=8, p value=0.568, Not Significant
* participants were asked to mention routes of
transmission in the form of open ended question (the
correct response taken to be 1.unsafe sexual contact, 2.

Sharma et al.,

Female(n=46)

Total (N=122)

5 (10.9%)
14 (30.4%)
12 (26.0%)
6 (13.0%)
9 (19.6%)

11 (9%)
33 (27.0%)
45 (36.9%)
17 (13.9%)
16 (13.1%)

from infected mother to child, 3. transfusion of infected


blood and 4. through infected needle and syringes)

869
Int J Med Res Health Sci. 2015;4(4):868-871

Table 2: Knowledge/Awareness about other routes of transmission (N=122)


Spreads throughYes
Injections
122 (100%)
Infected Blood Transfusion
120 (98.4%)
Unprotected Sexual contact
119 (97.5%)
Infected Mother to child
105 (86.1%)
Tattooing or ear piercing
86 (70.5%)
Breast Feeding
32 (26.2%)
Oral Sex
40 (32.8%)
Kissing
28 (23%)
Mosquito Bite
28 (23%)
During surgery
73 (59.8%)
During Tooth Extraction
22 (18%)
Coughing
23 (18.9%)
Touching/hand shaking
00 (00)
Sharing Food
06 (4.9%)
Using common cups/glasses
11(9%)
Used clothes/towels/soap
10 (8.2%)
Table 3: Knowledge/awareness about High Risk Groups
Male (n=76)
Knowledge about High Risk Groups

Female(n=46)

No
00 (00%)
02 (1.6%)
03 (2.5%)
10 (8.2%)
26 (21.3%)
72 (50.0%)
58 (47.5%)
91 (74.5%)
81 (66.4%)
42 (34.4%)
83 (68%)
89 (73%)
121 (99.2%)
114 (93.4%)
109 (89.3%)
108 (88.5%)

Total (N=122)

Dont Know
00 (00%)
00 (00%)
00 (0%)
7 (5.7%)
10 (8.2%)
18 (14.8%)
24 (19.7%)
03 (2.5%)
13 (10.7%)
7 (5.7%)
17 (14%)
10 (8.1%)
01 (0.8%)
02 (1.6 %)
02 (1.6%)
04 (3.3%)

P value*

Truck Drivers

28 (36.8%)

14 (30.4%)

42 (34.4%)

>0.05

Female Sex worker (FSW)

49 (64.5%)

37 (80.4%)

86 (70.5%)

>0.05

Patients suffering from STDs

42 (55.3%)

27 (58.9%)

69 (56.6%)

>0.05

Intra Venous Drug Users


Men Having Sex with Men

33 (43.4%)
21 (27.6%)

23 (50.0%)
10 (21.7%)

56 (45.9%)
31 (29.4%)

>0.05
>0.05

Clients of FSWs
44 (57.9%)
29 (63.0%)
73 (59.8%)
Recipients of repeated Blood transfusion
38 (50.0%)
28 (60.9%)
66 (54.1%)
*p>0.05 Non significant, p<0.05 Significant
Table 4: Knowledge/ Awareness about prevention & treatment and Attitude towards HIV/AIDS
Variables concerned
Male (n=76)
Female(n=46)
Total
(N=122)
HIV positive means patient is having AIDS
33 (43.4%)
20 (43.5%)
53 (43.4%)
Availability of any drug against HIV
31 (40.8%)
14 (30.4%)
45 (36.9%)
Permanent cure for HIV/AIDS available
2 (2.6%)
2 (4.3%)
4 (3.3%)
Ever discussed HIV/AIDS with anybody
60 (78.9%)
38 (82.6%)
98 (80.3%)
Working with a patient of HIV/AIDS is safe
60 (78.9%)
41 (89.1%)
101 (82.8%)
HIV patient should not be excluded from society
64 (84.2%)
45 (97.8%)
109 (89.3%)
No problem in sharing room with a patient of HIV
43 (56.6%)
36 (78.3%)
79 (64.8%)

>0.05
>0.05

P
value
>0.05
>0.05
>0.05
>0.05
>0.05
<0.05
<0.05

DISCUSSION
Present study was conducted among the first year
students of MBBS, who have spent just 3 months in the
medical curriculum, at the time of survey. As far as the
basic knowledge about HIV/AIDS is concerned, then all
of the respondents were aware about the viral aetiology,
most of the students were aware about the routes of
transmission. This is similar to a study conducted among
first year medical students in Karnataka in which most of
[10]
the students were aware about routes of transmission .
In our study no significant difference was observed
between the knowledge of transmission among male and
[11]
female student, similar to Joshi et al .
Most of the students were aware that it doesnt spread
through touching/hand shaking. In a study conducted
among general population in Karnataka, about one third
of the respondents thought it to be spread it just by

Sharma et al.,

touching a patient who is HIV positive. Some


misconception were also revealed in our study such as,
up to 36% students believed it to be spread through
mosquito bite, 18.9% students believed it to be spread by
coughing and 9% believed it to be spread by using
common utensils. The misconception of spread through
mosquito bite has also been reported among medical
[12]
students by Joshi et al and Basavayya
. In a study
conducted among young college student 6.3%
participants believed that it can be transmitted by
[8]
mosquito bite .
Knowledge and awareness regarding high risk groups
was varied in our study, on one hand as much as 70%
considered the female sex workers to be a risk group the
awareness went on to decrease up to the level that only
29.4% considered the MSMs to be a high risk group. In a

870
Int J Med Res Health Sci. 2015;4(4):868-871

study conducted among the college students, only 47%


[11]
were aware that STDs are at high risk of AIDS .
In our study only 3.3% participants believed that there is
a permanent cure available for HIV/AIDS, while in a study
conducted among the college students 10% believed so
[8]
whereas 45% students in Kerala were aware that AIDS
[11]
is non-curable at present time .
In our study as many as 89% believed that HIV patients
should not be excluded from the society, while 64%
reported to be having no problem in sharing room with a
HIV patient. About 74% college students in another study
[8]
in Lucknow, agreed to share a room with a HIV patient .
CONCLUSION
In our study the knowledge and awareness about
HIV/AIDS among first year medical students was found to
be variable. On one hand most of students were aware
about the basic knowledge while on another hand they
had misconceptions similar to non-medico students.
Considerable percentages of students were having
misconceptions related to transmission such as through
mosquito bite, coughing and sharing utensils. The
awareness regarding the high risk groups for HIV/AIDS
was also found to be very low.
Recommendations: The medical students should be
equipped more especially since the beginning of their
career. The students should also be engaged in the
health education session whereby they can learn by
doing, once they start explaining to the community,
automatically their hidden potentials of the learning will
eventually unfold.
Limitations: The questionnaire used was not a standard
questionnaire but was self-designed, thereby there remains
chances of missing many aspects so this may be counted
as a limitation of the study

4. Pramanik S, Chartier M, Koopman C. HIV/AIDS


Stigma and Knowledge among Predominantly
Middle-Class High School Students in New Delhi,
India. J. Commun. Dis. 2006, 38 (1):57-69.
5. Kumar P, Pore P, Patil U. HIV/AIDS Related KAP
among High-School Students of Municipal
Corporation School in Pune. - An Interventional
Study. National Journal of Community Medicine
2012; 3(1):74-79.
6. Gupta P, Anjum F, Bhardwaj P, Srivastav JP, Zaidi
ZH. Knowledge about HIV/AIDS among secondary
school students. North Am J Med Sci 2013;5: 11923.
7. Lal P, Nath A, Badhan S, Ingle GK. A study of
awareness about HIV/AIDS among senior secondary
school children of Delhi. Indian J Community Med
2008,33:190-2.
8. Dubey A, Sonker A, Chaudhary RK. Knowledge,
attitude, and beliefs of young, college student blood
donors about Human immunodeficiency virus. Asian
J Transfus Sci 2014; 8:39-42.
9. Kumar A, Lal P, Walia M, Arora R, Gulati N.
AIDS
awareness among nursing students of Delhi.
J Commun Dis. 1996; 28(1):207.
10. Joshi AV, Nikam K, Hungund BR, Viveki RG, Nikam
SV, et al. Knowledge about and attitude towards
HIV/AIDS among first year medical students: A
cross-sectional study. J Sci Soc 2013; 40:155-8.
11. Lal SS, Vasan RS, Sharma PS, Thankappan KR.
Knowledge and attitude of college students in
Kerala towards HIV/AIDS, sexually transmitted
diseases and sexuality. Natl Med J India 2000;
13:231-6.
12. Basa vayya GS. Awareness of HIV/AIDS among
medical students. Indian J Public Health
2005;49:31-2

ACKNOWLEDGMENT
The authors are thankful to the students who participated
in the study and the staff of department of community
medicine who actively participated in the data collection
of the study.
Conflict of interest: Nil
REFRENCES
1. Department of AIDS control. Annual Report 2013-14.
Ministry of Health & Family Welfare, Government of
India.
www.naco.gov.in/
upload/2014%20mslns/NACO_English%20201314.pdf
2. National AIDS Control Organization. Ministry of
Health & Family Welfare, Government of
India.http://www.naco.gov.in/NACO/Quick_Links/You
th
3. Unnikrishnan B, Mithra PP, Rekha T, Reshmi B.
Awareness and attitude of the general public toward
HIV/AIDS in coastal Karnataka. Indian J Community
Med 2010;35:142-46.

871
Sharma et al.,

Int J Med Res Health Sci. 2015;4(4):868-871

Available online at: www.ijmrhs.com


Research article

DOI: 10.5958/2319-5886.2015.00174.5
Open Access

TIBIAL TORSION; DOES IT DIFFER IN CHILDREN WITH CONGENITAL TALIPES


EQUINOVARUS (CTEV) COMPARED TO NORMAL ONES?
1

Amol Sanap , Tushar Chaudhari , Binoti Sheth , Dhruvilkumar Gandhi , Kaustubh Gate , Arun AA

ABSTRACT

ARTICLE INFO
th

Received: 6 Aug 2015


th
Revised: 20 Sep 2015
th
Accepted: 25 Sep 2015
1

Authors details: Assistant Professor,


2
Resident,
Department
of
Orthopaedics, Rural Medical College
and Pravara Rural Hospital, Loni,
Maharashtra, India
3
Professor,
Department
of
Orthopaedics,
Lokamanya
Tilak
Medical College, Sion, Mumbai,
Maharashtra, India
Corresponding author:
Tushar
Chaudhari
Resident,
Department
of
Orthopaedics, Rural Medical College
and Pravara Rural Hospital, Loni,
Maharashtra, India
Email: tushu25386@gmail.com
Keywords:
Congenital
equinovarus,
Tibial
Ultrasonography, Articular
Tibial planes

talipes
torsion,
surface,

Background: Congenital talipes equinovarus (CTEV) or clubfoot is one of


the commonest congenital orthopaedic conditions requiring intensive
treatment. A typical clubfoot consists of a deformed foot in equinus ,varus,
adduction. In some cases a cavus component is also there. Tibial torsion
is the angle between the transverse axes of the proximal and distal tibial
articular surfaces. Controversy exists concerning the presence or
absence of excessive medial or internal tibial torsion in CTEV. Materials
& Methods: A cross sectional study was done of thirty consenting
patients with CTEV and thirty children with injuries not involving the tibia
or fibula selected by convenience sampling attending the orthopaedic
clinic of a tertiary care hospital of Western Maharashtra . We measured
the angular difference between the proximal and distal posterior tibial
planes as defined by ultrasound scans thus minimising the error
introduced by the posterior shifting of lower end fibula in the fibular notch
after manipulative correction. The data was entered in excel and
appropriate statistic test was applied. Results: The mean external torsion
of the tibia in children with CTEV was 18 degrees (standard deviation
2.7), which was significantly less than the mean external torsion of tibia in
normal children (38.13 degrees; standard deviation 9.194) (p<0.05).
Conclusions: The children with CTEV have a relative tibial intorsion, as
compared to normal children.

INTRODUCTION
.
Congenital talipes equinovarus (CTEV) usually represents
congenital dysplasia of all musculoskeletal tissues distal to
knee. Incidence is 1-2 /1000 live births, more common in
Hawaiians and Caucasians compared to orientals, 50%
are bilateral, and male to female ratio is 2.5 : 1 .Most of
them are idiopathic but occasionally it may be associated
with other congenital malformations and syndromes such
[1,2]
as Arthrogryposis, myelomeningocoeletc . There have
been many methods for treatment of CTEV such as
Ponseti cast application method, External fixator
[3,4,5]
applications and various osteotomies
.Controversy
exists concerning the presence or absence of excessive
medial or internal tibial torsion. Many studies are
supporting the presence of tibial torsion in clubfoot. Many
of the observers have linked tibial torsion to recurrence of
[6,7]
deformity in treated clubfeet .The problem of whether
tibia has an abnormal torsion in clubfoot can only be
solved by measuring the relative alignment of its proximal
and distal articular surfaces ; this has not proved possible
in vivo . CT scans and ultrasonography have both been
used to produce images of the proximal and distal juxtaarticular surfaces of the tibia. These surfaces are thought
to relate closely to the plane of the nearby joint and can
therefore be used to measure tibial torsion. An
ultrasonography involves no ionising radiation and hence

can safely be used for this purpose. Different researchers


measure tibial torsion with different methods and reference
lines, resulting in a huge variation in the reported normal
[1,2,6,7,8]
ranges of tibialtorsion
. Each method has its own
advantages and disadvantages and no conventional
technique for routine assessment of tibial torsion has
[6,9]
gained wide acceptance yet
. The aim of the present
study was to measure tibial torsion with the help of
ultrasonography in children having CTEV and to compare
it with the tibial torsion in normal children measured
similarly.
MATERIALS AND METHODS
Study design: A analytical cross sectional study
Ethical approval: Approval of ethics committee of our
college was obtained. The informed consent form from the
parents was obtained.
Sample size: Thirty consenting patients with CTEV and
thirty patients with normal foot selected by convenience
sampling attending the Orthopaedic clinic of a tertiary care
hospital of Western Maharashtra over a period of 2 years
as per following inclusion criteria:
Inclusion criteria: Patients with diagnosis of CTEV under
12 years of age, patients with no history of fracture

872
Tushar et al.,

Int J Med Res Health Sci. 2015;4(4):872-875

involving the study leg, patients with no history of any bony


surgery done over study leg, Patients who were able to cooperate for the examination e.g. ability to lie immobile for
the period of examination.
Exclusion criteria: Patients whose parents were not
consenting for the investigation, patients who were unable
to co-operate for the procedure, Patients above 12 years
of age, Patients in whom any bony procedure was done as
treatment, patients who sustained any fracture in the study
leg in the past.
Study procedure:
Ultrasound study: Ultrasonography was done by using
7.5 MHz probe of a real time ultrasound without any prior
[6,9]
preparation required of the patient
.
Scanning technique: The child was asked to lie in prone
position on a firm table with the leg supported motionless
by a seated assistant.
The 7.5 MHz probe of a real time ultrasound scanner was
maintained in a vertical position for proximal & distal
measurement. The angular difference between the
proximal & distal posterior tibial planes was determined by
scans immediately distal to the proximal tibial articular
surface & just proximal to the ankle. The articular surface
of tibia was seen as a prominent line on the screen. Once
the proximal tibial articular surface line was determined,
the image was saved. With the patient in same position,
the ultrasonography probe was moved to distal articular
level of tibia. The distal tibial articular margin was
determined similar way. Again the image was saved. All
ultrasound settings were maintained same throughout the
procedure. With both the images side by side , print was
taken. The angle between proximal and distal tibial
articular surface was calculated which was the tibial
torsion. (fig 1&2)

Statistical analysis: Mann Whitney test was used for data


analysis as the values of tibial torsion in normal as well as
in children with congenital talipes equinovarus were
showing skewed distribution.
RESULTS
Thirty patients with CTEV deformity were studied for tibial
torsion with the help of ultrasonography by the method
described earlier. All patients were of the age below twelve
years. Thirty more children with normal feet were studied
for tibial torsion with the help of ultrasonography as control
group.
In normal children the distal posterior tibial plane was
found to be externally rotated in relation to the proximal
posterior tibial plane. Combining readings from right and
left legs, the mean external torsion was 38.13 degrees(
standard deviation 9.194 degrees) . There was no
significant difference in the mean angle at different ages (
p< 0.05).
Children with CTEV had the mean external torsion of the
tibia in the affected leg or legs of 18 degrees (standard
deviation 2.7), which was significantly less than
38.13degrees; the mean angle of control legs ( p< 0.05 ).
We used Mann Whitney test to compare the results of the
study and control group. The p value came out to be less
than 0.05.
Thus we conclude that children with CTEV had less
external torsion in tibia, as compared to normal children.
Table 1: values of mean external rotation in study and
comparison groups

GROUP
Tibial Study
torsion
Comparison

Fig 1:
Determination
ultrasonography

of

proximal

tibial

plane

Meanexternal
torsion
in Mean Sum of
Rank Ranks
degrees

30

182.7

16.02 480.5

30

38.139.19

44.98 1349.5

Mann-Whitney U

15.500

p value

< 0.05*

by

Fig 2: Determination of distal tibial plane by ultrasonography

Fig 3 : Graphical presentation of the tibial torsion


values in study and comparison groups

873
Tushar et al.,

Int J Med Res Health Sci. 2015;4(4):872-875

Fig 4:
Left half of image showing ultrasonographic
representation of proximal tibial plane with long black arrow
and right half showing the distal tibial plane with a short
black arrow.

DISCUSSION
Clubfoot deformity was first described by Hippocrates
around 300 B.C. Since then many people have done
research on clubfoot and its management. Descriptions
of pathological anatomy in clubfoot can be found in
some of the earliest orthopaedics writings and continue
to be essentially correct today, even as we have more
sophisticated methods of imaging to quantitate that
deformity.
Several authors have called attention to the internalrotation deformity within the long axis of the tibia, which
not infrequently accompanies congenital club-foot. Thus
every one interested in the treatment of club feet
recognizes this concomitant deformity, but opinion is
[10]
divided with regard to its correction. Campbell
in his
recent book stated that, with rare exception, the internalrotation deformity of the tibia may be disregarded from a
surgical viewpoint. In an endeavor to clarify his own
position, he reviewed a series of sixty-two consecutive
cases of congenital club feet that had been followed for
periods varying from two to five years, and the conclusion
was reached that not only does tibial torsion accompany
club-foot in a higher percentage of cases than was
formerly believed, but it also occurs in sufficient degree to
warrant surgical correction.
It was during the follow-up period on some cases of
bilateral club-foot that attention became focused upon
tibial torsion as a factor in recurrence of the deformity.
Previously it was noted that adduction was the chief
deformity recurring in those feet which relapse, and closer
observation has now- revealed that in over 90 percent of
these cases tibial torsion was present in the leg which
showed recurrence and absent in the others which had
maintained its correction.
Before the equinovarus deformity has been corrected it is
often difficult to determine whether internal rotation of the
tibia is present, or if present to what degree. However,
after the equinovarus has been corrected and the Child is
walking, it is easy to detect tibial torsion, since the child
invariably toes in on the affected side. A line dropped
from the anterior superior spine of the ilium, bisecting the
patella, will fall to the lateral border of the foot. Outside the
little toe, instead of between the great and second toes as
is normal. With the patella pointing straight forward,

palpation of the malleoli at the ankle will show the external


malleolus to be anterior to the medial malleolus instead of
parallel to it as is normal. Thus, when the child is walking,
the weight-bearing thrust falls obliquely across the long
axis of the foot and drives the navicular around to the
medial side of the head of the talus with recreation of the
adduction deformity of the forefoot. If this same vicious
force is allowed to continue, varus of the heel and
inversion of the foot will follow the adduction deformity.
These undesirable sequelae to correction of clubfoot can
be obviated if a rotation osteotomy of the tibia is done
when tibial torsion is present.
For that matter, we require a method to measure tibia l
torsion, which is simple, less time consuming, easily
available, with no health hazards to patients, and as
accurate as possible.
There are several publications on precise methods for
measuring tibial torsion.
The method described by Tohno at the 12th congress of
SICOT in 1973, using axial tomography, is perhaps the
most precise, but is also the most complicated, costly and
time consuming. On the other hand our method is simple,
cost effective, less time consuming and as precise as the
method described by Tohno.
Some of the simpler clinical methods as reported by
[11]
[12]
Dupuis in 1951 or Weissman in 1954 use the patella
as a point of reference, so that the resultant values
obtained are a combination of rotation at the knee and
torsion of the leg itself. Thus they are less accurate. The
[13]
X-ray measurement described by Rosen & Sandick
(1955) is relatively costly, with some radiation hazards and
time consuming as compared to the simpler clinical
methods and is no more precise. With the tropometer and
the caliper--the main practical difficulty was exact location
of the medial malleolus in severely deformed feet of small
children. This accounted for the difference in values as
reported by two observers. The caliper appeared,
however, to give more reproducible results. It is generally
agreed that clinical methods for measuring tibiofibular
torsion are subject to a wide range of inter-observer error
[14]
(Luchini and Stevens
1983). They all use the
bimalleolar plane as the distal line of reference ; the
malleoli are not easily defined, and the fibula is potentially
mobile within the fibular notch (Khermosh, Lior and
Weissman 1971).This is not a problem with our method as
we depend on articular margin of tibia which can be
[15]
objectively localized by ultrasonography. Joseph
et al
1987 reported the results of many of the previous studies
of tibiofibular torsion. Methods using a torsionometer
applied to the malleoli produced mean values in normal
children of less than 20 degrees (Wynne-Davies l964;
Turner and Smillie 1981). These results were confirmed by
Hutchins et al (1986) who used computerised tomography
(CT). Measurements of torsion in which the posterior tibial
surfaces are defined by CT scans or ultrasound, are more
accurate (Butler-Manuel, Guy and Heatley 1990).
Thus, in the normal child, the bimalleolar plane is
[16]
externally rotated. Hutchins
et al (1986) found that the
bimalleolar plane became more externally rotated during
growth, the torsion being only about 10 degrees in the
neonate, confirming reports of others who have used the
malleoli as the distal reference plane (Ritter, De Rosa and

874
Tushar et al.,

Int J Med Res Health Sci. 2015;4(4):872-875

Babcock 1976; Staheli et al 1985). According to Lloyd


[17]
Roberts et al.
(1974) and Swan et al (1969), the hind
foot and ankle mortise of incompletely corrected clubfeet
are laterally rotated on a tibia which itself has no rotational
deformity. Such a rotation is a complication of previous
treatment.
Our study shows that ultrasonography can be effectively
used to measure tibial torsion. It is safe, simple, quick and
very precise .Also ultrasonography is available at most of
the places.
Our results show that external torsion is diminished in the
affected legs of patients with CTEV.
The mean external torsion was 38.13degrees (standard
deviation 9.194 degrees), in children with CTEV compared
to 18 degrees (standard deviation 2.7) in normal children.
We found no limitation to our study.
As the values of tibial torsion in normal as well as in
children with CTEV were showing skewed distribution,
Mann Whitney test was applied for statistical analysis. The
difference found was statistically significant ( p< 0.05 )
.Thus children with CTEV have a relative internal tibial
torsion, despite treatment involving repeated dorsiflexion
and eversion. We believe such manipulation may be
responsible for the clinical observation of posterior
displacement of the distal fibula (Swann et al 1969).
Wynne-Davies (1964a) reported such displacement as
seen on lateral radiographs of the feet of patients with
CTEV. However, for such views the radiographer places
the plate parallel with the forefoot, and any residual
forefoot adduction may lead to an apparent posterior
displacement of the fibula (Simmons 1978).
If manipulation leads to fibular displacement it may also be
responsible for the late stiffness found in the feet of
children with CTEV. We hope in the future to define fibular
position at various stages during therapy using ultrasound
or CT scans in the transverse plane. External tibial
osteotomy seems only appropriate in these rare instances
of marked internal torsion which are not associated with
posterior fibular dislocation. One hesitates to draw a hard
and fast limit to the degree of deformity which requires
attention, since correction means an open operation on a
young child. Many of the surgeons feel, however, that no
tibial torsion of 15 degrees or more should be disregarded.
There is an advantage in derotating the tibia as soon as
the foot is corrected, because the child is already
accustomed to the plaster casts.
We look forward to find out the relation between the
abnormal tibial torsion and recurrence of deformity or
under correction of deformity in children with CTEV in our
future study so that these problems can be anticipated and
addressed early.

Acknowledgement: We acknowledge the co-operation


and support given to us in this endeavour by the
Department of Orthopaedics and Department of Radiology
Conflict of Interest: We had no conflicts of interest
REFERENCES
1.

Staheli LT, Corbett M, Wyss C, King H. Lowerextremity rotational problems in children. Normal
values to guide management. The Journal of Bone
and Joint Surgery.1985; 67, 39-47.
Staheli LT, Engel GM. Tibial torsion: a method of
assessment and asurvey of normal children. Clinical
Orthopaedics and Related Research 1972; 86, 183-86

2.

3.

Penny JN.

4.

5.

6.

7.

8.

9.
10.

11.
12.

13.

14.
15.

16.

CONCLUSION
17.
Our results show that external torsion is diminished in the
affected
legs of patients with
congenital talipes
equinovarus. Thus they have a relative internal tibial
torsion, despite treatment involving repeated dorsiflexion
and eversion. Hence we propose that ultrasonogtraphy is
an inexpensive, readily available, less hazardous and
effective tool to find out the proximal and distal tibial
planes and to calculate the angle between them i.e. the
tibial torsion.

The Neglected Clubfoot. Techniques in

orthopaedics. 2005; 20(2) : 153-166


Loureno AF, Morcuende JA. Correction of neglected
idiopathic clubfoot by Ponseti method. J Bone Joint
Surg Br. 2007: 89(3):378-381
Amin Abdel-Razak YA. The use of Ilizarov method in
management of relapsed club foot, Foot and ankle
orthopaedics 2010; 33(12) : 881
Milner CE, Soames, RW. A comparison of four in vivo
methods of measuring tibial torsion. Journal of
Anatomy 1998; 193: 139-144.
Wynne - Davies R. Talipes Equinovarus. A review or
eighty-four cases after completion of treatment.
Journal of Bone and Joint Surgery 1964; 46 B: 464
476
Herold HZ, Marcovich C. Tibial torsion in untreated
congenital
clubfoot.ActaOrthopaedicaScandinavica
1976; 47: 112-117.
Benjamin Joseph : Radiology in clubfoot Ind. Jurnol of
Orthopaedics.1981; 15 : 136-149
Beaty JH, Congenital clubfoot (talipes equinovarus).
In : Canale ST, editor. Campbells operative
orthopaedics. Mosby: Philadelphia; 2003 p. 988-1006.
Dupuis P. La torsion tibiale. Masson et Cie, Paris
1951
Weissman SI. External deformity? Of the leg following
poliomyelitis. Acfamrdicaorient. (Tel-Aoio) 1954; 12:
83-90.
Rosen, H. Sandick, H. The measurement of
tibiofibular torsion. J. Bone Jt Surg 1955 ;37-A(4):
847-855.
Luchini M, Stevens DB. Validity of torsional profile
examination. JPediatrOrthop1983; 3:41-4.
Joseph B, Carver BA, Bell MJ. Measurement of tibial
torsion by ultrasound. JPaediatr Orihop1987; 7:31723.
Hutchins PM, Rambicki D, Comacchio L, Paterson
DC. Tibiofibular torsion in normal and treated clubfoot
populations. J PediatrOrthop1986;6(4) : 452-455
Lloyd-Roberts GC, Swann, M. & Caterall, A. Medial
rotational osteotomy for severe residual deformity in
club foot. J. Bone Jt Surg. 1974; 56-B: 37-43

875
Tushar et al.,

Int J Med Res Health Sci. 2015;4(4):872-875

Available online at: www.ijmrhs.com


Research article

DOI: 10.5958/2319-5886.2015.00175.7
Open Access

A STUDY ON SERUM FSH, LH AND PROLACTIN LEVELS AMONG INFERTILE WOMEN


1

Prasad Bheem , Parmar Dinesh , Sharma NC

ARTICLE INFO
th

Received: 26 Aug 2015


th
Revised: 12 Sep 2015
th
Accepted: 24 Sep 2015
1

Author details:
Department of
Anatomy, All India Institute of Medical
Sciences, Patna, Bihar, India.
2
Department of Biochemistry &
Genetics,
Barkatullah
University,
Bhopal, Madhya Pradesh, India.
Corresponding author: Bheem Prasad,
1

Department of Anatomy, All India


Institute of Medical Sciences, Patna,
Bihar, India
Email: prasadbheem@gmail.com
Keywords:
Follicle
Stimulating
hormone,
Infertility,
Luteinizing
hormone, Ovulation, Prolactin.

ABSTRACT
Background: Study of hormonal imbalance and its implications in female
infertility are an interesting area that requires to be explored in recent time.
Hormonal imbalance can associated with irregular menstrual cycle,
Amenorrhea, obesity and infertility in women. Other medical conditions such
as polycystic ovarian syndrome, Endometriosis, stress, sexually transmitted
diseases and chromosomal anomalies may be responsible for infertility in
females. Objective: The aim of the present study was to evaluate the serum
levels of Follicle Stimulating hormone (FSH), Luteinizing hormone (LH) and
Prolactin hormone in infertile women that were referred from different infertility
clinics and centres. Materials and Methods: This study comprises total 176
female subjects with age ranging from 20 to 40 years and divided in two
groups. The total number of 88 infertile women along with 88 fertile women as
controls was included for the present study. Serum FSH, LH and Prolactin
levels were estimated by enzyme-linked immunosorbent assay (ELISA)
methods. Results: The results showed maximum infertile women were found
between the age group of 30-40 years. The Serum FSH, LH and Prolactin
levels among infertile women was 8.774.65, 7.645.16 and 18.597.50
respectively. Whereas, levels of FSH, LH and Prolactin in fertile women
showed that 6.714.12, 5.663.17 and 13.445.82 respectively. Conclusion:
In this study, we found that the hormone levels have statistically significant
with female infertility. The elevated levels of FSH, LH and Prolactin may be
one of the important causes for infertility in women.

INTRODUCTION
Infertility is described as failure to conceive after one year
[1]
of unprotected intercourse. The percent of infertility is
reported to be 10-15% worldwide. It is estimated that
infertility affects globally 50 to 80 million people and
currently 8-10 million infertile couples are estimated to be
[2]
in India. The major causes of female infertility may
include blockage of the Fallopian tubes, pelvic
inflammatory disease, age factors, chromosomal
anomalies,
Amenorrhoea
and
endocrinological
[1,3]
dysfunctions.
Infertility has been associated with
various anthropometric parameters and socioeconomic
[4,5]
conditions.
The association of age and infertility are
reported in several studies. The aged women decline their
[5,6]
fertility with time span.
Hormonal imbalances have been associated with female
infertility. The increased or decreased levels of FSH, LH
and Prolactin hormones may cause infertility. FSH and LH
hormones belong to glycoprotein family and play an
important role in follicular development and production of
[7-11]
oestrogen.
The study aimed to evaluate the serum
levels of Follicle Stimulating hormone, Luteinizing
hormone and Prolactin hormone in infertile women.
MATERIALS AND METHODS
Study design: Analytical cross sectional study
Study place and duration: All the subjects were enrolled
during July 2009 to January 2011 from different infertility

Bheem Prasad et al.,

clinics and centres in Bhopal and Rewa district of Madhya


Pradesh, India.
Ethical approval: This study was approved by the ethical
committee of the Institute and obtained written consent
from all the subjects.
Inclusion criteria: The inclusion criteria for the enrolled
infertile subjects were diagnosis of infertility, age (range
20-40 years) and duration of marriage more than two
years.
Exclusion criteria: The exclusion criteria were infertility
due to male factor, tubal factor, anatomical anomaly of the
urogenital tract and any organic lesion. The subjects with
sexually transmitted diseases were also excluded from the
study.
Sample size: One seventy six
Grouping: The present study included 176 women
subjects and grouped them into infertile (n=88) and fertile
as a control (n=88). 88 normal women with at least one
child birth belonging to the same age group and
socioeconomic status were selected as a control group.
Methodology: Five ml of whole blood was taken
aseptically through antecubital vein from the subjects in
the fasting state during mid cycle 14-16 day. The whole
blood was allowed to clot, thereafter, serum was decanted
0
and used for analysis. The serum was kept at -20 C and
[8]
assay were completed within three days. FSH, LH and
Prolactin
hormone
levels
were
evaluated
by
Immunoenzymetic assay by ELISA Reader with standard
[9]
kits.

Int J Med Res Health Sci. 2015;4(4):876-878

876

Statistical analysis: The student t-test method was used


for statistical analysis and the results were showed in the
form of a table.
RESULTS
A total of 88 infertile women were involved in the present
study. The maximum infertile women population was found
between the age group of 30-40 years. The ratio of
patients to control was 1:1. Table I depicts that detailed
hormone levels in control and infertile group. We found
that mean serum level of FSH of 8.774.65 mIU/ml in
infertile women was higher than mean serum levels of
FSH of 6.714.12 mIU/ml in fertile women that were
statistically significant (p=0.0022). The mean serum level
of LH was 7.645.16 mIU/ml in infertile women was higher
than mean serum level of LH of 5.663.17 mIU/ml in fertile
women which were statistically significant (p=0.0025). The
mean serum level of Prolactin was 18.597.50 ng/ml in
infertile women was higher than the mean serum level of
Prolactin of 13.445.82 ng/ml in fertile women which was
highly significant (p=0.0001).
There was statistically significant difference between
levels of serum FSH, LH and Prolactin in infertile and
fertile women as shown in Table I.
Table I: Hormone levels in Fertile and Infertile women.
Parameter Control
Infertile
t-value p-value
Group
Group
FSH
6.714.12 8.774.65
3.11
0.0022**
(mIU/ml)
LH
5.663.17 7.645.16
3.06
0.0025**
(mIU/ml)
Prolactin 13.445.82 18.597.50 5.09
0.0001***
(ng/ml)
**Very Significant, ***extremely significant, Data
expressed as MeanSD.
DISCUSSION
Female infertility is multi factorial, but primarily it is due to
ovulation problems, blockage of Fallopian tube, uterine
problem, stress, obesity, infectious disease and hormonal
[10]
imbalance etc. Scott et al., (1989) and Ban et al., (2013)
found a significant association between hormonal
[11,12]
imbalance and female infertility.
Fertility has been
associated with various anthropometric parameters and
socioeconomic conditions.
This study was carried out to determine the levels of FSH,
LH and Prolactin in infertile women. The increased levels
of FSH, LH and Prolactin were found in infertile group
when compared with the control group. These findings are
in agreement with Ban et al., (2013) and Aroma et al.,
[12,13]
(2014).
Scott MG et al., (1989) and Choudhury et al.,
(1995) reported that the elevated levels of Prolactin
hormone are very common in infertile women as
[11,14]
compared with fertile women.
In the present study FSH levels were significantly higher in
infertile women compared with fertile women. FSH is the
predominant circulating gonadotropin hormone in women.
During the ovulation cycle, it is stimulating the
development of ovarian follicles and a selection of the

Bheem Prasad et al.,

dominant follicle. The LH levels were significantly


increased in infertile women compared with fertile women.
Generally, increased LH levels are associated with ovarian
[12,13]
dysfunction.
Aroma et al., (2014) emphasized that
increased FSH, LH and Prolactin levels are significantly
[13]
associated with infertile women.
The serum Prolactin levels were increased in infertile
women as compared to fertile women. The main function
of Prolactin is the development and regulation of lactation
in females. The increased levels of Prolactin results in
amenorrhea, unexpected lactation, hypoestrogenism and
lack of ovulation. The present study showed that the
hyperprolactinemia as the cause for infertility in women.
Similarly, increased levels of Prolactin have also been
reported by Parijatham and Saikumar (2014), Goswami et
[15-17]
al., (2009) and Kumkum et al., (2006).
Follicle Stimulating hormone and Luteinizing hormone play
a very important role in follicle development and oestrogen
production. The hormonal imbalance is associated with
infertility in women. The increased or decreased levels
[18,19]
have an impact on ovulation and menstruation.
Many
studies showed that the hormonal imbalance is in not only
associated with chronic disease, but it also has the risk of
[20,21]
infertility.
The results indicated elevated levels of
FSH, LH and Prolactin in infertile women. The Prolactin
levels are high in infertile women as compared to fertile
women. These results are in agreements with Ban et al.,
(2013) and Aroma et al., (2014) who also found increased
[12,13]
levels of FSH, LH and Prolactin in infertile women.
CONCLUSION
The increased hormonal levels of FSH, LH and Prolactin
were found in infertile women as compared to the control
group. We should analyse the responsible factors for
elevated levels of FSH, LH and Prolactin. The increased
levels of hormone may be associated with infertility and
other clinical manifestations. The elucidation of such
studies helps us to achieve a more thorough
understanding of female infertility. This study will be very
useful in prevention and management of infertility. This
can establish counseling strategies possible for those who
are affected by the reproductive dysfunction. Endocrine
tests should be undertaken to identify all infertile women.
Limitation of study: Large scale studies are required to
confirm further results.
Acknowledgments: We are grateful to Dr. Sarvesh
Saxena, Saxena Infertility & Diagnostic Research Centre,
Rewa and Dr. Abha Jain, Life Line Hospital, Bhopal for
providing the samples for the study.
Conflict of interest: We declare that we have no conflicts
of interest.

REFERENCES
1.
2.

Balen AH and Rutherford AJ. Management of


infertility. J Mol Biol. 2007;335: 608-11.
Sciarra J. Infertility: An international health problem.
Int J Gynaecol Obstet. 1994 Aug;46(2):155-63.

Int J Med Res Health Sci. 2015;4(4):876-878

877

3.

4.

5.

6.
7.

8.
9.

10.

11.

12.

13.

14.

15.

16.

17.

Prasad B. and Jain R. The cytogenetic basis of


human infertility: A review. IOSR JDMS. 2014
Aug;13(8): 83-8.
Kumar D. Prevalence of female infertility and its socioeconomic factors in tribal communities of Central
India. Rural remote Health. 2007 Apr-Jun;7(2): 456.
Rich-Edwards JW, Spiegelman D, Garland M,
Hertzmark E, Hunter DJ, Colditz GA, Willett WC. and
Manson JE. Physical activity, body mass index and
ovulatiory disorder infertility. Epidemiology. 2002
Mar;13(2): 184-90.
Menken J, Trussell J. and Larsen U. Age and
infertility. Science. 1986 Sep 26;233 (4771): 1389-94.
Mohan K and Sultana M. Follicle Stimulating
Hormone, Luteinizing Hormone and Prolactin Levels
in Infertile Women in North Chennai. J Bio Sci Res.
2010;1(4): 279-84.
Saxema BB and Demura HM. Determination of FSH.
J Clin Endocrinol Metab. 1968;28: 591.
Odell WD and Parlow AF. Estimation of FSH test
assay. Journal of clinical investigation. 1981;47: 2551.
Roupa Z, Polikandrioti M, Sotiropoulou P, Faros E,
Koulouri A and Wozniak G. Causes of infertility in
women at reproductive age, Health Science J. 2009;3:
80-7.
Scott MG, Ladenson JH, Green ED. and Gast MJ.
Hormonal evaluation of female infertility and
reproductive disorders. Clin Chem.1989 Apr;35(4):
620-9.
Ban Mousa Rashid, tayfoor Jalil Mahmoud and
Beston F. Nore. Hormonal study of primary infertile
women. Journal of Zankoy sulaimani-Part A (IJS-A)
2013;15(2): 137-43.
Aroma Solomon Odiba, Parker Elijah Joshua,
Chimere
Young
Ukegbu
and
Iruoghene
Onosakponome. Evaluation of the quantitative
expression and correlation between follicle stimulating
hormone (FSH) and Luteinizing hormone (LH) during
follicular phase in primary infertile women of
reproductive age. IOSR JDMS. 2014 Jan;13(1): 60-5.
Choudhury SD and Goswami A. Hyperprolactinemia
and reproductive disorders--a profile from north
east. J Assoc Physicians India. 1995;3(9): 6178.
Parijatham S Saikumar P. Serum levels of Follicle
Stimulating Hormone, Luteinizing Hormone and
Prolactin in Primary female infertility in rural
population. Research Journal of pharmaceutical,
Biological and Chemical sciences. 2014;5(2): 1155-8.
Goswami B, Patel S, Chatterjee M, Koner BC and
Saxena A. Correlation of Prolactin and Thyroid
Hormone Concentration with Menstrual Patterns in
Infertile Women. J Reprod Infertil. 2009;10(3): 207-12.
Kumkum A, Jasmine K, Shweta G and Pal Ajeshwar
N. Hyperprolactinema and its coorelation with

Bheem Prasad et al.,

18.

19.

20.

21.

hypothyroidism in infertile women. J Obstet Gynecol


India. 2006;56(1): 6871.
Mohammed A. Z. Correlation of Prolactin and Thyroid
Hormone Concentration with Menstrual Patterns in
Infertile Women. Ann Afr Med;2003; 4: 3.
Mishra R, Baveja R and Gupta V. Prolactin level in
infertility with menstrual irregularities. J Obstet
Gynecol India. 2002;52: 403.
Singh VK and Vishnol K. A. Study of uterine and
serum Prolactin in cases of female infertility of
unknown aetiology. J Obstet Gynecol India. 1981;31:
788 -93.
Iris. A, Kawuwa MB, Habu SA and Adebayo A.
Prolactin Levels among infertile women in Maiduguri,
Nigeria. Trop J Obstet Gynaecol. 2003;20: 97-100.

Int J Med Res Health Sci. 2015;4(4):876-878

878

Available online at: www.ijmrhs.com

DOI: 10.5958/2319-5886.2015.00176.9

Research article

Open Access

MEDICAL AUDIT OF CHILDREN WITH AMBIGUOUS GENITALIA- REVIEW OF


CHILDREN TREATED OVER 18 YEARS
Praburam P. M

ARTICLE INFO
th

Received: 04 Sep 2015


th
Revised : 14 Sep 2015
th
Accepted: 27 Sep2015
Authors details: Department of Child
Health, Christian Medical College and
Hospital, Vellore, India
Corresponding author: Praburam
P.M.
Department of Child Health, Christian
Medical College and Hospital, Vellore,
India.
Email: praburampm@gmail.com
Keywords: Ambiguous genitalia,
intersex, hermaphrodite, congenital
adrenal hyperplasia, hypogonadism.

ABSTRACT
Introduction: The survival of a newborn or a child presenting with ambiguous
genitalia depends upon the timely diagnosis and institution of appropriate
medical care. We undertook this study with the aim to determine if appropriate
clinical and confirmatory diagnosis was arrived on time and if the treatment
instituted was relevant and satisfactory. Methods: All children who were
evaluated for ambiguous genitalia under the Department of Pediatric
Endocrinology over the preceding 18 years were invited for a review. Data
including time taken to make a clinical diagnosis, time taken to confirm the
diagnosis, reasons for delay if any, and appropriateness of the sex assigned for
rearing and treatment instituted were collected from the charts. Patients were
evaluated for adequacy of response to treatment, compliance, problems
encountered if any and subjective parental satisfaction. Results: A total of 165
children were diagnosed to have conditions with ambiguous genitalia and were
called for a review. 33 children attended the review. 15 were being raised as
boys and 18 as girls. 12 children had virilising congenital adrenal hyperplasia
(CAH), 6 had cryptorchidism, 6 had hypospadias, 3 had complete and 1 had
partial testicular feminisation, 2 had mixed gonadal dysgenesis (MGD), 2 had
hypogonadism and 1 was a true hermaphrodite. An appropriate clinical diagnosis
was made in 30childrenon the day one and a final confirmatory diagnosis was
made within a month in 23. Conclusion: In most conditions presenting with
ambiguous genitalia, a clinical and confirmatory diagnosis can be made in a short
duration. Initiation of appropriate treatment results in favourable outcomes in
terms of growth sexual identity and adaptation.

INTRODUCTION
A neonate with abnormal genitalia presents with a difficult
diagnostic and treatment challenge. Relevant clinical
findings and investigations are useful in making an
accurate diagnosis. Specific guidelines are available for
[1, 2, 3]
the same
. It becomes essential to make a definitive
diagnosis at the earliest to initiate appropriate treatment
and minimize complications.
Ambiguous genitalia is defined as a condition in which
there is difficulty in assigning sex of an individual based
[4]
on the appearance of external genitalia . The term
ambiguous genitalia applies to any confusing appearance
[5]
of the external genitalia .This includes any infant with
1. A phallus but bilaterally un palpable testes
2. Unilateral cryptorchidism and hypospadias
3. Penoscrotal or perineoscrotal hypospadias, even if
the testes are descended
If an infant has a phallus that is intermediate in size
between a normal penis and a normal clitoris, an
aberrantly located urethral opening, and at least one
impalpable gonad, the term ambiguous genitalia may be
[2]
used .
Aims and objectives
1. To identify the time interval from presentation to
diagnosis and the reason for any undue delay if
present.
2. To assess the appropriateness of the final diagnosis
based on the investigations done.

3. To assess the compliance with drugs, follow up and


advice given to patients who came for review.
4. To assess the appropriateness of the current height,
growth velocity and pubertal stage for age.
5. Identify and enlist problems faced by the child or parent
and suggest remedial measures.
MATERIALS AND METHODS
Study Design: A retrospective, descriptive study using
review of charts and a clinical reassessment of patients
who were diagnosed to have a condition with ambiguity
of genitalia over the prior 18 years by the
Department of Pediatric Endocrinology, Christian Medical
College, Vellore. After ethical clearance, 165 patients
who were diagnosed to have a condition with ambiguity
of genitalia were invited by post for a review. Inclusion
Criteria: All patients who attended the review and had a
condition causing ambiguity of genitalia as final diagnosis
were included in to the study.
Exclusion criteria: Patients who did not attend the review
were excluded. 33 patients attended the review and had
a condition causing ambiguity of genitalia and were
included in to the study after an informed consent.
Data Collection: Data including age at presentation,
clinical diagnosis, time taken for assigning a clinical
diagnosis, investigations done, treatment given and time
taken for assigning a final diagnosis were collected from
the charts. Patients were assessed for response to

879
Praburam

Int J Med Res Health Sci. 2015;4(4):879-883

treatment, growth, bone age, compliance with treatment


and satisfaction with sex assigned for rearing.
Statistical analysis: Percentage, mean and range were
used to describe continuous and categorical variables,
respectively.
RESULTS
Data from 33 patients who attended the review was
collected and evaluated. 15 children (45%) were being
raised as boys and 18 (55%) were being raised as girls.
Virilising Congenital Adrenal Hyperplasia (CAH) was the
commonest diagnosis and was made in 12 (37%)
patients. Cryptorchism and Hypospadias (penoscrotal
and perineoscrotal) were the next common cause with 6
children in each group. This was followed in frequency by
Testicular Feminisation (complete - 3, partial 2), Mixed
Gonadal Dysgenesis (2), Hypogonadism (2) and true
hermaphroditism (1).

Fig 1: Final Diagnosis of Children Presenting with


Ambiguous Genitalia
Virilizing
Congenital
Adrenal
Hyperplasia
(A),
Cryptorchidism (B), Hypospadias (C), Complete
Testicular
Feminization
(D),
Partial
Testicular
Feminization (E), Mixed Gonadal Dysgenesis (F),
Hypogonadism (G), True Hermaphrodite (H). As evident
from the figure CAH was the commonest diagnosis in our
study.
Five children were on follow up for more than 15 years, 6
between 10 to 15 years, 13 between 5 to 10 years and 9
were on follow up for less than 5 years. This long period
of follow up allowed us to study the effect of treatment on
long term outcomes like height attained, growth velocity
and age of onset of pubertal changes.
Table 1: Duration of follow up
Duration of
follow up

Number of
Patients

Percentage

Less than 5 years

27

5 to 10 years
10 to 15 years

13
6

40
18

More than 15 years

15

presentation.One of these children presented as a girl


with inguinal hernia, no ambiguity was suspected and
testes were detected per operatively. The other two
patients (both had mixed gonadal dysgenesis) were not
given an exact diagnosis till the surgery and biopsy were
undertaken. In 23 children an appropriate confirmatory
diagnosis was assigned following investigations. Delay in
8 children were due to delay in performing karyotyping
(4), hormonal investigations (3) or biopsy (1), and in two it
was due to patients social factors like delay in returning.
Table 2: Reasons for Delay in Diagnosis
Reason for delay

Number

Percentage

Biopsy awaited

10

Karyotype awaited

40

Hormonal
investigations

30

Delay in follow up

20

Total

10

100

All the patients who came for the review had diagnoses
[1]
which were appropriate as per the AAP guidelines .All
the patients with mixed gonadal dysgenesis, testicular
feminization or true hermaphroditism had undergone a
karyotyping. But only 4 patients with congenital adrenal
hyperplasia and 2 patients with perineoscrotal
hypospadias had had a karyotyping done. None of the
patients with cryptorchidism or hypogonadism were
subjected to karyotyping.
Medical management of children with CAH: All the 12
children with CAH claimed to be on very regular
treatment and apparently dont miss even a single dose
except on a very rare occasion. All of them were
satisfied with the outcome. They all had an understanding
of the risks of discontinuing treatment and the need to
modify drug dosages during illnesses. Also they were
compliant with the advices given. Height for age in all
rd
th
these was between the 3 and 97 centile, but the
th
growth velocity was below the 50 centile in 5 (41%).
Table 3: Height for Age at Review
Number
of patients

Percentage

58

42

>97 centile

Total

12

100

Final height
rd

<3 centile
rd

Total
33
100
Thirty of the 33 patients who attended the review had an
appropriate clinical diagnosis assigned on the day of
presentation. For 3 children an appropriate clinical
diagnosis was given only after a month since

th

3 to 50 centile
th

th

50 to 97 centile
th

880
Praburam

Int J Med Res Health Sci. 2015;4(4):879-883

Pubertal signs were appropriate for age in 10 children


and were delayed in 2. No child had advanced pubertal
signs, though the ones who had already attained full
maturity may have done so earlier than normal.
Medical management of conditions other than CAH: Of
the 2 children with hypogonadism, one was treated with
human chorionic gonadotropin (hCG) and the other was
treated with testosterone. The child who was on hCG
showed adequate response. The child on testosterone
also had cerebral palsy and significant mental
retardation. Hence his parents were unenthusiastic about
further treatment. Two children with perineoscrotal
hypospadias were treated with hCG. Both showed
response though one childs response was inadequate
and his penile length remained smaller for his age.
Testosterone injections had been planned. The other
child showed good response and his secondary sexual
characters were appropriate for his age.
Surgical management: One child with cryptorchidism had
undergone treatment with hCG with no response.
Orchidopexy was done and the outcome was
satisfactory. The child with true hermaphroditism was on
testosterone propionate after he had undergone left
salpingo oophorectomy, hypospadias correction and
bilateral mastectomy. His height, external genitalia, penile
length and other secondary sexual characters were
appropriate for his age. All the patients with mixed
gonadal dysgenesis, testicular feminization or true
hermaphroditism had undergone surgery and the parents
were fully satisfied with the outcome (subjective grading
of 5 on a scale of 1 to 5).Two patients with perineoscrotal
hypospadias had undergone surgery and four were
planned. All the parents were fully satisfied with the
outcome (subjective grading of 5 on a scale of 1 to 5).11
patients with CAH had undergone a feminizing
genitoplasty and 1 more was planned. Of these 11 only
one mother seemed unsatisfied (subjective grading of 2
on a scale of 1 to 5). The genitalia however seemed near
normal and wasas expected.Four patients with
cryptorchidism had undergone orchidopexy and all of
them were satisfied with the outcome. Surgery has been
advised for the others, of which one had been lost to
follow up since his earlier visit.
Parental knowledge and psychological aspects: Most
children were well adjusted to their family and the society
and the sexual identity and orientation wereconsistent
with the assigned sex. One child with mixed gonadal
dysgenesis raised as a girl had behavioral features of a
boy as observed by her mother. But her gender identity
was to be that of a girl.All parents of children with mixed
gonadal dysgenesis, testicular feminization and true
hermaphroditism had the knowledge that their child would
be infertile and had come to terms with that.Parents of
children with CAH were unsure of the fertility of their
children. Besides, all the parents of children with CAH
(except one) found it hard to bear the expenses incurred
in the management of their children and expected
financial problems in the future.One universal feature
noticed was that all parents were unsure of the long term
outcome of their children and were apprehensive of the
medical, psychological, marital, sexual and social
problems that their child would face in the future.

DISCUSSION
This study was undertaken as an audit of all the patients
with ambiguous genitalia treated in the Christian Medical
College and Hospital (CMCH), Vellore. Various aspects
including time interval between arrival of a patient and an
appropriate diagnosis, treatment compliance, outcome
and psychological aspects were studied.Of the total 165
patients with ambiguous genitalia treated in CMCH, 33
(20%) came for the review. This could be due to the fact
that most of the patients were from other states and were
probably unable to come for the review. But this could
also be that patients with good compliance or those who
were satisfied with their treatment alone came for the
review and thus give falsely good or confounding results.
There were a higher number of female patients, as many
conditions in patients with ambiguous genitalia favour
female sex of rearing as compared to a male sex of
rearing. Kulkarni et al, Erdogan S et al and Joshi et al in
their studies found 46XY to be the commonest karyotype
[6, 7, 8]
. As most of our patients did not have a karyotype
this could not be compared. The commonest condition in
our study was a virilizing congenital adrenal hyperplasia
in a female child (37% of all the patients). This is
consistent with other studies which have found CAH to be
the commonest cause of disorders of sexual
[9, 10, 11]
differentiation
. CAH was followed in frequency by
cryptorchidism and hypospadias. Other conditions
included partial and complete testicular feminization,
mixed gonadal dysgenesis, hypogonadism and true
hermaphroditism.
Most patients (91%) were assigned an appropriate
clinical diagnosis within the first day. There seemed to be
no undue delay in assigning a clinical diagnosis in any
patient. All patients with CAH were correctly diagnosed
clinically almost immediately on arrival. This is important
as appropriate diagnosis and prompt treatment is
essential for survival, given significant mortality even in
[12]
developed countries .A final diagnosis was assigned to
23 (70%) within 1 month. Delays in diagnosis in the
earlier days were mainly due to non-availability of
karyotyping facilities (40%). Diagnoses like mixed
gonadal dysgenesis and true hermaphroditism required a
biopsy be done before a final diagnosis was made. In
such conditions there was a delay in the final diagnosis
due to a delay in the surgeries, which were undertaken
only on a semi urgent basis. Hormonal investigations
were not always readily available in the earlier days
which resulted in a delay in 3 (30%) patients. Two
patients were lost to follow up and had to be called by
post for evaluation, which resulted in a delay.
Medical management was the cornerstone of patient with
CAH. Compliance with drugs was excellent among the
patients with CAH who came for the review. Hundred
percent of them (12 patients) had taken the drugs without
missing a single dose in the preceding 3 months. They
also claimed to have strictly adhered to the advice given
regarding the change in dosage during any illness.All the
patients with CAH who came for the review had heights
between the third and the ninety seventh centiles grossly
indicating adequate growth. Similar results were obtained

881
Praburam

Int J Med Res Health Sci. 2015;4(4):879-883

by Scott A. Rivkees et al who demonstrated that normal


growth was achievable by their study on 26 children with
[13]
CAH using once a day Dexamethasone therapy . A
metaanalysis done by Erica A. Eugster et al also showed
that in CAH with 21-hydroxylase deficiency, adult heights
within 1 standard deviation of target height was
[14]
achievable .But many of our patients (41%) had growth
th
velocities less than the 50 centile for that age indicating
the importance of monitoring the height velocity rather
than the absolute height. A metaanalysis done by
KalpanaMuthusamy et al showed that adult heights
attained in patients with CAH were not only lower than
normal adult heights but also was lower than their own
[15]
target heights given their parental heights
. This
highlights the importance of monitoring not just the height
for age, but also the height velocity over time to pick up
growth retardation early for timely intervention.
Testosterone and hCG had been used in patients with
hypogonadism. The results were satisfactory.
It was noted that all patients managed surgically had a
good outcome in terms of anatomical appearance.
Almost all patients and parents were satisfied with the
treatment. Functionality could not be commented upon as
most patients were children or adolescents below the age
of 18 years.This is consistent with Newman et al who
reported satisfactory anatomic and functional results
[16]
when clitoral surgery alone was required .He also
reported poor functional results for patients with
extensive vaginal reconstruction. This could not be
verified in our study. Also Randolph et al in their follow up
of 37 patients who had undergone clitoroplasty found that
[17]
27 had excellent outcome .
The main area where there was discordance between
[1]
American Academy of Pediatrics (AAP) guidelines and
the approach used in our patients was in the use of
karyotyping in patients with 46 XX patients with CAH. It
was not routinely carried out on our patients as it may not
contribute much to an otherwise straight forward
diagnosis. But caution needs to be exercised before
assigning a diagnosis without doing a karyotype and is
not recommended by the AAP. The clinical diagnoses at
presentation and the final diagnoses based on
appropriate investigations were correlating well in all the
patients.
One feature that came out as expected was that the
financial burden on the parents is enormous and is a
probably a major hindering factor in the appropriate
management of such children. Detailed counseling is
needed to allay the fears and doubts that would be
expected in a parent of a child with such conditions. A
humane approach is as important as appropriate medical
and surgical management followed by adequate follow
up.
Limitations: Most patients were too young to understand
the condition and its implications and hence could not
contribute voluntarily to the assessment on long term
psychological outcome. It was also a limiting factor to the
assessment of their long-term sexual identity, orientation,
satisfaction with the sex of rearing and satisfaction with
their marital and sexual life. Long term studies involving a
significant number of adolescent and adult patients are
needed to address such issues.

CONCLUSION
Most patients were appropriately diagnosed without
undue delay. Instances where there was a delay could
have been rectified by easier access to investigations like
karyotyping and hormonal studies. With the facilities
currently available these studies can be carried out
without any delay.Both medical and surgical
management
were
associated
with
favorable
outcomes.Compliance with drugs and health promoting
advices was excellent among the patients who came for
the review.It is important to follow up patients with CAH
by their height velocity rather than the absolute height as
interventions can be carried out at an earlier
stage.Detailed counseling is needed to allay the fears
and doubts that would be expected in a parent of a child
with such conditions. Long term Indian studies involving a
significant number of adolescent and adult patients are
needed to address issues of long-term sexual identity,
orientation, satisfaction with the sex of rearing and
satisfaction with their marital and sexual life.
ACKNOWLEDGMENT
I would like to thank Dr. P. Raghupathy and Dr. Sarah
Mathai, Professors in Pediatrics, Department of Child
Health, Christian Medical College and Hospital, Vellore
for their guidance and support.
Conflict of Interest: Nil.
REFERENCES
1. American Academy of Pediatrics Committee on
Genetics. Evaluation of the newborn with
developmental anomalies of the external genitalia.
Pediatrics 2000;106:138-42.
2. Garry L. Warne, Jeffrey D. Zajac. Disorders of sexual
differentiation. Endocrinology and Metabolism Clinics
of North America. 1998, Dec; 27(4): 945-967.
3. ZoranKrsti, Sava Perovic, Slobodan Radmanovi,
SvetislavNeci, SvetislavNeci, eljkoSmoljani,
PredragJevti. Surgical treatment of intersex
disorders; Journal of Pediatric Surgery 1995,
September; 30(9): 1273 81.
4. Arnold G. Coran, Theodore Z. Polley Jr. Surgical
management of ambiguous genitalia in the infant and
child. Journal of Pediatric Surgery 1991, 26(7): 812820.
5. Norman P. Spack, Mary Deming Scott. In :John P.
Cloherty, Ann R. Stark, Eric C. Eichenwald (eds.),
Manual of neonatal care, Lippincott Williams and
th
Wilkins, 2004; 5 edition, p607.
6. Ketan Prasad Kulkarni, InushaPanigrahi, Reena
Das, SurinderKaur and Ram Kumar Marwaha.
Pediatric Disorders of Sex Development. Indian
Journal of Pediatrics 2009; 76 (9): 956-958.
7. Erdogan S et al. Etiological Classification and
Clinical Assessment of Children and Adolescents
with Disorders of Sex Development. J Clin Res Ped
Endo 2011;3(2):77-83.

882
Praburam

Int J Med Res Health Sci. 2015;4(4):879-883

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Joshi RR, Rao S, Desai M. Etiology and Clinical


Profile ofAmbiguous Genitalia - An Overview of 10
Years
Experience.
Indian
Pediatrics
Nov2006;43:974-979.
Rajendran R, Hariharan S. Profile of intersex
children in South India. Indian Pediatrics1995;32:
666-671.
Nimkarn S, Likitmaskul S, Sangacharoenkit P et al.
Ambiguous genitalia: an overview of 22 years
experience and the diagnostic approach in the
pediatric department, Siriraj Hospital. J Med Assoc
Thai 2002;85:496-505.
Gupta DK, Menon PSN. Ambiguous Genitalia: An
Indian
perspective.
Indian
Journal
ofPediatrics1997;64: 189-194.
J Jskelinen and R Voutilainen. Long-term
outcome of classical 21-hydroxylase deficiency:
diagnosis, complications and quality of life.
ActaPaediatrica. Feb 2000; Vol 89, Issue 2, pp 183
187.
Scott A. Rivkees, John D. Crawford. Dexamethasone
Treatment
of
Virilizing
Congenital
Adrenal
Hyperplasia: The Ability to Achieve Normal Growth.
Pediatrics October 2000; Vol. 106 No. 4 pp. 767 773.
Erica A. Eugster, Linda A. DiMeglio, James C.
Wright, Gary R. Freidenberg, RoopaSeshadri, Ora H.
Pescovitz. Height outcome in congenital adrenal
hyperplasia caused by 21-hydroxylase deficiency: A
meta-analysis. The Journal of Pediatrics Jan 2001;
Vol 138, Issue 1, Pages 2632.
KalpanaMuthusamy, Mohamed B. Elamin, Galina
Smushkin, Mohammad Hassan Murad, Julianna F.
Lampropulos, Khalid B. Elamin, Nisrin O. Abu
Elnour, Juan F. Gallegos-Orozco, Mitra M.
Fatourechi, NeeraAgrwal, Melanie A. Lane, Felipe N.
Albuquerque, Patricia J. Erwin, and Victor M.
Montori. Adult Height in Patients with Congenital
Adrenal Hyperplasia: A Systematic Review and
Metaanalysis. J ClinEndocrinolMetab, September
2010, 95(9):4161 4172.
Newman K, Randolph J, Anderson K. The surgical
management of infants and children with ambiguous
genitalia. Lessons learned from 25 years.Ann Surg.
1992 Jun; 215(6):644-53.
Randolph J, Hung W, Rathlev MC. Clitoroplasty for
females born with ambiguous genitalia: a long-term
study of 37 patients. J Pediatr Surg. 1981 Dec;
16(6):882-7.

883
Praburam

Int J Med Res Health Sci. 2015;4(4):879-883

Available online at: www.ijmrhs.com


Research article

DOI: 10.5958/2319-5886.2015.00177.0
Open Access

A STUDY ON PREVALENCE OF CONGENITAL OCULAR ANOMALIES IN


PAEDIATRIC AGE GROUP
1

Tupe Parag N , Chaudhari Sagar V

ARTICLE INFO
Received: 15th Sep 2015
Revised: 25nd Sep 2015
Accepted: 30th Sep 2015
1

Assistant Professor,
Post graduate student, Department of
Ophthalmology,
Rural
Medical
College,
Loni,
Ahmednagar,
Maharashtra,
Corresponding author: Tupe Parag N
Assistant Professor, Department of
Ophthalmology,
Rural
Medical
College,
Loni,
Ahmednagar,
Maharashtra,
Email: dr.paragtupe@rediffmail.com
Authors details:
2

Paediatric,
Ocular Anomaly.
Keywords:

Congenital,

ABSTRACT
Introduction: Most congenital anomalies are present long before the time
th
of birth, some in the embryonic period (up to the7 week of gestation) and
th
other in the fetal period (8 week to term) Purpose: To study the incidence
of congenital ocular anomalies in paediatric age group. Materials &
Methods: In this study total 9350 patients were screened. The age and sex
of the patient, gestational age, occurrence of consanguineous, distribution
of various subtype of congenital anomalies, subtype of congenital cataract,
age at presentation and diagnosis were noted. Results: The age variation
in the study was between 0-12 years. The maximum number of patients
were in the age group of 0-2 years. Male: female ratio was 1:1.4. Number
cases were reported in anterior segment with full term delivery.32 cases
having no positive history of consanguineous marriage. Total 12 cases
were found about chronic dacryocystitis, 8 cases of coloboma of iris and
choroid and each 5 cases of congenital cataract and Microhthalmos were
found. None of the cases had any history of antenatal, obstetric
complication, radiation and drug intake. Conclusion: A prevalence of
0.053% of congenital ocular anomalies. Most common anomaly was
congenital dacryocystitis (24%), congenital cataract and microphthalmos
being the second most common anomalies (14%) each.

INTRODUCTION
A congenital
anomaly is an abnormality that is present at
.
birth, even if not diagnosed until months or years later.
Most congenital anomalies are present long before the
th
time of birth, some in the embryonic period (up to the7
th
week of gestation) and other in the fetal period (8 week to
term). The anomaly covers all the major classes of
abnormalities of development which there are four major
[1]
categories as follow

Malformation, Deformation , Disruption, Dysplasia


Congenital anomalies contribute a significant proportion of
infant morbidity and mortality, as well as fetal mortality. As
a consequence, it is essential to have basic
epidemiological information on these anomalies.
The precise of congenital malformations is not known for
as many as 50 60% of the total. It is believed that
overall, multifactorial etiology account for 20-25% of all
abnormalities; 6-8% are monogenic, that is cause by
mutations in the single gene; 6-8% by chromosomal
abnormalities; and 6-8% by environmental factors such as
[2]
maternal illness, infections, drugs, radiation and alcohol.
Major cause is maternal infection during pregency,
[2]
caused by some important infectious agents as follow
Rubella, Varicella, Cytomegalovirus, Toxoplasmosis
In a survey conducted for blindness in India 1968, a total
of 4047 cases of blindness were noted. Out of these 48
[3]
were due to a congenital defect forming 1% of the total.
There are many records of various forms of blindness and
those due to congenital defect at least a small percentage
[4]
of causes.

Tupe Parag

Congenital deformities are due to two etiological causes:


1. Primary due to germinal causes 2. Secondary due to
environmental causes
Here, the title, Prevalence of congenital ocular anomalies
in the pediatric age group is chosen with deliberation in
order to limit, its scope for an immense range of
abnormalities conditions, indeed much of the medicine
could be included under the umbrella of anomalies of
development.
MATERIAL AND METHODS
Study design: Observational Study
Ethical approval: Ethical approval was obtained form IEC
of our College, Informed consent was taken before
performing all procedures.
Research place: The study was carried out over a period
of two years. Study was conducted at Department of
Ophthalmology, in a tertiary care teaching hospital located
in rural area of western Maharashtra.
Inclusion criteria: These included all the new born babies
in the pediatric ward, all patients attending ophthalmology
OPD and camps. Cases were of the age group 0-12 years.
Exclusion criteria: Also, cases of retinopathy of
prematurity and retinoblastoma were not included in this
study
Sample size: Nine thousand three hundred fifty
Methodology:
Screening consisted of name, age sex, residence, religion
and OPD number of the patients. Detailed antenatal
history was taken which included consanguinity, any
unwanted event in the early pregnancy, drug intake,

Int J Med Res Health Sci. 2015;4(4):884-888

884

radiation during pregnancy, any disparity detected


between periods of gestation.
Nature of delivery, full term or premature and natural,
assisted or operative was also taken into consideration.
APGAR
(Appearance, Pulse, Grimace, Activity,
and Respiration)[1] score in relevant cases was also
noted. General examination and systemic examination for
other congenital anomalies.
The complete detail examination was carried out with the
help of torch light (and slit lamp wherever possible).
Rough assessment of vision was done in all new born with
torch light, pre-school children (3-5 years) was done by
[5,6]
illiterate E-cutout test.
Measurement of vision in school
children (above 5 years) was done with Snellens chart.
A case which required investigations like ocular tension,
indentation tonometry and measurement of corneal
diameter and gonioscopy to rule out bupthalmos were
undertaken in general anesthesia.
A case of ptosis was examined for the presence of degree
of ptosis, squint, Marcus- Gunn phenomenon, presence
and absence of Bells phenomenon, MRD 1 & 2 to
measure the amount of ptosis, leavator function test
[6]
performed.
In a case of squint cover test, cover-uncover test, alternate
[6]
cover test and Hirschberg test were performed.
All patients of congenital anomaly were investigated in
detail for base line investigations like X-ray of the chest,
complete haemogram, urine routine and microscopic, USG
abdomen and pelvis to assess the complete nature of
anomaly. Fundus examination in all cases with help of
direct ophthalmoscope.

During study period, 9350 children below the age of 12


years were examined. The number of children that were
detected to have congenital ocular anomalies were 50,
giving prevalence of 0.53%. In this study, the age range
was from birth to 12 years of age. From below graph
maximum 27 cases were found in the age group 0-2
years, giving percentage of 54%. (Fig 1)

20

with degree
Present

Agewise distribution of
congenital anomalies

0
0-2

2-4

4-6

12
6-8

2nd

3rd

14

36%

32

64%

Table 2: Distribution of various subtypes of congenital


anomalies:
Anomaly observed
Both Right Left
Total
%
eye

eye

eye

0.03

and

0.05

with

0.01

12

0.11

Congenital ptosis

0.02

Congenital ectropion

0.01

Congenital esotropia

0.01

Congenital

0.02

Megalocornea

0.01

Aniridia

0.02

Coloboma of the iris

0.09

Heterochromia iridum

0.01

Congenital cataract

0.05

Congenital glaucoma

0.03

PHPV

0.02

Coloboma of the disc

0.02

Leber optic atrophy

0.01

Crouzons disease

0.02

Anophthalmos
Microphthalmos
microcornea
Orbital

cyst

rudimentary eye
dacryocystitis

corneal

opacity

and choroid

27

10

1st

Absent

Congenital

RESULTS

30

with congenital cataract and one with megalocornea were


detected.
It was observed that anterior segment had more cases 41
(82%) and only 4 cases of posterior segment anomalies
were detected. 5(10%) cases were found to have both
anterior and posterior segment.
It was observed that in 18 cases (36%) parents gave a
st
history of consanguinity, of these 16% had 1 degree of
nd
consanguinity, 78% had 2 degree consanguinity and
rd
only 6% subjects 3 degree consanguineous relations in
marriage. (Table 1)
Table 1: Occurrence of consanguinity in the study:
Consanguinity
Number of cases Percentage

8-10

10-12

Agewise distribution of congenital anomalies


Fig 1: Age of distribution of the patients with
congenital ocular anomalies
Gender (male: female) ratio in our study was 1:1.4. Most
of the children with congenital anomalies were full term
deliveries (48 cases); two cases with preterm birth one

Table 3: Age at presentation and diagnosis:

Tupe Parag

Int J Med Res Health Sci. 2015;4(4):884-888

885

Anomaly observed

Anophthalmos (fig 1a)


Microphthalmos and
micro cornea
Orbital cyst with
rudimentary eye (fig
1b)
Congenital
dacryocystitis (Fig 1c)
Congenital ptosis
Congenital ectropion
Congenital esotropia
Congenital
corneal
opacity
Megalocornea

No of Laterality
cases
3
5

3 bilateral
5 bilateral

Average
age of
diagnosis
Day 1
4.4 years

Bilateral

7 Days

12

8 Bilateral 4 Unilateral

2 YRS

2
1
1
2

1 Bilateral 1 Unilateral
Bilateral
Unilateral
2 Bilateral
-

8.5 Yrs
Day1
1 Year
3.5 M

Aniridia
2
Coloboma of the iris
8
and choroid
Heterochromia iridium
1
(fig 1d)
Congenital cataract
5
(fig 1e)
Congenital glaucoma
3
PHPV
2
Coloboma of the disc
2
Leber optic atrophy
1
Crouzons disease
2
(fig 1f)
Yrs: Years, M : Months

Unilateral

2 Bilateral
3 Bilateral 5 Unilateral

1M
8.5 yrs
5.5Yrs

Unilateral

7 Yrs

5 Bilateral

5.1Yrs

3 Bilateral
1 Bilateral 1 Unilateral
2 Unilateral
Bilateral
Bilateral
-

2.6M
2.5 M
9M
6 Yrs
1.5Yrs

Fig 1A: Anophthalmos B: Orbital Cyst C: Congenital


Dacryocystitis D:
Heterochromia Iridium E: Congenital
Cataract F: Crouzons Disease

DISCUSSION

Tupe Parag

The complexity of the process by which a fully fertilized


egg develops into a fully formed individual and the
extreme rapidity with which revolutionary changes occur
especially in the early stages of growth astonished us that
so many of us are born normal.
In the magnitude of congenital anomalies, we noted a
(5)
prevalence of 0.53%. In a study conducted by Stoll, et al
on the epidemiology of congenital eye malformation in
Strasbourg, France 1978 to 1988, the reported prevalence
was 0.75% which was similar to our study. In a study
[7]
conducted by Singh, et al
the incidence of congenital
anomalies was 0.105%. the differed between this study
[8]
and ours is statistically insignificant. Bermejo, et al
found, a prevalence of congenital malformations to be only
0.037%. However, this difference is of no statistical
significance.
In a survey conducted for blindness in India (1968), a total
of 4047 cases of blindness were noted. Out of these 48
[8]
were due to a congenital defect forming 1% of the total ,
which also correlates with our study. In our age distribution
of the patients with congenital ocular anomalies, the age
range was from birth to 12 years of age. We found
maximum 27 numbers of cases were found in the age
group 0-2 years, giving a percentage of 54%. This finding
[8].
was similar to a study, by Bermejo et al This may be
because of literacy and early detection of congenital
anomalies.
In our gender distribution shows male to female ratio 1:1.4.
This finding was similar to a study by chukka-Okosa, et
[9]
al this study also reported a male preponderance of
congenital ocular anomalies with male to female ratio
[5]
1:1.2. In a study by Stoll, et al the sex ratio was 1:1.22
which corroborates with our study.
In our gestational age birth 4 % cases of congenital ocular
anomalies gave a positive history of premature birth;
however this percentage is statistically insignificant when
compared to the total number of children examined in both
full term and premature birth categories. In a study by
[10]
Rahi, et al , it was reported that in 60% of severely
visually, impaired /blind children, vision loss was
attributable to factors operating in the prenatal period, in
47% the prenatal factors were known and definite, and in
13 prenatal factors were the most probable causes.
In our distribution of cases in anterior and posterior
segment was observed that anterior had more cases 41
and only 4 cases of posterior segment anomaly. 5 cases
were found to have both anterior and posterior segment. In
our study occurrence of a history of consanguinity as high
as in 36% cases, but this incidence is statically
insignificant. Our finding matched with that of Narchi, et
[11]
al . He undertook a study of congenital anomalies
diagnosed in AL-Hasa area in Saudi Arabia between Jan
(5)
1987 and Dec 1992. In a study conducted by Stoll, et al
on the epidemiology of congenital eye malformations in
Strasbourg, France 1978to 1988, a significant association
reported.
The incidence of anophthalmos in our study was 6% of
congenital anomalies. In a study conducted by Bermejo, et
[8]
al
found a prevalence of anophthalmos to 5%. In a
(5)
[12],
study, Stoll, et al was 4.6%.and in Hormby, et al
was
2.35%.
In our study 5 cases microphthalmos were
detected, which make prevalence of 0.5 per thousand
[13]
populations. According to Alberta
it was 0.09per

Int J Med Res Health Sci. 2015;4(4):884-888

886

[14]

thousand and Kallen, et al


to be about 1.5 per 10000
populations.
One case of orbital cyst with rudimentary eye noted. The
prevalence was 1/10000 population. The cases have
[15]
bilateral involvement. In the Jain, et al
bilateral orbital
cyst is more commonly associated with major systemic
abnormalities.
In our study, 12 cases congenital dacryocystitis were
[13]
recorded. The prevalence was 0.12%. In Alberta
study
it was 0.08%. In our study two cases of congenital ptosis
[11]
were recorded. Yilmaz, et al
reported a case of
congenital ptosis with associated multiple ocular and
congenital malformations were the associated ocular
malformations.
One case of congenital ectropion was detected. Therefore,
prevalence is very low i.e. 0.01 per hundred populations.
[14]
Ruben, et al has reported 0.3 per hundred populations.
One case of congenital esotropia found in our study. In
[16]
hunter et al
reported the incidence of associated
congenital ocular and systemic was much more with
congenital exotropia than congenital esotropia.
Only one case of primary congenital corneal opacity was
detected in our study. In a study conducted by Rezende et
[14]
al
reported that only 6.9%of corneal opacities. One
cases of megalocornea was found in our study. No
associated ocular or systemic malformations were
detected.
We reported thee cases of bupthalmos,
incidence 0.3 per thousand populations. All cases were
[16]
bilateral. Levy, et al
reported incidence of congenital
[13]
glaucoma as 0.1 per thousand populations. The Alberta
reported congenital glaucoma to be 0.03 per thousand
populations. We found 5 cases of congenital cataract
means 0.3 per thousand populations in our study. In
[13]
Alberta
has reported 0.13 per thousand populations.
[18]
Koraszewska et al
reported a prevalence of 0.07%. We
found 8 cases of coloboma of iris, choroid and both. The
uveal coloboma 0.08 per thousand populations. According
[13])
to Alberta
it is 0.10 per thousand populations. Clarke
found 2.4 per thousand populations.

the cases had any history of antenatal, obstetric


complication, radiation and drug intake. Most of cases
occurred
sporadically,
suggesting
more
often
environmental factor.
Limitations of the study: There are a varying number
of congenital anomalies which appear much later in life.
This study restricts to a study of mainly cases with gross
anatomical abnormalities. As serological examinations like
TORCH are not routinely done in this hospital, blood
samples were sent outside in relevant cases only.
Conflict of Interest: Nil

REFERENCE
1.

2.

3.

4.
5.

6.
7.

8.

CONCLUSIONS
In our study we noted a prevalence of 0.053% of
congenital ocular anomalies in the total population in
region of our study area. The age wise distribution of
congenital anomalies showed that the peak age at
presentation is in the first two years of life (56%). We
found a male preponderance in occurrence of congenital
ocular anomalies, with a sex ratio of 1:1.4. The incidence
of infants with congenital ocular anomalies that had
premature birth was 4%in our study. We found a positive
history of consanguinity in 36%of our study.
Amongst the ocular anomalies 82% involved the anterior
segment and only 8% posterior segment. We found that
40% of the congenital anomalies caused severe visual
impairment or blindness. All of these cases were bilateral.
Most common anomaly in our study was congenital
dacryocystitis
(24%),
congenital
cataract
and
microphthalmos being the second most common
anomalies (14%) each. The incidence of congenital
systemic anomalies associated with ocular anomalies in
our study was 10%. We noted that only 17% of
colobomatous defect of the uvea were complete. None of

Tupe Parag

9.

10.

11.

12.

13.
14.

15.

LowryRB, Sibbald B. The Alberta Congenital


Anomalies Surveillance System, fifth report ,19801998; Dec 2001;2-4.
Professor Helen Dolk, Dr. Pat Doyle, Dr. Ester Garne.
A Review of Environmental Risk Factors for
Congenital Anomalies edition.1 (uploaded to website
29 April 2004);7-30.
J.K.
Pasricha:
Blindness
in
India,
Indian
nd
Ophthalmology Today proceedings, 52
Annual
Conference. All India Ophthalmology society,
Calcutta, , published by J.K. Pasricha; 1994474-476.
Carnatam MC, Goldstein DA, Congenital Cataract,
Current Opinion in Ophthalmology. 1995;6(1):;10-11.
Stoll C, Alembik Y, Dott B. Epidemiology of
Congenital Eye Malformations in 131,760 consecutive
births.
Ophthalmic
Paediatric
Genetic
.1992;13(3);179-86.
Pradeep Insan Sharma, Strabismus Simplified, CBS
publisher, second edition:2005;52-68.
Singh YP, Gupta SL, Jain IS, Gupta A, Bhakoo ON.
Congenital Ocular Abnormalities of The New Born. J
pediatric ophthalmic strabismus.1980;17(3);162-5.
Bermejo E, Martinez-Frias ML. Congenital Eye
Malformations Clinical-Epidemiological analysis of
1,124,654 consecutive birth in Spain. AM J Med
genet.1998;75(5);497-504.
Chukka-Okosa: Congenital eye anomalies in Enugu,
South eastern Nigeria. West African journal of
medicine; 2005;24(2):112-114.
Rahi JS, Sripathi S, Gilbert CE, Foster A. The
Importance of Pre-Natal Factor in Childhood
Blindness in India. Dev Med Child Neurol
.1997;39(7);449-55.
Narachi H, Kulaylat N. Congenital Malformations; are
they more prevalent in population with a high
incidence of consanguineous marriages? Annals of
Saudi Medicine. 1997;17(2):
Hornby SJ, Gillbert CE, Rahi JK; Regional Variation in
Blindness due to Microphthalmos and Coloboma.
Ophthalmic epidemiology .2000 Jun;7(2):127-138.
Alberta: Congenital Anomalies Surveillance System,
Fifth Report,1980-1998.
Kallen B, Tornqvisr K:
The Epidemiology of
Anophthalmia and Microhthalmia in Sweden. Eur J
Epidemiology , 2005;20(4);345-348.
Wiese KG, Vogel M, Gut Hoff R; Treatment of
Congenital Anophthalmos with Self-Inflating Polymer

Int J Med Res Health Sci. 2015;4(4):884-888

887

Expanders; a new method. Cranionmaxillaface


surg.1999;27(2);72-76.
16. Vogt G, Puho E, C Zeisel AE: A Population-Based
Case Control Study of Isolated Ocular Coloboma.
Ophthalmic Epidemiology 2005;12(3):191-7.
17. Levy j, Tessler Z, Tamir O, Lifshitz T: Primary
Congenital
Glaucoma.
Harefuah
.2004
Dec;143(12):876-80,910.
18. Koraszewska - Matuszewska B, Smochowiec-Donocik
E: Eye Growth in Children with Primary Congenital
Glaucoma
after
Trabculetomy.
Kiln
Oczna.2002;104(3-4);211-3.

Tupe Parag

Int J Med Res Health Sci. 2015;4(4):884-888

888

Available online at: www.ijmrhs.com

DOI: 10.5958/2319-5886.2015.00178.2

Letter to Editor

Open Access

PREVALENCE OF HEPATITIS B AND C VIRAL MARKERS AMONG THE TRIBAL


POPULATION OF NILGIRIS, TAMIL NADU
1

Krishnasamy Narayanasamy , Senthilkumar Ramalingam , Sathishkumar Elumalai , Jaya Lakshmi ,


4
4
Ramachandar S , Rameshkumar Manickam

ARTICLE INFO

Dear Editor,

Hepatitis B virus and C viruses (HBV and HCV, respectively) infects the liver
which results in a wide range of disease outcomes. Worldwide, over 7%
(350 million) and 3% (170 million) people are chronically infected with HBV
[1]
and HCV, respectively. HBV is transmitted through exposure to infective
1
Authors details: Professor & Head,
blood, semen, and other body fluids or through infected mothers to infants at
2
3
Associate Professor, Research
the time of birth. Transmission may also occur through transfusions of HBV4
Assistant, Lab Technologist,
contaminated blood and blood products, contaminated injections during
Department of Hepatology, Madras
medical procedures, and through transfusions of HCV-contaminated blood
Medical College, Rajiv Gandhi
and blood products, contaminated injections during medical procedures, and
[2]
Government General Hospital,
through injection drug use. Sexual transmission is also possible.
Chennai, Tamil Nadu
Individuals with chronic hepatitis B and/or C virus infection remain infectious
Corresponding author: Krishnasamy
to others and are at risk of serious liver disease such as liver cirrhosis or
[3,4]
Narayanasamy
hepatocellular cancer (HCC).
Study reports revealed that HBV and/or
1
Professor & Head, Department of
HCV infections are the major causes of morbidity and mortality in HIV
[5,6]
Hepatology, Madras Medical College,
positive population related to liver cirrhosis and hepatocellular carcinoma.
Rajiv Gandhi Government General
Though studies on the prevalence of HBV (rarely on HCV) among tribal
[7,8]
Hospital, Chennai, Tamil Nadu
population in India were available , there is no recent reports from
southern part of India. Hence, the present study was conducted to assess
Email: drkns_1963@yahoo.com
the prevalence of HBV and HCV among tribal population in Kotagiri, Nilgiris.
After obtaining the informed consent, blood samples (5 ml each) from a total
Keywords: Hepatitis B & C, Viral
of 196 participants (103 males and 93 females) were collected and sera
Markers, Tribal population, Nilgiris
were separated on site. Samples which showed positive for HBsAg and antiHCV by rapid test were confirmed by ELISA technique using commercial kits
Reliable Pro-detect Biomedical Ltd, India and Erba Lisa, Germany,
respectively. Of the 196 individuals screened, none of them was positive for
the viral markers. Several studies from India reported varying range of HBsAg and anti-HCV positivity among general and
[7,8]
tribal population
, whereas in our study none of them was found positive for the viral markers. The possible reason for
the absence of HBV and HCV infection in our study population may be due to the differences in their lifestyle,
sociodemographic factors and cultural practices. Though we found HBsAg and anti-HCV negativity, continuous
monitoring is necessary to prevent the spread of these hepatitis viruses among the tribal community.
Conflict of interest - No conflict of interest
rd

Received: 3 June 2015


th
Revised: 25 July 2015
th
Accepted: 4 Aug 2015

REFERENCES
1.
2.

3.
4.
5.
6.

7.
8.

Shaw-Stiffel TA. Chronic hepatitis. In: Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious
Diseases, Churchill Livingstone; 2000; 5th edition: 1297-1321.
Ayele AG, Gebre-Selassie S. Prevalence and risk factors of Hepatitis B and Hepatitis C virus infections among
patients with chronic liver diseases in public hospitals in Addis Ababa, Ethiopia, ISRN Trop Med. 2013;
2013:563821.
Lok AS. Chronic hepatitis B. N Engl J Med. 2002;346(22):1682-1683.
Seeff LB. Natural history of chronic hepatitis C. Hepatology. 2002;36(5 Suppl 1):S35-46.
Andreoni M, Giacometti A, Maida I, Meraviglia P, Ripamonti D, Sarmati L. HIV-HCV co-infection: epidemiology,
pathogenesis and therapeutic implications. Eur Rev Med Pharmacol Sci. 2012;16(11):1473-1483.
Tien PC; Veterans Affairs Hepatitis C Resource Center Program; National Hepatitis C Program Office. Management
and treatment of hepatitis C virus infection in HIV-infected adults: recommendations from the Veterans Affairs
Hepatitis C Resource Center Program and National Hepatitis C Program Office. Am J Gastroenterol.
2005;100(10):2338-2354.
Batham A, Narula D, Toteja T, Sreenivas V, Puliyel JM. Sytematic review and meta-analysis of prevalence of
hepatitis B in India. Indian Pediatr. 2007;44(9):663-674.
Mukhopadhya A. Hepatitis C in India; J Biosci. 2008;33:465-473.

Krishnasamy et al.,

889
Int J Med Res Health Sci. 2015;4(3): 889-889

Available online at: www.ijmrhs.com


Review article

DOI: 10.5958/2319-5886.2015.00179.4
Open Access

ANESTHESIA FOR ELECTROCONVULSIVE THERAPY: A NOBLE APPROACH


1

Rashmi Pal , Virendra Singh Pal

ARTICLE INFO

ABSTRACT

th

Received: 25 May 2015


Revised: 2nd Aug 2015
Accepted: 12th Aug 2015
Author details: 1Assistant Professor,
Department of Anesthesiology, M.G.M.
Medical College Indore, Madhya Pradesh,
India
2
Associate Professor, Psychiatry, M.G.M.
Medical College Indore, Madhya Pradesh,
India
Corresponding author: Rashmi Pal,
Assistant
Professor,
Department
of
Anesthesiology, M.G.M. Medical College
Indore, Madhya Pradesh, India
Email: rashmidrpal@gmail.com

Electroconvulsive therapy (ECT) has always proved to be an effective mode


of therapy in the field of Psychiatry. Modified ECT is applied in the form of
electrical stimulus to the central nervous system; it is associated with acute
physiologic response leading to autonomic nervous system stimulation with
an initial parasympathetic stimulation followed by a more prominent
sympathetic response as well as post-ictal effects like confusion and
delirium. The factors governing the efficacy of Modified ECT are the
strength of electrical current applied and the duration of the seizure activity.
Modified ECT requires the use of general anesthesia and many of the
anesthetic drugs also have an effect on the duration of seizure and could
adversely affect the efficacy of the Modified ECT treatments. Therefore,
there has to be a delicate balance between achieving an adequate
anesthetic state and optimal duration of seizure activity.

Keywords:
Electroconvulsive
therapy,
General
anesthesia,
Methohexital,
Mivacurium, Propofol

INTRODUCTION
Electroconvulsive therapy was first used to provoke
generalized epileptic seizures as treatment for
schizophrenia by Italian neurologist, lucio bini and ugo
cerletti on April 18, 1938 & was performed without
[1]
anesthesia for almost 30 years . Later came the period
of modified ECT- including the use of general
anesthesia & muscle relaxants, which led to its current
acceptance as a result of reduced physical & physiologic
trauma. The world health organization has now called for
a worldwide ban on unmodified ECT.
How does ECT work? ECT consists of programmed
electrical stimulation of the central nervous system to
initiate seizure activity. According to one theory, seizure
activity itself causes an alteration of the chemical
messengers in the brain known as neurotransmitters and
another theory proposes that ECT treatment adjusts the
stress hormone regulations in the brain, which may affect
energy sleep, appetite and mood. The electrical stimulus
results in generalized tonic activity for approximately 10
seconds followed by generalized clonic activity for
variable period lasting up to 120 seconds. The seizure
should ideally last for more than 15 seconds and less
than 120 seconds. Modified ECT is typically
administered as a series of treatments two to three times
a week for 6 to 12 treatments, in its acute phase
.Maintenance therapy can be performed at progressively
increasing intervals from once a week to once a month to
[2]
prevent relapses .
Indications: The National Institute of Clinical Excellence
[3]
(NICE) UK Guidelines 2009 recommend that the ECT
be considered for the patients who are suffering from 1. Acute, life threatening depression (high suicide risk
or very poor fluid intake)

Rashmi Pal et al.,

2.

Drug resistant depression (failure to respond to two


medications given at adequate dose for adequate
period of time) or where treatment is limited by
unacceptable side effects. It may also be
appropriate to consider initiation of ECT early if a
patient has shown good response previously or it is
known that they only respond to ECT
3. Acute catatonia (where first line treatment with intra
muscular benzodiazepines has failed to produce
improvement)
4. Mania, where treatment has failed to alleviate the
condition or is limited by side effects.
There are no absolute medical contra-indications to ECT
in current dates whereas relative contra-indications
include space occupying lesions of the brain , high
intracranial pressure , intracerebral bleeding , recent
cerebral infarction , recent myocardial infarction(<3
months) , retinal detachment, pheochromocytoma,
untreated cerebral aneurysm, unstable major fractures or
cervical , uncontrolled cardiac failure or severe valvular
disease, deep venus thrombosis, pulmonary conditions
like COPD, asthma or pneumonia, adolescents and
children and anesthetic risk rated as ASA level 4 or 5 or
a significant medical illness risk outweighs potential
benefit .
Anesthetic management: The essential elements of
anesthesia for Modified ECT include rapid loss of
consciousness, effective attenuation of the hyper
dynamic response to the electrical stimulus, avoidance of
gross movements, minimal interference with seizure
activity and prompt recovery of spontaneous ventilation
and consciousness.

890
Int J Med Res Health Sci. 2015;4(4):890-895

Pre ECT evaluation: Pre ECT evaluation is a


collaborative approach between the psychiatrist,
anesthetist and medical consultants and should include
[4, 5,6,7,8,9,10]

A thorough psychiatric history and examination


including history of response to other treatments
A medical history and examination with special
attention to cardiovascular, pulmonary, neurological
and musculo skeletal systems
A history of dental problems and examination for loose
or missing teeth.
A history of personal and family experiences with
anesthesia.
A cognitive assessment (at minimum, evaluation of
orientation and memory)
A minimum battery of laboratory test includes
complete blood count, serum chemistry, renal function,
and an electrocardiogram and urine analysis.
Additional test identified during preliminary evaluation
are as follows:
Chest radiograph (especially with cardiovascular and
pulmonary disease or history of smoking)
Electroencephalogram
guided by history and
examination.
Neurological /neuropsychological tests guided by
history and examination
Spinal radiograph (especially with known or suspected
spinal disease)
Consultation with medical specialties such as
cardiology, neurology, neurosurgery or endocrinology
as requested by special medical conditions.
Informed consent: Patients have the right to be fully
informed about the proposed Modified ECT treatments,
unless they lack capacity which is determined by the
attending psychiatrist. Patients have the right to consent
to Modified ECT treatment or to refuse treatment. If a
patient, determined to have capacity refuses Modified
ECT treatment, Modified ECT treatment would not be
sought through court authorization, court authorization
would be sought only in cases where the patient is
[7]
determined to lack capacity . Prior to Modified ECT
treatment, informed consent for Modified ECT must be
obtained from the patients(18 years & older)or if the
patient is under 18 years, from the parents or the legal
guardian except when it has been determined that the
[7]
patient lacks capacity to consent
Anesthetic implications of psychotropic drugs: The
management of the patients on psychoactive
medications in the perioperative period is based on the
individual clinicians experience. Challenges for the
anesthetists arise from the nature of the psychiatric
condition itself, interaction of psychoactive and
anesthetic drugs.
Tri cyclic anti depressants: May cause sedation and
reduce the seizure threshold so anticholinergics should
be avoided in such cases. One of the most significant
interaction for the aneshtesists is to be aware of the
potentiating effect of indirectly acting sympathomimetics
(ephedrine and metaraminol) by TCAs .These should be
avoided if possible and directly acting sympathomimetics
used cautiously to prevent hypertensive crisis

Rashmi Pal et al.,

Selective serotonin reuptake inhibitors: Considering


more serious withdrawal symptoms and risks associated
with remaining on an SSRI being low, it is better to
continue these drugs throughout the peri- operative
period.
Mono-amine oxidase inhibitors: The metabolism of
indirectly acting sympathomimetics is inhibited by MAOIS
resulting in the potentiation of their action. Traditionally,
irreversible MAOIS have been stopped two weeks before
operation; however omitting the dose of moclobemide (a
reversible MAOI) on the day of surgery is acceptable in
elective cases. Patients can be switched from an
irreversible MAOI to moclobemide to avoid a prolonged
[11]
period of discontinuation .
Mood stabilizers: Lithium should be stopped at least
24hr before the anesthesia .Valproate is associated with
platelet- dysfunction. Carbamazepine being an Inducer
of hepatic-cytochrome P450 can reduce the effects of
other drugs metabolized by that system.
Antipsychotics: Antipsychotics, when discontinued are
associated with a high relapse rate since they block
dopamine receptors in limbic systems and their side
effects are due to blockade of dopamine receptors
histamine, alpha 1 adrenergic & cholinergic receptors.
Anxiolytics: Signs of withdrawal from benzodiazepines
should be monitored particularly in patients who remain
fasted for long periods
Regional and local anesthetics: May lead to
hypertensive crisis due to adrenaline in patients
receiving TCAs and MAOIS.
General Anesthesia for Modified ECT: A standard
general anesthesia for Modified ECT should be the one
which meets the optimum clinical response which is
predicted by the degree to which the electrical stimulus
[12]
exceeds the seizure threshold . So earlier the stimulus
exceeds the seizure threshold, quicker will be the
generation of seizure activity leading to seizure duration
of sufficient length, which is the final determining factor.
So the efficacy of ECT in alleviating acute depression is
[13,14]
dependent on the duration of the induced seizure
.
EEG seizure activity lasting from 25 to 50 sec. is alleged
to produce the optimal antidepressant response.
Because many of the anesthetic drugs used for ECT
have anticonvulsant properties, they would be expected
to decrease the duration of ECT induced seizure activity
in a dose dependent manner. Use of larger than
necessary dosages of general anesthetics will shorten
the duration of ECT induced seizure activity and could
adversely affect the efficacy of the ECT treatments
therefore there is a delicate balance between achieving
an adequate anesthetic state and an optimal duration of
seizure activity. The type of anesthetic used has a
[15]
significant impact on efficacy of the treatment
. The
goal of ECT is to produce an EEG seizure that lasts long
[16]
enough to elicit an optimal anti depressant effect . The
ideal anesthetic agent should have a rapid onset of
action and short recovery time. The pharmacokinetic
properties of the anesthetic agent determine the duration
of therapy. The main concerning factor with these agents
is their anti-convulsant properties; therefore the effects
on seizure duration, strength of the stimulus charge and
recovery time after each treatment are important. All of

891
Int J Med Res Health Sci. 2015;4(4):890-895

these factors must be taken into consideration while


managing
the
patients
long
term
cognitive
complications.
Induction agents: According to American Psychiatric
Association, Methohexital remains the most widely used
general anesthetic for ECT and is considered the gold
standard. Although there are data to suggest that
outcome are no different between methohexital and
propofol despite the decreased seizure duration with
propofol. With respect to recovery of cognitive function
after ECT, propofol and etomidate offered no advantage
[14]
over methohexital
. Therefore, unless there is a
specific contraindication to barbiturates (e.g. - acute
intermittent porphyria) methohexital should be the
anesthetic of choice. It is effective and has established
safety record and low cost. When thiopentone was
compared with methohexital, it showed a frequency of
increased sinus bradycardia, premature ventricular
[17]
contractions
. Etomidate reduces seizure threshold
and is associated with longer seizure duration and may
be helpful in patient with short seizure times (<20
[14,18,19]
seconds) despite a maximal electrical stimulus
Ketamine is an anesthetic agent with analgesic
properties that are less desirable due to its ability to
increase intracranial pressure. Benzodiazepines should
be ruled out as an option because of their noticeable
anticonvulsant activity. Although sevoflurane can be
used to produce an adequate anesthetic state for ECT,
being a volatile agent it is more time consuming and
possesses no advantage over other IV anesthetics
except for women requiring ECT in the late stages of
pregnancy when it may reduce post ECT uterine
contractions.
Muscle relaxants: Although it is not essential to have
complete muscle paralysis, muscle relaxants are the
indispensable drugs for modified ECT, if not used will
result in vigorous physical restrained during the seizure
and severe myalgia after the procedure.
As ECT is a short duration procedure, succinyl choline
0.5mg/kg is the agent of choice due to its rapid onset
and short duration. In patients with a history of post ECT
agitation related to increased levels of plasma lactate,
increasing the dose of succinylcholine up to 1.5mg/kg
[20]
may decrease the emergence delirium .
Even small doses of this rapid and short acting muscle
relaxants can produce side effects(e.g.- myalgias,
hyperthermia and hyperkalemia ) in at risk patients with
susceptibility to malignant hyperthermia , neuroleptic
malignant syndrome (NMS), catatonic schizophrenia and
[21,22,23]
organophosphate poisoning
. Therefore an ultra
short acting non depolarizing muscle relaxant would be
valuable
addition
to
the
anesthesiologists
armamentarium. Mivacurium is the drug most often
administered as an alternative to succinylcholine during
[21,24,25,26,27]
ECT
.
Mivacurium
(0.08mg/kg)
when
compared to succinylcholine (0.5mg/kg), succinylcholine
was found to be more effective in preventing muscular
[25]
contractions during ECT . In a patient with a history of
NMS, only a full intubating dose of mivacurium (0.2mg/kg
[24]
I.V) was effective for ECT
. But a full intubating dose
of mivacurium can be associated with a clinically
significant histamine release and occasional hypotension

Rashmi Pal et al.,

and requires the use of anti-cholinesterase drugs to


reverse residual paralysis after ECT. Rapacuronium is a
newer amino steroid muscle relaxant with a rapid onset
and short duration of action. It is associated with
bronchospasm. Other non-depolarizing muscle relaxants
like atracurium (0.3-0.5 mg/kg) or rocuronium (0.6
mg/kg) can be safely used, though sufficient time must
be allowed for the onset of the drug and airway,
management must be anticipated while waiting for the
effects to wear off.
Drugs used to control cardiovascular response: Anti-cholinergic drugs are used to block parasympathetic
responses, whereas acute sympathetic responses are
attenuated with B-blockers, calcium channel blockers,
alpha2-agonists and direct acting vasodilators. Rapid
short acting opioid analgesics also posses sympatholytic
affect and have recently been investigated as adjuvants
during ECT.
Anti-cholinergics; Glycopyrrolate does not cross bloodbrain barrier and is preferred over atropine as it reduces
oral secretions and bradycardia without producing postECT side effects.
B-blockers: Esmolol (short acting B1-receptor blocker)
1.0 mg/kg more effectively attenuates the blood pressure
response than labetolol (0.3 mg/kg). However Labetolol
[28,29,30]
is controversial about reducing seizure duration
.
To minimize this labetolol can be administered
immediately before or after the electrical stimulation is
applied.
Calcium-channel blockers: Nicardipine (1.25-2.5 mg/kg
i/v) in combination with Labetolol (10 mg/kg) more
effectively reduces ECT induced hemodynamic
response. Nicardipine in a bolus dose of more than 5 mg
i/v was accompanied by a reflex increase in heart rate.
Small dose of nicardipine did not alter the ECT induced
[31]
seizure duration
. Nifidipine has to be given
sublingually 20 min before ECT.
Alpha-2 Agonists/Antagonists: Clonidine ( alpha-2
agonist/antagonist) when given orally in a dose of .05-0.3
mg , 60-90 min before induction of anesthesia produced
a dose related decrease in mean arterial pressure but
not in heart rate immediately before the electrical
stimulus was applied , but no significant effect after the
stimulus. Dexmedetomidine (an alpha -2 agonist) despite
having no effect on seizure duration does not appear to
control the acute hemodynamic response.
Direct vasodilators: Nitroglycerine (NTG) in a dose of
3g/kg i/v effectively reduces hyperdynamic response
without having any effect on seizure duration. It should
be considered for ECT patients who are at a high risk of
developing myocardial ischemia. It partially inhibits the
increase in cerebral blood flow velocity associated with
ECT.
Ganglion blockers: Trimethaphan in bolus doses of 5,
10 &15 mg also controls the hyperdynamic response
during ECT without altering the duration of seizure.
Local anesthetics: Lidocaine (1.0 mg/kg) is not effective
and it produces dose-related decrease in the duration of
both motor and EEG activity.
Opioid analgesics: Alfentanil , a short acting opioid
analgesic , in a dose of 25 g/kg i/v has been found to
increase the seizure duration by 45% when combined

892
Int J Med Res Health Sci. 2015;4(4):890-895

with methohexital (0.5 mg/kg) in comparison to standard


[32]
dose of methohexital 0.75 mg/kg alone
. Fentanyl
does not attenuate the hyperdynamic response post[33]
ECT. Remifentanil also prolongs the seizure duration
.
Therefore increased seizure duration associated with the
short acting opioid analgesic alfentanil and remifentanil
appears to be related to a reduction in the intravenous
anesthetic dosage requirements. In ECT patients with
borderline seizure times, adjunctive use of a potent rapid
and short acting opiod analgesic could be very
beneficial.
Standard general anesthetic technique: Although
patients are required to fast overnight for solid food, clear
liquids are allowed for taking oral medications up to 1
hour before the procedure. Patients with cardiovascular
disease should be encouraged to take all chronic
antihypertensive medications before ECT. To prevent
post-ECT myalgias patients can be pre-medicated with
enteric-coated aspirin (650 mg orally) or acetaminophen
(650mg orally). In younger patients at risk for severe
ECT induced myalgias, headaches or both Ketorolac 30
mg i/v can also be administered before the induction of
anesthesia. Finally, to minimize the pain on injection of
methohexital and propofol, lidocaine 0.5-1.0 ml can be
injected in i/v catheter immediately before administering
the induction drug. Patient is oxygenated for 3 minutes.
Adequate neuromuscular blockade is achieved;
satisfactory ventilation with oxygen is ensured using a
face mask with a standard circle or a simple bag-maskvalve system. A bite block is placed routinely before
electrical stimulus is delivered. Since, ECT procedure
lasts only a few minutes, tracheal intubation is not
recommended except in very specific situations (e.g.
Late pregnancy, emergency treatments with full stomach
precautions, hiatal hernia and oesophgeal reflux).Rapid
sequence induction and endotracheal intubation with
cricoids pressure is a reasonable approach in such
cases. Adequate ventilation is ensured because hypoxia
[34,35]
and hypercarbia decrease seizure duration
. Manual
ventilation is commenced during the clonic phase to
avoid oxygen-desaturation and should be maintained
until adequate spontaneous ventilation resumes.
Peripheral seizure is monitored by electromyogram and
the
central
seizure
is
monitored
by
electroencephalogram. Central seizure duration may
outlast peripheral clonic manifestations. A blood
pressure cuff inflated on a limb to isolate it prior to
neuromuscular block administration can assist in
monitoring of peripheral seizure. During the recovery
period, the most common side effects are confusion,
agitation,
amnesia
and
headache.
Intranasal
administration of 5-hydroxy tryptamine-1 agonist,
sumatriptan may be used to treat headache. Nausea,
vomiting and dizziness are infrequent complications after
ECT. Standard non-invasive hemodynamic variables and
oxygen saturation should be monitored for 15-30
[36],
minutes
however
adjusting
the
dose
of
succinylcholine and adding a small dose of methohexital
(10mg i/v) at the end of the seizure may reduce the
incidence of post-ECT agitation.
Special cases:

Rashmi Pal et al.,

Patients with cerebral aneurysm: Because ECT


provokes abrupt changes in both systemic and cerebral
hemodynamics, the cerebrovascular changes increase
wall stress in aneurysm leading to enlargement or
rupture, arterial cannulation is required to control blood
[37]
pressure
. Administration of sodium-nitroprusside 30
g/min i/v in combination with atenolol 50 mg orally
effectively controlled the cardiovascular changes
[38]
associated with ECT
.
Intracranial mass Patients with subdural hemorrhage
and lesion: In such patients intracranial pressure should
be reduced by pre-treatment with steroids and diuretics
and by hyperventilation before applying the electrical
[39]
stimulus
Use of dose-titration method of ECT with
unilateral electrode placement away from the site of the
lesion minimizes the risk of adverse neurologic outcomes
and
post-procedure
neuroimaging
scans
are
recommended.
Patients with pre-existing cardiovascular disease:
Pre-treatment
with
beta-blockers
is
strongly
[40].
recommended in patients with coronary artery disease
In patients with atrial fibrillation, considering high risk of
embolization anticoagulation therapy should be started
before ECT. In cases with pre-existing bradycardia (or
sick sinus syndrome) pre-treatment with atropine is
strongly recommended, especially in patients with
myasthenia gravis who are receiving pyridostigmine.
Patients with NMS: It shares some clinical similarities to
malignant hyperthermia. Well known triggering drugs
(e.g Succinylcholine and sevoflurane should be
avoided). Non-depolarizing muscle-relaxants (e.g. mivacurium) have been successfully used in place of
succinylcholine.
Patients with inadequate seizure activity: Etomidate is
the drug of choice in patients experiencing inadequate
seizure activity when a maximal electrical stimulus is
[14]
[41]
applied
. Aminophylline
has been reported to
lengthen the seizure duration. Theophylline 100-200 mg
infused approximately 30 min before the ECT treatment
prolonged the seizure duration. Caffeine is also reported
for the same.
Pregnant patients: ECT is considered safe and
effective for the mother and fetus in the treatment of
[42]
major depressive disorder during pregnancy
.Patients
in late pregnancy should lie on their left side during ECT
to ensure adequate blood flow to the fetus.
[43]
Hyperventilation is to be avoided
. In addition to
securing patients trachea with endotracheal tube , after
a rapid sequence induction with cricoids pressure,
consideration should be given to prophylactic use of
tocolytic therapy in cases of premature labor or uterine
contractions. In later stages of pregnancy, use of
sevoflurane as an alternative to methohexital may
reduce the risk of uterine contractions.
ECT in elderly: As seizure threshold may rise with
increasing age and effective seizures may be hard to
44
induce. Geriatric, patients may be at a higher risk for
persistent confusion and greater memory deficits during
[44]
and after ECT
.
CONCLUSION

893
Int J Med Res Health Sci. 2015;4(4):890-895

As, despite many advancements in pharmacologic


management of psychiatric illnesses, electroconvulsive
therapy still remains the effective mode of treatment in
many drug resistant cases. An effective treatment
results, only when an adequate seizure of a minimum of
30 seconds duration results. This can be achieved only
with a thorough knowledge and understanding of
anesthetic drugs, their interactions with many other
concurrent psychotropic drugs and various other special
conditions often encountered in such patients. So, the
role
of
a
balanced
general
anesthesia
in
electroconvulsive therapy can never be ignored.
Conflict of interest: None
REFERENCES
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.
12.
13.

Khan A, Mirollo MH, Hughes D, Bierut L.


Electroconvulsive therapy. Psychiatr Clin North Am
1993;16:497-513
Fink M, Abrahms R, Bailine S et al: Ambulatory
Electroconvulsive therapy: Report of a task force of
the Association for convulsive therapy. Convuls
therapy, 1996;12(1);pg-42-55
National Institute for Health and Care Excellence.
Guidelines, (2009). http://guidance.nice.org.uk/CG.
A Accessed on April 25 2015
Pandya M, Pozuelo L, Malone D. Electroconvulsive
therapy: what the internist needs to know. Cleve Clin
J Med. 2007; 74(9):679-85
Taylor S. Electroconvulsive therapy: a review of
history, patient selection, technique and medication
management. South Med J. 2007; 100(5):494-8
American Psychiatric Association Committee on
Electroconvulsive Therapy. The Practice of
electroconvulsive therapy: recommendations for
nd
treatment, training and privileging. 2
ed.
Washington,
DC:
American
Psychiatric
Association.2001.
Lisanby SH. Electroconvulsive therapy for
depression. N Engl J Med. Nov8 2007;
357(19):1939-45.
Greenberg RM, Kellner CH. Electroconvulsive
therapy: a selected review. Am J Geriatric
Psychiatry. Apr 2005; 13(4):268-81
Sadock BJ, Sadock VA. Brain Stimulation Methods.
In: Kaplan & Shaddocks synopsis of psychiatry:
th
Behavioral sciences/Clinical Psychiatry. 10 ed.
Lippincott Williams & Wilkins; 2007; chapter 36, 37.
Electroconvulsive Therapy. In: Blazer DG, Steffens
rd
DC, Busse EW. Textbook of Geriatric Psychiatry. 3
ed.Washington,
DC:
American
Psychiatric
Publishing; 2004: chapter 25; 413-26.
Becker DE. Psychoactive drugs: implications for
dental practice. Anesth Prog 2008; 55:89-99.
Fink M. Convulsive therapy. Theory and practice.
New York. Raven Press. 1979
Sackeim HA, Devanand DP, Prudic J. Stimulus
intensity, seizure threshold and seizure duration:
Impact
on
the
efficacy
and
safety
of
electroconvulsive therapy. Psychiatry Clinical North
Am 1991; 14:803-43.

Rashmi Pal et al.,

14. Avramov MN, Husain MM, White PF. The


comparative effects of methohexital, propofol and
etomidate on electroconvulsive therapy .Anesth Anal
1995; 81:596-602.
15. Walker S, Bowley C, Walker H: Anesthesia for ECT,
The handbook. 2004,pg 14-27.
16. Uppal V, Dourish J, Macfarlane A. Anesthesia for
electroconvulsive therapy. Continue Educ Anaesth
Crit Care Pain.2010;10:192-96
17. Mokriski
BK,
Nagle
SE,Papuchis
GC.
Electrconvulsive induced cardiac arrhythmias during
anesthesia with methohexital, thiamylal or
thiopentone sodium. J Clin Anesth 1992; 4:208-12.
18. Safer S, Berk M. Anesthetic induction for ECT with
etomidate is associated with longer seizure duration
than thiopentone. J ECT 1998; 14:89-93.
19. Trzepacz PT, Weniger FC, Greenhouse J.
Etomidate anesthesia increases seizure duration
during ECT: a retrospective study. Gen Hosp
Psychiatry 1993; 15:115-20.
20. Auriacombe M, Reneric JP, Usandizaga D, et al.
Post- ECT agitation and plasma lactate
concentrations. J ECT 2000; 16:263-7.
21. Kelly D, Bruell SJ. Neuroleptic malignant syndrome:
a safe alternative to succinylcholine? Can J Anesth
1994; 41:845-9.
22. Cooper RC, Baumann PL, McDonald WM. An
unexpected
hyperkalemic
response
to
succinylcholine during electroconvulsive therapy for
catatonic schizophrenia. Anesthesiology 1999;
91:574-5
23. Jaksa
RJ,
Palahniuk
RJ.
Attempted
organophosphate suicide: a unique cause of
prolonged paralysis during electroconvulsive
therapy. Anesth Analg 1995; 80:832-3.
24. Fredman B, Smith I, d Etienne J, White PF. Use of
muscle relaxants for electroconvulsive therapy; how
much is long enough? Anesth Analg 1994;78:195-6.
25. Cheam EW, Crotchety LA, Chiu PT, et al. Low dose
mivacurium is less effective than succinylcholine in
electroconvulsive
therapy.
Can
JAnaesth
1999;46:49-51.
26. Liu S, Modell JH. Anesthetic management for
patients with post-polio syndrome receiving
electroconvulsive therapy. Anesthesiology 2001; 95;
799-801.
27. Gitlin MC, Jahr JS, Margolis MA, McCain J. Is
mivacurium chloride effective in electroconvulsive
therapy?A report of four cases, including a patient
with myasthenia gravis.Anesth Analg 1993;77:392-4
28. Weigner MB, PartridgeBL, Hauger R, Mirrow A.
Prevention
of
the
cardiovascular
and
neuroendocrine response to electroconvulsive
therapy.I. Effectiveness of pretreatment regimens on
hemodynamics. Anesth Analg 19991;73: 556-62
29. Van den Broek WW, Leentjens AF, Mulder PG, et
al. Low-dose esmolol bolus reduces seizure duration
during electroconvulsive therapy: a double blind,
placebo-controlled study.Br J Anaesth 1999;83:2714.

894
Int J Med Res Health Sci. 2015;4(4):890-895

30. McCall WV, Zvara D, Brooker R, Arias L. Effects of


esmolol pretreatment on EEG morphology in RUL
ECT. Convuls ther 1997; 13:175-80.
31. Avramov MN, Stool LA, White PF, Husain MM.
Effects of nicardipine and labetolol on the acute
hemodynamic response to electroconvulsive
therapy. J Clin Anesth 1998; 10:394-400.
32. Dinwiddie SH, Isenberg KE. Combined alfentanylmethohexital anesthesia in electroconvulsive
therapy.Convuls ther 1995; 11:170-6.
33. Anderson FA, Arsland D, Holst-Larsen H.Effects of
combined methohexitone - remifentanil anesthesia
in electroconvulsive therapy. Acta Anesthesiol
Scand 2001; 45:830-3.
34. Chater SN, Simpson KH. Effect of passive
hyperventilation on seizure duration in patients
undergoing electroconvulsive therapy. Br J Anaesth
60:70, 1988.
35. Rasanen J, Martin DJ, Downs JB. Oxygen
Supplementation
during
electroconvulsive
therapy.Br J Anaesth 61:593, 1988.
36. Mc Cormick AS, Saunders DA. Oxygen saturation of
patients
recovering
from
electroconvulsive
therapy...Anaesthesia 1996; 51; 525-7.
37. Zhu BL, Ishida K, Oritani S.Sudden death following
psychiatric electroconvulsive therapy: a case report.
Nippon Hoigaku Zasshi 1998;52:149-52
38. Viguera A, Rordorf G, Schouten R, et al. Intracranial
hemodynamics during attenuated responses to
electroconvulsive therapy in the presence of an
intracerebral aneurysm. J Neurol Neurosurg
Psychiatry 1998;64;802-5.
39. Salaris S, Szuba MP, Traber K. ECT and intracranial
vascular masses.J ECT 2000;16:198-03
40. Applegate RJ. Diagnosis and management of
ischemic heart disease in patients scheduled to
undergo electroconvulsive therapy.Convuls Ther
1997;13:128-44.
41. Stern L, Dannon PN, Hirschmann S. Aminophylline
increases seizure duration during electroconvulsive
therapy.J ECT 1999;15:252-7.
42. American
Psychiatric
Association.
Practice
guidelines for the treatment of patients with major
nd
depressive disorder, 2
edition. American
Psychiatric Association Practice Guidelines.2000.
43. Eberhard-Gran M, Eskild A, Opjordsmoen S.
Treating mood disorders during pregnancy: Safety
considerations. Drug Saf.2005;28(8):695-706
44. American Psychiatric Association. The Practice of
Electroconvulsive Therapy: Recommendations for
Treatment, Training and Privileging. A Task Force
nd
Report of the American Psychiatric Association. 2
ed. American Psychiatric Publishing; 2001.

Rashmi Pal et al.,

895
Int J Med Res Health Sci. 2015;4(4):890-895

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00180.0
Open Access

ISOLATED GASTRIC TUBERCULOSIS MASQUERADING AS CHRONIC PEPTIC


ULCER: A CASE REPORT
1

Poflee Sandhya V , Baste Balaji D , Umap Pradeep S , Shrivastava Alok C

ARTICLE INFO
th

Received: 12 May 2015


th
Revised: 15 June 2015
th
Accepted: 7 Aug 2015
1

Author details: Assistant Professor,


2
3
Resident,
Associate
Professor,
Department of Pathology, IGGMC,
Nagpur, Maharashtra, India
Corresponding author: Poflee
Sandhya V
1
Assistant Professor, Department of
Pathology, IGGMC, Nagpur,
Maharashtra, India
Email: spoflee@yahoo.com
Keywords:
Gastric
Chronic peptic ulcer

ABSTRACT
Abdominal Tuberculosis (TB) most commonly affects ileo-caecal region.
Isolated stomach involvement by TB, without pulmonary infection is rare.
Clinical presentation of Stomach TB may be non-specific, radiological
findings non-contributory and superficial endoscopic biopsies may not be
able to settle the diagnosis. Many cases are diagnosed only after
histopathological examination of surgical specimens. High degree of
suspicion is needed for early diagnosis of gastric tuberculosis, if
unnecessary surgical interventions are to be avoided. A young patient who
was being treated as a case of chronic peptic ulcer for one year was
referred for treatment of gastric outlet obstruction. Histopathological
examination of gastrectomy specimen of the patient showed multiple
caseating granulomas characteristic of tuberculosis and presence of acidfast bacilli on Fite-Faraco staining, with no evidence of tuberculosis at
pulmonary or other body sites. This case of isolated gastric TB is reported
for its rarity.

tuberculosis,

INTRODUCTION
Extrapulmonary tuberculosis (TB) accounts for 10-15%
of all cases of TB and the incidence reaches higher in
[1]
patients with AIDS. Gastro-intestinal tract (GIT) is the
sixth most frequent extra pulmonary site involved by
tuberculosis (TB) and ileo-caecal region is the most
[2,3]
common site of involvement in GIT TB.
Gastroduodenal or isolated gastric TB is uncommon even in
parts of the world where intestinal TB is endemic
including India and stomach and duodenal TB comprises
[4,5]
1% each of abdominal TB.
The presenting symptoms
of gastric TB are non-specific and misleading and often
[6]
mimic peptic ulcer disease or malignancy.
Primary
isolated gastric TB in absence of pulmonary TB in
[7]
immune competent host is rare.
This rare occurrence
of isolated gastric TB presenting as gastric outlet
obstruction in a patient without evidence of pulmonary
TB or immunodeficient state is presented.

any major illness. Her personal and family history was


not particular.
On general examination, the patient was a malnourished,
pale, afebrile female without
any other significant
clinical abnormality. Her abdominal examination revealed
epigastric fullness with suction splash and no
organomegaly. Complete hemogram showed low
hemoglobin level, dimorphic anemia and neutrophilic
leucocytosis. Her liver and kidney function tests were
within normal limits and her +HIV status was nonreactive.
Chest x-ray was normal and abdominal ultrasound
showed features suggestive of gastric outlet obstruction.
Barium studies revealed a distended stomach (Fig1A).

CASE REPORT
A 32 years old female was referred from a rural hospital
for abdominal distension and constipation since five
days. She gave history of abdominal pain since one year
associated with intermittent episodes of vomiting and low
grade fever off and on. Pain was localized to epigastrium
and umbilical region and was mild, intermittent in
character with no relation to food. The patient was being
treated as a case of chronic peptic ulcer without much
relief and has noticed significant loss of weight during
last six months. There was no history of cough,
hematemesis, diarrhea or malena and no past history of

Poflee et al.,

Fig 1(A): Barium study showing distended stomach. 1 (B):


Partial Gastrectomy specimen showing multiple ulcers with
undermined edges at the pyloric end of the stomach

Upper GI endoscopy revealed multiple pyloric ulcers


after sucking out fluid and debris from a grossly

896
Int J Med Res Health Sci., 2015;4(4):896-898

distended stomach with a non-negotiable pyloric


stenosis. No mass lesion was identified.
With diagnosis of gastric outlet obstruction secondary to
chronic peptic ulcer with pyloric stenosis, the patient
underwent exploratory laparotomy. Total truncal
vagotomy with distal partial gastrectomy and Billroth II
Roux-en-Y gastrojejunostomy with jejunojejunostomy
was undertaken. Rest of the abdomen was normal.
Partial gastrectomy specimen showed multiple ulcers
with undermined edges at the pyloric end of the stomach
(FIG1B).Necrotic material was expressed from the
ulcers. On histopathological examination sections
revealed ulcerated atrophic gastric mucosa and
presence of multiple granulomas in the wall of the
stomach (FIG2a).The granulomas comprised of central
area of caseous necrosis surrounded by groups of
epithelioid cells, Langhans giant cells and lymphocytes
(FIG 2a- inset).

Fig 2(a): Photomicrograph showing ulcerated and


atrophic gastric mucosa and presence of multiple
caseating granulomas in the wall of stomach (H & E,
400x). Inset: Photomicrograph showing granuloma
comprising of epithelioid cells, Langhans giant cell
and
lymphocytes
(H
&
E,
1000x).
2(b):
Photomicrograph showing acid fast TB bacillus on
special stain (Fite-Faraco, 1000x).
Diagnosis of TB was confirmed after visualizing acid-fast
Mycobacterium tuberculosis organisms on Fite-Faraco
stain (FIG2b). The patient was discharged after an
uneventful post-operative period and was enrolled under
Category-I of DOTS program. On monthly follow-up
visits, she showed remarkable improvement in her
general condition.
DISCUSSION
Gastric TB is commonly associated with TB at another
site, usually pulmonary or with an immunocompromised
state. Primary isolated gastric TB is rare in immune
[7]
competent host. First case of stomach TB was reported
[8].
by Barkhausen in 1824
The rarity of gastric tuberculosis is due to bactericidal
property of gastric acid, continuous motor activity of the
stomach and the scarcity of lymphatic follicles in the
[9].
gastric wall
The possible routes of infection include
direct infection of the mucosa by infected sputum,
hematogenous spread or extension from neighbouring

Poflee et al.,

[2]

tuberculous lymph nodes and fallopian tubes.


The
lesser curvature of antrum and prepyloric regions of
stomach are the most common sites involved.
Presenting symptoms of gastric TB are highly
nonspecific, vomiting and epigastric pain being the most
common and symptoms like weight loss, upper GI
bleeding, and fever with variable duration may be
[7]
present.
Clinical presentation of Gastric TB may
[10]
simulate gastritis, peptic ulcer or gastric carcinoma.
The patients usually land in surgery wards with
complications
such
as
gastric
outlet
obstruction,hematemesis,perforation or gastro-bronchial
[9]
fistula. Case reported here was referred to our centre
when the patient developed complication that needed
immediate surgical intervention.
There is lack of pathognomonic findings on imaging
studies in cases of gastric TB. Barium contrast study in
gastric TB,shows narrowing of gastric antrum and filling
defects. CT may show gastric wall thickening.
Upper Gastro-intestinal endoscopy in gastric TB reveals
single or multiple ulcers or hypertrophic nodular
[4]
lesions. In stomach TB a solitary ulcer may be seen in
fundus due to TB vasculitis with involvement of regional
lymph nodes. Four peculiarities of gastric TB described
on gastroscopy are- serpiginous nature of the ulcer with
undermined edges,multiple fistulous openings through
the mucosa and presence of superficial tubercles near
[7]
the lesion. However, Endoscopic biopsies are rarely
diagnostic as tubercular granulomas are mostly
submucosal, an area not included in endoscopic
[11]
biopsy
Granulomatous gastritis is a rare morphological
diagnosis and a variety of infectious and non-infectious
causes have to be considered in differential diagnosis.
Pathologic criteria established by Broders in 1917, for
diagnosis of gastric tuberculosis are similar to those
accepted today and require demonstration of caseating
epithelioid granuloma and presence of acid fast bacilli in
tissue. Histopathological examination of either a
gastroscopic biopsy or gastrectomy specimen for
characteristic morphological features and special stain
(Ziehl-Neelson or Fite Faraco) thus becomes most
important. But gastro duodenal TB is a pauci-bacillary
disease and demonstration of acid fast bacilli may not be
[1]
possible. PCR test of the biopsy specimen is essential
[8]
if culture study is not able to yield acid fast bacilli and
provides a faster alternative for the diagnosis. Antitubercular chemotherapy is the main modality for
management of gastric tuberculosis when the diagnosis
is established before surgery. Surgical intervention
becomes necessary when the patient presents with
complications such as gastric outlet obstruction,
[5,11,12]
perforation or fistula formation.
CONCLUSION
TB can involve any site in GIT and may present with
non-characteristic clinico-radiological features and
without
evidence
of
pulmonary
disease
or
immunodeficiency. High index of suspicion is needed for
diagnosis of gastric TB, especially in patients presenting

897
Int J Med Res Health Sci., 2015;4(4):896-898

with endoscopic evidence of chronic inflammatory


activity and associated with non-specific fever.
Acknowledgements: Dr AV Shrikhande- Professor and
Head, Pathology and Dr. SM Lanjewar- Professor and
Head, Surgery IGGMC Nagpur for permission to publish
the case.
Conflict of interest: Nil
REFERENCES
1.

Gupta
P,Guleria
S,Mathur
SR,Ahuja
V.
Gastroduodenal Tuberculosis: A Rare cause of
gastric outlet obstruction. Surgery Journal.2010; 5
(3-4):36-39
2. Sharma MP, Bhatia V. Abdominal Tuberculosis.
Indian J Med Res. 2004;120:305-15
3. Dasgupta A, Singh N, Bhatia A. Abdominal
Tuberculosis: A histopathological study with special
reference to intestinal perforation and mesenteric
vasculopathy.
Journal
of
laboratory
physician,Delhi.2010;1(2):56-61
4. Bandyopadhyay S, Bandyopadhyay R, Chatterjee U.
Isolated gastric tuberculosis presenting as
haematemesis. J Postgrad Med 2002; 48(1):72-73
5. Mukhopadhyay M, Rahaman QM, Mallick NR, Khan
D, Roy S, Biswas N. Isolated gastric tuberculosis: a
case report and review of literature. Indian J
Surg.2010; 75(5):412-413.
6. Ecka Rs, Wani ZA, Sharma M. Gastric Tubercolosis
with Outlet Obstruction: A Case Report Presenting
with a Mass Lesion. Case Reports in
Medicine.2013;Article ID 169051:1-3
7. Dixit R, Srivastava V, Kumar M, Shukla M, Pande M.
Primary Gastric Tuberculosis. World Journal of
Medical and Surgical Case Reports. 2012; 3:1-7
8. Reddy DB, Krishnan M.K.R. Tuberculosis of the
Stomach. Ind. J. Tub, 1962, X(1),1-10
9. Amarapurkar DN, Patel ND, Amrapurkar AD.
Primary Gastric Tuberculosis report of 5 cases.
BMC Gastroenterology. 2003; 3:6:1-4
10. Kim SE, Shim KN, Moon II H. A Case of Gastric
Tuberculosis Mimicking Advanced Gastric Cancer.
KJIM.2008; 21(1):62-67
11. Rao YG, Pande GK, Sahni P,Chattopadhyay
TK.Gastroduodenal
tuberculosis
management
guidelines, based on a large experience and a
review of the literature. Can J Surg. 2004; 47:364-8.
12. Gill RS, Gill SS, Mangat H, Logssetty S. Gastric
Perforation Associated with Tuberculosis: A case
Report. Case reports in Medicine.2011;Article ID
392769: 1-3.

Poflee et al.,

898
Int J Med Res Health Sci., 2015;4(4):896-898

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00181.2
Open Access

LUPUS VULGARIS FOLLOWING EAR-PIERCING


1

Vaishnavi L , Prasad PVS , Kaviarasan PK

ARTICLE INFO
th

Received: 19 May 2015


Revised: 8th Jul 2015
Accepted: 29th Jul 2015
Author details: 1Junior resident,
2
3
Professor,
Professor
&
Head,
Department
of
Dermatology,
Venereology, Leprosy, Rajah Muthiah
Medical
College
and
Hospital,
Annamalai University, Chidambaram,
Tamil Nadu
Corresponding author: Vaishnavi L,
Department
of
Dermatology,
Venereology, Leprosy, Rajah Muthiah
Medical
College
and
Hospital,
Annamalai University, Chidambaram,
Tamil Nadu
Email: lvaishu@gmail.com
Keywords: Cutaneous tuberculosis,
Lupus vulgaris, Ear piercing

ABSTRACT
In India, two-thirds of cutaneous tuberculosis cases are found to be lupus
vulgaris. Lupus vulgaris could be due to primary or secondary infection to
Mycobacterium tuberculosis. Innumerable cases of lupus vulgaris,
secondary to a systemic affliction i.e., arising from an underlying focus of
tuberculosis have been noted. Very few cases of primary lupus vulgaris
have been reported. It may appear as a solitary lesion in the skin at a site
of primary inoculation such as tattooing or ear-piercing. We hereby report
a case of lupus vulgaris in a 21-year-old female following ear-piercing.
Cutaneous examination revealed a soft, erythematous plaque-like growth,
involving the entire posterior aspect of both ear lobules completely
obscuring the site of ear piercing. It also involved the lower one thirds of
anterior aspect of both ear lobules. The overlying skin was smooth with
few indentations. Histopathological examination (Fig.2) revealed focal
hyperplastic changes in epidermis & multiple epithelioid cell granulomas &
a diffuse lymphocytic infiltrate in the entire dermis, extending into the
subcutaneous fat. On the basis of these clinical features &
histopathological examination findings, a diagnosis of lupus vulgaris was
made and she was started on anti-tuberculous treatment. The lesions
started regressing after 2weeks.

INTRODUCTION
Tuberculosis (TB) is one of the most common, rampant
infectious diseases in underdeveloped countries. In
countries like India, while great progress has been
made, TB is still very common; with 2.3 million new
[1]
cases diagnosed every year
.The pattern of
cutaneous TB has been changing over the last few
decades. By 1980s the incidence of cutaneous TB in
[2]
India had fallen to 0.15% . More recent reports
suggest that cutaneous TB is again becoming more
[2]
prevalent with incidence of 0.26% . A current problem
is that atypical and even standard presentations may be
overlooked, through lack of familiarity with the various
patterns that may occur.
Among the cases of cutaneous TB reported in India,
[2]
57.69% are found to be that of lupus vulgaris . These
lesions are acquired exogenously or endogenously,
although the former is significantly less common. Lupus
vulgaris can arise at the site of a primary inoculation
such as tattooing, ear piercing or following BCG
immunization.

discharge from the growth or the site of ear piercing.


She presented to the out-patient department in view of
cosmetic disfigurement.
Cutaneous examination (Fig.1) revealed a soft,
erythematous plaque-like growth, involving the entire
posterior aspect of both ear lobules completely
obscuring the site of ear piercing. It also involved the
lower one thirds of anterior aspect of both ear lobules.
The overlying skin was smooth with few indentations. It
was neither warm nor tender. Systemic examination
was unremarkable. A differential diagnosis of lupus
vulgaris, foreign body granuloma & keloid was
considered.

CASE REPORT
A 21-year-old woman, presented to our out-patient
department, with a history of a fleshy growth in both ear
lobules since 3years. She first noticed the growth, at 2
weeks, following piercing of her ears for attaching
adornments. Interestingly the growth started at the site
of piercing and gradually progressed to involve the
entire posterior aspect of both ear lobules. She did not
complain of pain, itching, bleeding or any form of

Fig 1: showing the soft plaque-like growth in right


and left ear lobules respectively

899
Vaishnavi et al.,

Int J Med Res Health Sci. 2015;4(4):899-901

Fig 2: Multiple epithelioid cell granulomas and


diffuse lymphocytic infiltrate in dermis (H & E,10x)
Routine laboratory investigations, sputum AFB, chest Xray done did not reveal any abnormal finding. Mantoux
test done was positive measuring 20 x 24mm. AFB
could not be demonstrated from the lesions. Skin
biopsy was done.
Histopathological examination (Fig.2) revealed focal
hyperplastic changes in epidermis & multiple epithelioid
cell granulomas & a diffuse lymphocytic infiltrate in the
entire dermis, extending into the subcutaneous fat.
On the basis of these clinical features &
histopathological examination findings, a diagnosis of
lupus vulgaris was made and she was started on antituberculous treatment. The lesions started regressing
after 2weeks of rifampicin 450mg/day, isoniazid
300mg/day and pyrazinamide 1000mg/day. After two
months of intensive treatment with these drugs, which
were given according to her weight, she showed further
improvement. Treatment was continued for four months
with rifampicin 450mg/day and isoniazid 300mg/day,
after which complete clearance of lesions were seen.
The patient was followed up for one year and there was
no recurrence.

Lupus vulgaris is a chronic, progressive, post primary,


paucibacillary form of cutaneous tuberculosis, occurring
in a person with a moderate or higher degree of
[9]
immunity . It originates from an underlying focus of
tuberculosis, typically in a bone, joint or lymph node. It
may arise by either contiguous extension of disease
from underlying affected tissue or by hematogenous or
lymphatic spread. Lupus vulgaris may also arise due to
direct inoculation of mycobacterium tuberculosis into
the skin in a non-sensitized patient. This may result
from minor abrasion, tattooing, ear piercing, minor
surgical procedures or infections. There is a 10% risk of
developing squamous cell carcinoma from a lupus
[9]
vulgaris lesion that may be left untreated . This
necessitates the need for knowledge, of the fact that
lupus vulgaris occurs not only as a post-primary lesion,
but also due to primary inoculation of the
Mycobacterium.
CONCLUSION
As ear piercing practices are most common across the
world, the rarer & treatable complications of this
procedure have to be considered. This case of lupus
vulgaris following ear-piercing, has been highlighted for
its rarity and also to create awareness among
dermatologists.
Acknowledgment:
Conflict of interest: Nil
REFERENCES
1.
2.

3.

DISCUSSION
Ear piercing has been a popular practice in India since
time immemorial. The risk of acute complications
following ear-piercing, depends on the experience of
the piercer, on the hygiene-sanitation conditions under
which the procedure takes place and on general
piercing aftercare. Specific complications associated
with piercing the pinna include, hypertrophic /keloid
scarring, chondritis / perichondritis & incrustation. The
most common complication is infection, occurring in 10[3,4]
20% of cases . Microorganisms like staphylococcus
aureus, group A streptococci & pseudomonas species
are usually thought to be the causative organisms of
[6]
infections following ear piercing
. Less common
infective organisms associated with piercings are
[4]
coagulase negative staphylococci, Lactobacillus ,
[3,4]
Mycobacterium
tuberculosis
and
atypical
mycobacteria. Among the various forms of cutaneous
TB, lupus vulgaris is most common manifestation as is
[8]
evidently seen in 75% of the cases .

Vaishnavi et al.,

4.

5.

6.

7.

8.

9.

Revised national TB Control programme. Annual


status report: Tb epidemiology; March 2013:19-24.
Patra AC, Gharammi RC, Banerjee PK. A profile of
cutaneous tuberculosis.Indian J Dermatol 2006;
51:105-7.
Martin Kaatz, Peter Elsner, Andrea Bauer. Bodymodifying concepts & dermatological problems
tattooing & piercings. Clinics in dermatology 2008;
26:35-44.
Razavi B, Schilling M. Chondritis attributable to
Lactobacillus after ear piercing. Diagn Microbiol
Infect Dis. 2000; 37:75-6.
Kaur C, Sarkar R, Kanwar AJ. How safe is nosepiercing? Inoculation cutaneous tuberculosis
revisited. Int J Dermatol. 2003; 42:645-6.
Vikram K Mahajan, Sharma N,Sharma R. WereWolf cutaneous tuberculosis. Int. J. Lepr. 2004;
72:473-9.
Mataix J, Silvestre J F. Cutaneous adverse
reactions to tattoos & piercings.
Actas
Dermosifiliogr 2009; 100: 643-56.
Yates V M. Mycobacterial infections. Burns T,
Breathnach S, Cox N, Griffiths C. Eds. Eighth
edition.
Rooks
Textbook
of
Dermatology.Oxford;Blackwell
Publishing
Ltd.
2010:31.16.
Gerhard T. Tuberculosis and infections with
Atypical mycobacteria. Wolff K, Goldsmith L,Katz
S, Gilchrest B, Paller A S, Leffell D J.Eds. Seventh
edition. Fitzpatricks Dermatology in General

900
Int J Med Res Health Sci. 2015;4(4):899-901

Medicine. USA,The McGraw-Hill companies,Inc.


2008:1768.
10. Guiard-Schmid JB, Picard H, Slama, et al. Piercing
and its infectious complications. A public health
issue in France. Presse Med 2000; 29:1948-56.
11. Cumberworth VL, Hogarth TB. Hazards of earpiercing procedures which traverse cartilage: report
of Pseudomonas perichondritis and review of other
complications. Br J Clin Pract 1990; 44:512-3.
12. Tweeten SS, Rickman LS. Infectious complications
of body piercing. Clin Infect Dis 1998; 26:735-40.

Vaishnavi et al.,

901
Int J Med Res Health Sci. 2015;4(4):899-901

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00181.2
Open Access

LUPUS VULGARIS FOLLOWING EAR-PIERCING


1

Vaishnavi L , Prasad PVS , Kaviarasan PK

ARTICLE INFO
th

Received: 19 May 2015


Revised: 8th Jul 2015
Accepted: 29th Jul 2015
Author details: 1Junior resident,
2
3
Professor,
Professor
&
Head,
Department
of
Dermatology,
Venereology, Leprosy, Rajah Muthiah
Medical
College
and
Hospital,
Annamalai University, Chidambaram,
Tamil Nadu
Corresponding author: Vaishnavi L,
Department
of
Dermatology,
Venereology, Leprosy, Rajah Muthiah
Medical
College
and
Hospital,
Annamalai University, Chidambaram,
Tamil Nadu
Email: lvaishu@gmail.com
Keywords: Cutaneous tuberculosis,
Lupus vulgaris, Ear piercing

ABSTRACT
In India, two-thirds of cutaneous tuberculosis cases are found to be lupus
vulgaris. Lupus vulgaris could be due to primary or secondary infection to
Mycobacterium tuberculosis. Innumerable cases of lupus vulgaris,
secondary to a systemic affliction i.e., arising from an underlying focus of
tuberculosis have been noted. Very few cases of primary lupus vulgaris
have been reported. It may appear as a solitary lesion in the skin at a site
of primary inoculation such as tattooing or ear-piercing. We hereby report
a case of lupus vulgaris in a 21-year-old female following ear-piercing.
Cutaneous examination revealed a soft, erythematous plaque-like growth,
involving the entire posterior aspect of both ear lobules completely
obscuring the site of ear piercing. It also involved the lower one thirds of
anterior aspect of both ear lobules. The overlying skin was smooth with
few indentations. Histopathological examination (Fig.2) revealed focal
hyperplastic changes in epidermis & multiple epithelioid cell granulomas &
a diffuse lymphocytic infiltrate in the entire dermis, extending into the
subcutaneous fat. On the basis of these clinical features &
histopathological examination findings, a diagnosis of lupus vulgaris was
made and she was started on anti-tuberculous treatment. The lesions
started regressing after 2weeks.

INTRODUCTION
Tuberculosis (TB) is one of the most common, rampant
infectious diseases in underdeveloped countries. In
countries like India, while great progress has been
made, TB is still very common; with 2.3 million new
[1]
cases diagnosed every year
.The pattern of
cutaneous TB has been changing over the last few
decades. By 1980s the incidence of cutaneous TB in
[2]
India had fallen to 0.15% . More recent reports
suggest that cutaneous TB is again becoming more
[2]
prevalent with incidence of 0.26% . A current problem
is that atypical and even standard presentations may be
overlooked, through lack of familiarity with the various
patterns that may occur.
Among the cases of cutaneous TB reported in India,
[2]
57.69% are found to be that of lupus vulgaris . These
lesions are acquired exogenously or endogenously,
although the former is significantly less common. Lupus
vulgaris can arise at the site of a primary inoculation
such as tattooing, ear piercing or following BCG
immunization.

discharge from the growth or the site of ear piercing.


She presented to the out-patient department in view of
cosmetic disfigurement.
Cutaneous examination (Fig.1) revealed a soft,
erythematous plaque-like growth, involving the entire
posterior aspect of both ear lobules completely
obscuring the site of ear piercing. It also involved the
lower one thirds of anterior aspect of both ear lobules.
The overlying skin was smooth with few indentations. It
was neither warm nor tender. Systemic examination
was unremarkable. A differential diagnosis of lupus
vulgaris, foreign body granuloma & keloid was
considered.

CASE REPORT
A 21-year-old woman, presented to our out-patient
department, with a history of a fleshy growth in both ear
lobules since 3years. She first noticed the growth, at 2
weeks, following piercing of her ears for attaching
adornments. Interestingly the growth started at the site
of piercing and gradually progressed to involve the
entire posterior aspect of both ear lobules. She did not
complain of pain, itching, bleeding or any form of

Fig 1: showing the soft plaque-like growth in right


and left ear lobules respectively

899
Vaishnavi et al.,

Int J Med Res Health Sci. 2015;4(4):899-901

Fig 2: Multiple epithelioid cell granulomas and


diffuse lymphocytic infiltrate in dermis (H & E,10x)
Routine laboratory investigations, sputum AFB, chest Xray done did not reveal any abnormal finding. Mantoux
test done was positive measuring 20 x 24mm. AFB
could not be demonstrated from the lesions. Skin
biopsy was done.
Histopathological examination (Fig.2) revealed focal
hyperplastic changes in epidermis & multiple epithelioid
cell granulomas & a diffuse lymphocytic infiltrate in the
entire dermis, extending into the subcutaneous fat.
On the basis of these clinical features &
histopathological examination findings, a diagnosis of
lupus vulgaris was made and she was started on antituberculous treatment. The lesions started regressing
after 2weeks of rifampicin 450mg/day, isoniazid
300mg/day and pyrazinamide 1000mg/day. After two
months of intensive treatment with these drugs, which
were given according to her weight, she showed further
improvement. Treatment was continued for four months
with rifampicin 450mg/day and isoniazid 300mg/day,
after which complete clearance of lesions were seen.
The patient was followed up for one year and there was
no recurrence.

Lupus vulgaris is a chronic, progressive, post primary,


paucibacillary form of cutaneous tuberculosis, occurring
in a person with a moderate or higher degree of
[9]
immunity . It originates from an underlying focus of
tuberculosis, typically in a bone, joint or lymph node. It
may arise by either contiguous extension of disease
from underlying affected tissue or by hematogenous or
lymphatic spread. Lupus vulgaris may also arise due to
direct inoculation of mycobacterium tuberculosis into
the skin in a non-sensitized patient. This may result
from minor abrasion, tattooing, ear piercing, minor
surgical procedures or infections. There is a 10% risk of
developing squamous cell carcinoma from a lupus
[9]
vulgaris lesion that may be left untreated . This
necessitates the need for knowledge, of the fact that
lupus vulgaris occurs not only as a post-primary lesion,
but also due to primary inoculation of the
Mycobacterium.
CONCLUSION
As ear piercing practices are most common across the
world, the rarer & treatable complications of this
procedure have to be considered. This case of lupus
vulgaris following ear-piercing, has been highlighted for
its rarity and also to create awareness among
dermatologists.
Acknowledgment:
Conflict of interest: Nil
REFERENCES
1.
2.

3.

DISCUSSION
Ear piercing has been a popular practice in India since
time immemorial. The risk of acute complications
following ear-piercing, depends on the experience of
the piercer, on the hygiene-sanitation conditions under
which the procedure takes place and on general
piercing aftercare. Specific complications associated
with piercing the pinna include, hypertrophic /keloid
scarring, chondritis / perichondritis & incrustation. The
most common complication is infection, occurring in 10[3,4]
20% of cases . Microorganisms like staphylococcus
aureus, group A streptococci & pseudomonas species
are usually thought to be the causative organisms of
[6]
infections following ear piercing
. Less common
infective organisms associated with piercings are
[4]
coagulase negative staphylococci, Lactobacillus ,
[3,4]
Mycobacterium
tuberculosis
and
atypical
mycobacteria. Among the various forms of cutaneous
TB, lupus vulgaris is most common manifestation as is
[8]
evidently seen in 75% of the cases .

Vaishnavi et al.,

4.

5.

6.

7.

8.

9.

Revised national TB Control programme. Annual


status report: Tb epidemiology; March 2013:19-24.
Patra AC, Gharammi RC, Banerjee PK. A profile of
cutaneous tuberculosis.Indian J Dermatol 2006;
51:105-7.
Martin Kaatz, Peter Elsner, Andrea Bauer. Bodymodifying concepts & dermatological problems
tattooing & piercings. Clinics in dermatology 2008;
26:35-44.
Razavi B, Schilling M. Chondritis attributable to
Lactobacillus after ear piercing. Diagn Microbiol
Infect Dis. 2000; 37:75-6.
Kaur C, Sarkar R, Kanwar AJ. How safe is nosepiercing? Inoculation cutaneous tuberculosis
revisited. Int J Dermatol. 2003; 42:645-6.
Vikram K Mahajan, Sharma N,Sharma R. WereWolf cutaneous tuberculosis. Int. J. Lepr. 2004;
72:473-9.
Mataix J, Silvestre J F. Cutaneous adverse
reactions to tattoos & piercings.
Actas
Dermosifiliogr 2009; 100: 643-56.
Yates V M. Mycobacterial infections. Burns T,
Breathnach S, Cox N, Griffiths C. Eds. Eighth
edition.
Rooks
Textbook
of
Dermatology.Oxford;Blackwell
Publishing
Ltd.
2010:31.16.
Gerhard T. Tuberculosis and infections with
Atypical mycobacteria. Wolff K, Goldsmith L,Katz
S, Gilchrest B, Paller A S, Leffell D J.Eds. Seventh
edition. Fitzpatricks Dermatology in General

900
Int J Med Res Health Sci. 2015;4(4):899-901

Medicine. USA,The McGraw-Hill companies,Inc.


2008:1768.
10. Guiard-Schmid JB, Picard H, Slama, et al. Piercing
and its infectious complications. A public health
issue in France. Presse Med 2000; 29:1948-56.
11. Cumberworth VL, Hogarth TB. Hazards of earpiercing procedures which traverse cartilage: report
of Pseudomonas perichondritis and review of other
complications. Br J Clin Pract 1990; 44:512-3.
12. Tweeten SS, Rickman LS. Infectious complications
of body piercing. Clin Infect Dis 1998; 26:735-40.

Vaishnavi et al.,

901
Int J Med Res Health Sci. 2015;4(4):899-901

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00183.6
Open Access

ACROMEGALY: A CASE REPORT


1

Vedant R Awasthi , Rushikesh S. Haridas , Sumedh Kirdak , Pratik Shete , Shardul Kulkarni , Srivatshava
6,
7
8
Pendyala Ghosh AK , Deshpande JJ

ARTICLE INFO
th

Received: 20 Jun 2015


th
Revised: 30 Jul 2015
st
Accepted: 31 Aug 2015
1-6

Authors details:
Junior Resident,
7
8
Professor, Professor and Head,
Department of Medicine, Rural
Medical College, Loni, Ahmednagar,
Maharashtra, India
Corresponding author: Vedant RA,
Junior Resident, Department of
Medicine, Rural Medical College, Loni,
Ahmednagar, Maharashtra, India
Email: vedant.awasthi@gmail.com

ABSTRACT
Acromegaly is a rare disease caused due to hyper secretion of growth
hormone. Most of the cases of acromegaly are caused by pitutary adenoma
which can be microadenoma or macroadenomas. These adenomas are
never malignant, but can have significant morbidity and mortality. We report
a 35 year old female patient presented herewith classical presentation of
acromegaly with chief complain of weight gain, excessive sweating ,
widening of both hands and feet and was diagnosed as a case of
acromegaly due to macroadenoma of pirtutary gland, on the basis of typical
clinical features and hormonal parameters also radiological findings. Patient
underwent transsphenoidal surgical resection of macroadenoma and
recovered completely from the disease. Early recognition and diagnosis will
help to avoid the complications of disease.

Keywords: Acromegaly,
Macroadenoma, Growth hormone,
Insulin like growth factor 1
INTRODUCTION
Acromegaly is a rare disease occurs with a prevalence of
50 to 70 cases per million and an incidence of 3 cases
[1]
per million per year . Acromegaly is a rare disease
caused due to hyper secretion of growth hormone. Most
of the cases of acromegaly are caused by pitutary
adenoma
which
can
be
microadenoma
or
macroadenomas. These adenomas are never malignant,
[2,3]
but can have significant morbidity and mortality .
[3,4,5]
Clinical
features:
Cardiovasular SystemHypertension, Ventricular Hypertrophy, Cardiomyopathy,
Congestive Heart Failure Etc. Respiratory System- Sleep
apnoea, Upper airway obstruction due To macroglossia,
Gastointestinal System- Colon polyp, MetabolicDiabetes Mellitus, Imapaired Glucose Tolerance,
Muscluloskeletal- Prognathism, Frontal Bossing, Acral
Enlargment, Arthralgia, Myopathies Etc. Skin- Oily Skin,
Acnthosis
Nigricans,
VisceralomegalyGoiter,
Macroglossia,
Hepatomegaly,
Splenomegaly,
Neurological- Carpal Tunnel Syndrome, Aneurysm,
Headache, Local effect due to tumous- Visual field
defect, Cranial nerve palsy Etc.
[3,4]
Diagnosis:
The diagnosis of acromegaly is based
mainly on symptoms and signs with biochemical
investigation and radiography. The biochemical
diagnosis of acromegaly is done by raised level of
growth hormone and insulin like growth factor.
Acromegaly is mainly associated with raised levels of
IGF1 level. So normal IGF1 level excludes the diagnosis
in most of the patients. After diagnosis of acromegaly
based on biochemical investigation, documentation is
needed for pitutary adenoma which is most common
cause of acromegaly. In patient of acromegaly visual

Awasthi et al.,

field assessment is also necessary in cases of


macroadenoma which are close to optic chiasm.
Also xray of limbs and skull and chest also needed.
Colonoscopy is needed to look for polyp.
Echocardiography and Holter electrocardiography
indicated if patient is having cardiac involvement on
[6]
clinical examination .
[7,8]
Treatment:
The choice of treatment in acromegaly
due to pitutary adenoma is transsphenoidal surgery.
Medical therapy can also be used for treatment which
includes dopamine agonist, somatostatin analogs, GHreceptor blocking agents. Most commonly used drug is
octerotide. Surgery is preferred over medical treatment
as it has advantages. It gives quick relief with symptoms
and signs, also stops the organ damage due to hormone
excess. The outcome of surgery is good for
microadenoma than macroadenoma. So for recurrence
[3]
of adenomas radiotherapy can also be used.
CASE REPORT
A 35 year old female patient came to OPD with chief
complains of weight gain, excessive sweating , widening
of both hands and feet since 4 to 5 years. She also give
complains of change in voice. Also she is having
headache intermittently. No history of convulsions or
altered sensorium or she doesn't have any visual
complains or any weakness. For amenorrhorea she
underwent total abdominal hysterectomy 9 years back.
On examinations patients vitals are normal that means
pulse rate-84/min blood pressure-138/90 respiratory
rate-18/cycles per min. There was no pallor, cyanosis,
clubbing, lymphadenopathy.

907
Int J Med Res Health Sci. 2015;4(4):907-910

BSL: Blood Sugar level:,

C
Fig 2A: Hand xray shows tufting of terminal phalanges
arrow head appearance, 2B: Heel pad thickness is
increases (>18mm), 2C: Prominent supraorbital ridges, and
jaw, enlargement of pituitary fossa.

Fig 1: A: Prognathism and prominent supraorbital


ridges., B:Macroglossia., C:Thick lips and widening
of teeth spaces., D & E: Spade like hands.
But patients general appearance didn't look normal.
Careful examination from head to toe showed prominent
supraorbital ridges, prognathism, widening of teeth
spaces , macroglossia with thick lips, large ears and
fleshy nose , patient also had spade like hands and feet
and also had deep, husky voice which was not before.
Systemic examination was normal. Soon all these
features we suspected the provisional diagnosis of
'acromegaly'.
Table 1: Lab investigations:
Hb % (gm/dl)
11.6
FSH(mIU/ml)
1.26
TLC(cumm)
5206 LH(mIU/ml)
0.06
Platelet
2.65
Testosterone(ng/ml)
0.18
(lakhs/cumm)
BIL(T) mg/dl
0.86
Prolactin(ng/ml)
107
BIL(C) mg/dl
0.24
IGF1(ng/ml)
861
SGOT(IU/L)
31.6
GH(ng/ml)
>40
SGPT(IU/L)
34
T3(ng/ml)
131
ALP(IU/L)
192
T4(g/ml)
7.7
Urea(mg/dl)
11.9
TSH(IU/ml)
5.72
Creatinine(mg/dl) 0.24
BSL (mg/dl)
126
Sodium(mEq/L)
141.6 Magnesium(mg/dl)
1.6
Potassium(mEq/L) 4.5
Triclycerides(mg/dl)
86
Calcium (mg%)
11
Total
150
cholesterol(mg/dl)
TLC: Total leukocyte count, BIL(T) : Bilirubin total:,
BIL(C)Bilirubin conjugated:, SGOT: Serum glutamic
oxaloacetic transaminase, SGPT: serum glutamic
pyruvic transaminase, ALP: Alkaline phosphatase, FSH:
Follicle Stimulating Hormone, LH: luteinizing hormone,
IGF: Insulin like growth factor1, GH: Growth Hormone,

Awasthi et al.,

MRI brain shows: 3.1*2.4*1.6cm sized, well defined


lesion, with moderate enhancement on post contrast
study in sellar and supra sellar region with extension and
mass effect over adjustant structures s/o sellar or supra
sellar SOL like pitutary macroadenoma.[Fig 3]
Treatment:
Treatment
was
started
with
oral
hypopglycemic drugs i.e. metformin 500mg for impaired
fasting blood glucose level before surgery and
Transsphenoidal surgical resection (TSS)' was done.
Patient developed diabetis insipidus in postoperative state
required one dose of vasopressin. Diabetis incipidus
subsided after 3 days. Patient is now stable and her
postoperative GH level is 7.94ng/ml. And patient is
discharged on tab prednisolone 5mg half tab daily, and
patient is called for follow up after 3 months. There were
noticiable changes were seen in patient after surgery. She
lost 7kg weight in 2 months. (Fig 4)

Fig 3: MRI BRAIN SHOWING MACROADENOMA

Fig 4: Before surgery, 2 Months after surgery

908
Int J Med Res Health Sci. 2015;4(4):907-910

DISCUSSION
Most of cases of acromegaly are caused by excessive
[9].
secretion of growth hormone i.e. 95% approximately
Pituitary tumors represented by 10-20% of somatotropic
adenomas and less commonly by lactotropic and
[10]
gonadotropic
adenomas .The
prevalence
of
acromegaly is 40 to 70 cases per million worldwide, it is
[11]
seen equally in both sexes . From diagnostic point of
view, about 8 to 10 years of delay is commonly observed
[12]
from the onset of symptoms to recognition . To improve
prognosis of disease early recognition and diagnosis and
[12]
management is necessory . Primary symptoms were
weight gain, sweating, headache and sometimes joint
[13]
pain etc . Which had been present for at least 4 years
before diagnosis. Acromegaly have multisystem
involvement cardiovascular, endocrinal, musculoskeletal,
cutaneous
neurological
and
also
psychiatric
[9,10,12].
disturbance
Diabetes mellitus was observed in
about 25% of cases. Due to counteraction of growth
hormone on effect of insulin. Complete clinical
examination, raised IGF-1 levels and MRI Brain showing
pitutary macroadenoma is a key to diagnosis in this
case. A diagnosis of acromegaly is made on the basis of
signs and symptoms of the condition, in addition to
[14]
biochemical testing . A pituitary MRI should be
obtained after biochemical testing to confirm the
presence of a pituitary macroadenoma. If the pituitary
tumor is found incidentally, and if acromegaly is
suspected based on signs or symptoms, IGF1 level
should be measured. IGF-binding protein 3 has been
shown to be another useful marker of growth hormone
[15].
excess, if other tests are inconclusive
Unless GH levels are controlled, survival is reduced by
an average of 10 years compared with an age-matched
[16]
control population . This patient was detected in early
phase hence these all serious complications were not
seen in this patient.
The goal of treatment is to control IGF-1 and GH
hypersecretion. Hence surgical resection of the GHsecreting adenomas is the initial treatment for most of
the patients. Transsphenoidal surgical resection by an
experienced surgeon is the preferred primary
16
treatment. Growth hormone level normalize within an
hour and IGF-1 levels comes down to baseline in three
to four days, as seen in this patient.

Acknowledgment: I thank you to my guide Dr J J


Deshpande and Dr A K Ghosh sir for their guidance.
REFERENCES
1.

2.

3.

4.

5.

6.

7.

8.

CONCLUSION

9.

Acromegaly is a rare disease caused due to excessive


secretion of growth hormone and insulin like growth
factor type 1 mostly due to pituitary adenoma. Which
leads to clinical feature like prognathism, frontal bossing,
macroglossia, spade like hands, thick heel pad,
thickening of lips, sweating , headache as seen in this
patient.
Early recognition and treatment of disease helped in
prognosis of disease and arrested the complications like
hypertension, cardiomyopathy, diabetes mellitus, visual
disturbances etc. Hence early recognition and
management is a key to success in better prognosis and
improved quality of life.

10.

Awasthi et al.,

11.

12.
13.

Acromegaly Therapy Consensus Development


Panel. Consensus statement: benefits versus risks
of medical therapy for acromegaly. Am J Med
1994;97:468-73
Katznelson L, Atkinson JL, Cook DM, Ezzat SZ,
Hamrahian AH, Miller KK; American Association of
Clinical Endocrinologists. American Association of
Clinical Endocrinologists medical guidelines for
clinical practice for the diagnosis and treatment of
acromegaly-2011 update. Endocr Pract. 2011 JulAug;17Suppl 4:1-44.
Cristina Capatina, John A H Wass;60 Years Of
Neuroendocrinology: Acromegaly J Endocrinol.
2015 Aug;226(2):T141-60.
Katznelson L, Laws ER Jr, Melmed S, Molitch ME,
Murad MH, Utz A & Wass JA 2014 Acromegaly: an
endocrine society clinical practice guideline. Journal
of Clinical Endocrinology and Metabolism 99 3933
3951.
Reid TJ, Post KD, Bruce JN, Nabi KM, Reyes-Vidal
CM & Freda PU 2010 Features at diagnosis of 324
patients with acromegaly did not change from 1981
to 2006: acromegaly remains under-recognized and
underdiagnosed. Clinical Endocrinology 72 203
208.
Mestron A, Webb SM, Astorga R, Benito P, Catala
M, Gaztambide S, Gomez JM, Halperin I, LucasMorante T, Moreno B et al. 2004 Epidemiology,
clinical characteristics, outcome, morbidity and
mortality in acromegaly based on the Spanish
Acromegaly Registry (Registro Espanol de
Acromegalia,
REA).
European
Journal
of
Endocrinology 151 439446.
Ferdinand Roelfsema , Nienke R. Biermasz, Alberto
M. Pereira. Clinical factors involved in the
recurrence of pituitary adenomas after surgical
remission: a structured review and meta-analysis.
Pituitary (2012) 15:7183
Ferdinand Roelfsema. Treatment of acromegaly:
Are we satisfied with the outcome?. EBioMedicine.
2014 Dec 20;2(1):5-6.
Melmed S. Acromegaly. N Engl J Med. 1990; 322:
96677
Klibanski A and Zervas NT. Diagnosis and
management
of
hormone-secreting
pituitary
adenomas. N Engl J Med. 1991;324: 82231
Bengtsson BA. Epidemiology and long-term survival
in acromegaly: a study of 166 cases diagnosed
between 1955 and 1984. Acta Med Scand.
1988;223: 327-35
Nabarro JD. Acromegaly. Clin Endocrinol. 1987;26:
481512.
Clemmons DR. Optimizing control of acromegaly:
integrating a growth hormone receptor antagonist
into the treatment algorithm. J Clin Endocrinol
Metab.2003;88: 475967

909
Int J Med Res Health Sci. 2015;4(4):907-910

14. Giustina A. Criteria for cure of acromegaly: a


consensus statement. J Clin Endocrinol Metab.
2000;85:52629
15. Grinspoon S. Serum insulin-like growth factorbinding protein-3 levels in the diagnosis of
acromegaly. J Clin Endocrinol Meta. 1995;80:927
32
16. Shlomo Melmed, J. Larry Jameson Anterior pitutary
syndrome in : Dennis Kasper, Anthony Fauci,
Stephen Hauser, Dan Longo, J. Larry Jameson,
Joseph Loscalzo Harrison's Principles of Internal
Medicine; 19edition 403:2261-71.

Awasthi et al.,

910
Int J Med Res Health Sci. 2015;4(4):907-910

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00184.8
Open access

COLD AGGLUTININ INDUCED HEMOLYTIC ANEMIA IN A PATIENT WITH


PULMONARY TUBERCULOSIS
1

Lohmror Anurag , Choudhary Richa

ARTICLE INFO

ABSTRACT

th

Received: 30 June 2015


th
Revised: 10 July 2015
nd
Accepted: 2 Sep 2015
1

Senior Resident,
Department of Medicine, Sawai Man
Singh Medical College, Jaipur, India
2
Senior Resident, Department of
Paediatrics, Sawai Man Singh Medical
College, Jaipur, India
Authors details:

author:
Lohmror
Anurag
Senior Resident, Department of
Medicine, Sawai Man Singh Medical
College, Jaipur, India
Email: dr.alohmror@rediffmail.com
Corresponding

Autoimmune hemolytic anemias (AIHA) are an uncommon group of disorders


characterized by red cell destruction due to autoantibodies. Though usually
idiopathic, AIHA is commonly associated with lymphoproliferative disorders,
infections, autoimmune disease, and some drugs. This report describes a case
of 25 year old female presenting history of fever associated with cough and
fatigue. There was a past history of receiving blood transfusion on four
occasions. The HRCT thorax demonstrated fine nodular densities in right upper
lobe, suggestive of tuberculosis. Abdominal ultrasonography revealed mild
splenomegaly. A bone marrow biopsy performed on the patient revealed
erythroid hyperplasia. There was no evidence of any malignancy. Diagnosis of
cold autoantibody hemolytic anemia complicated by pulmonary tuberculosis was
made. The patient was managed with blood transfusions and treated with antitubercular agents. The occurrence of AIHA in pulmonary tuberculosis is rare.

Autoimmune hemolytic
anemia, Tuberculosis, Cold agglutinin
Keywords:

INTRODUCTION
Autoimmune hemolytic anemia (AIHA) occurs when a
patient produces pathologic antibodies that attach to and
lead to the destruction of their RBCs with consequent
anemia. AIHA can be classified as warm AIHA and cold
AIHA according to the characteristic temperature activity of
[1]
the antibodies . Occasionally, a patient may have mixed
cold and warm active antibodies. Primary (idiopathic) AIHA
[2]
is less frequent than secondary AIHA . Autoimmune
antibodies, particularly cold-reactive antibodies, are
sometimes produced following an infection or immune
[3,4,5,6]
defects or lympho proliferative disorders or drugs
.
These secondary cases are often challenging since not
only AIHA, but also the underlying disease must be
diagnosed and treated. Association of autoimmune
haemolytic anaemia with pulmonary tuberculosis has been
seldom reported. Tuberculosis being a common disease,
the association with hemolytic anemia should be
recognized and treated judiciously.
CASE REPORT
A 25 year old female presented to our department with a
history of fever associated with cough and fatigue. Physical
examination revealed pallor and mild splenomegaly. Blood
pressure, pulse rate and temperature were within normal
limits. Bilateral crepitations could be heard on chest
auscultation. Other findings on physical examination were
unremarkable. There was a past history of receiving blood
transfusion on four occasions. The laboratory investigations
demonstrated severe anemia (Hemoglobin 4.5 g/dl; MCV
74.3fl MCH 18.4pg MCHC 24.7g/dl) with a normal white

blood count and platelet count. The peripheral blood smear


showed
microcytic
hypochromic
RBCs
with
anisopoikilocytosis, elliptocytes, tear drop cells, target cells.
The reticulocyte count was 5.82% and reticulocyte index
was calculated to be 2.0. Serum LDH was raised (991 U/L).
The Direct Coombs test was positive with anti-C3d
specificity; anti-IgG was negative. The cold agglutinin titre
was 1:256. The patient tested negative for anti nuclear
antibodies and ds-DNA antibodies, HIV, Hepatitis B surface
antigen and anti HCV antibodies. Sputum was positive for
acid fast bacilli. Chest X-ray showed diffuse small nodular
infiltrates over right lung fields. The HRCT thorax
demonstrated fine nodular densities in right upper lobe,
suggestive of tuberculosis. Abdominal ultrasonography
revealed mild splenomegaly. A bone marrow biopsy
performed on the patient revealed erythroid hyperplasia.
There was no evidence of any malignancy. Based on the
characteristics discussed in the preceding paragraphs and
available literature, a diagnosis of cold autoantibody
hemolytic anemia complicated by pulmonary tuberculosis
was made.
The patient was managed with blood
transfusions and treated with anti-tubercular agents.
DISCUSSION
Autoimmune hemolytic anemia (AIHA) is a rare disease. In
[7]
a recent population based study
the incidence was
[8]
0.8/100.000/year, but the prevalence is 17/100.000 . There
are two main types of autoimmune hemolytic anemia: warm
antibody and cold antibody induced hemolytic anemia

911
Anurag et al.,

Int J Med Res Health Sci. 2015;4(4):911-912

based on the ability of the autoantibodies to attach to and


destroy red blood cells at different temperatures.
Cold active autoantibodies have the capability to
agglutinate red blood cells at temperatures well below the
normal body temperatures, fix complement, and lead to
immediate intravascular RBC destruction or hepatic
mediated clearance. Two different clinical syndromes are
manifested from cold auto immune antibodies. Cold
Agglutinin Disease is associated with IgM antibodies
usually directed at the RBC I antigen. The responsible
pathologic IgM antibodies are distinguished from naturally
occurring cold autoantibodies by their titre and thermal
amplitude. Natural cold autoantibodies occur in titres less
than 1:64 at 4 C and have no activity at temperatures much
higher than that. However, pathologic cold agglutinins
typically have titres well over 1:1000 and may react at 28[1]
31 C or even up to 37 C . An IgG type of cold reactive
autoantibody with anti P specificity, known as Donath
Landsteiner antibody, characterizes Paroxysmal Cold
Hemoglobinuria.
In contrast, warm active antibodies are typically IgG, may or
may not fix complement, and primarily lead to RBC loss by
splenic removal of sensitized cells. Both CAD and PCH are
less common than warm AIHA and make up approximately
[1]
20% or less of AIHAs.
Almost all cases of cold AIHA in adults seem to be
secondary. The underlying conditions in most cases are
lymphoproliferative diseases, less commonly autoimmune
diseases(SLE) or infections(infectious mononucleosis,
Mycoplasma pneumonia, advanced HIV infections) , and
[3,4,5,6]
rarely drugs
.In some of the cases , the etiology
remains obscured labeling them as primary or idiopathic.
The key component to treatment remains avoidance of
exposure to cold and management of underlying infectious
or malignant process. In contrast to warm AIHA, cold AIHA
[2]
does not respond well to steroids and/or splenectomy .
Transfusion of red cells in AIHA can result in rapid in vivo
destruction of transfused cells due to the presence of auto
antibodies, hence it is of transient benefit, but may be
[2]
required initially in managing severe anemia.
In tuberculosis, hematologic abnormalities like anemia are
common. Possible mechanisms include nutritional
deficiency, malabsorption syndrome, marrow suppression,
[9]
and failure of iron utilization . However, the association of
immune hemolytic anemia with tuberculosis is relatively
[10]
rare . The majority of the cases reported in literature are
disseminated or extra pulmonary tuberculosis.
In our patient with cold autoantibody induced hemolytic
anemia, the work up for secondary causes of AIHA like
lymphoproliferative disorders and SLE was negative, and
tuberculosis was diagnosed on the basis of isolation of
organism in sputum and clinical and radiological findings.
The patient responded to anti tubercular treatment, steroids
were not given.

CONCLUSION
Although rare, pulmonary tuberculosis may be associated
with autoimmune hemolytic anemia. Tuberculosis should be
considered as a differential diagnosis of the etiology of
secondary AIHA because administration of steroids alone
to treat AIHA in such untreated tuberculosis cases may be
detrimental to the patient.
ACKNOWLEDGEMENT: none
Conflict of Interest: Nil
REFERENCES
1.

Friedberg R C. Autoimmune Haemolytic Anaemias. In:


Greer JP, Foerster J, editors. Wintrobes Clinical
Haematology. 12th ed. Philadelphia: Lippincott
Williams and Wilkins; 2009; 956-96.
2. Lechner K, Jager U: How I treat autoimmune hemolytic
anemias in adults. Blood 2010; 116:1831-38
3. Petz LD. Cold antibody autoimmune hemolytic
anemias. Blood Rev. 2008; 22(1):1-15.
4. Jeffries M, Hamadeh F, Aberle T, Glenn S, Kamen DL,
Kelly JA, et al. Haemolytic anaemia in a multi-ethnic
cohort of lupus patients: a clinical and serological
perspective. Lupus 2008;17(8):739-43
5. Nazel Khosroshahi B, Jafari M, Vazini H, Ahmadi A,
Shams K, Kholoujini M. Cold Autoimmune Hemolytic
Anemia due to High-grade non Hodgkin's B cell
Lymphoma with Weak Response to Rituximab and
Chemotherapy Regimens. Int J Hematol Oncol Stem
Cell Res. 2015;9(3):157-60.
6. Harada Y, Yamamoto H, Sato M, Kodaira M, Kono T.
Autoimmune hemolytic anemia during adalimumab
treatment for plaque psoriasis. Intern Med.
2015;54(9):1103-4
7. Klein NP, Ray P, Carpenter D, Hansen et al. Rates of
autoimmune diseases in Kaiser Permanente for use in
vaccine adverse event safety studies. Vaccine 2010;
28(4):1062-68.
8. Eaton WW, Rose NR, Kalaydjian A, Pedersen MG,
Mortensen PB. Epidemiology of auto immune diseases
in Denmark. J Autoimmun. 2007; 29(1):1-9.
9. Glasser RM, Walker RI, Herion JC. The significance of
hematologic abnormalities in patients with tuberculosis.
Arch Intern Med 1970; 125: 691-5.
10. Bahbahani H, Al-Rashed M, Almahmeed M.
Tuberculosis and autoimmune hemolytic anemia: Case
report and literature review. J Appl Hematol 2014;
5:164-7.

912
Anurag et al.,

Int J Med Res Health Sci. 2015;4(4):911-912

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00185.X
Open Access

WILLIAMS-CAMPBELL SYNDROME- A RARE ENTITY OF CONGENITAL


BRONCHIECTASIS: A CASE REPORT IN ADULT
1

Sukla Mitra , Anadi Roy Chowdhury , Goutam Bandyopadhyay

ARTICLE INFO
th

Received: 6 Jul 2015


Revised: 7th Sep 2015
Accepted: 16th Sep 2015
Author details: 1Senior Resident,
2
3
Associate
professor,
Professor,
Department of Pathology, R G Kar
Medical College & Hospital, Kolkata700004
Corresponding author: Department of
Pathology, R G Kar Medical College &
Hospital, Kolkata-700004
Email: sukla21feb@gmail.com
Keywords:
Williams
Campbell
Syndrome, Congenital bronchiectasis,
Surgical resection, Cartilage deficiency.

ABSTRACT
Williams-Campbell syndrome is a rare entity of congenital bronchiectasis
due to developmental arrest in the tracheobronchial tree, in which extensive
loss of bronchial cartilage is associated with diffuse cystic bronchiectasis;
may be unilateral or bilateral. Clinical manifestations start from infancy with
subsequent recurrent pulmonary infection leading to respiratory failure.
Patients may survive into late adulthood and require lung transplantation.
We report such a rare case diagnosed on the basis of clinico-radiological
presentation and histopathological examination of the pneumonectomy
specimen. A 40 years patient was presented with severe breathlessness
and had history of recurrent episode of productive cough with low grade
fever since childhood for which he was admitted in hospital and treated
symptomatically. Chest roentgenogram revealed right hyperlucent lung,
deviation of trachea towards left; while the left lung showed multiple
scattered large thin walled cysts along with elevation of left dome of
diaphragm. High resolution computed tomography revealed multiple cystic
thin walled airways in the left hemithorax, suggestive of bronchiectasis with
collapse of left lung and compensatory hyperinflation of right lung along with
herniation of right upper lobe to the left.

INTRODUCTION
Bronchiectasis is the irreversible dilatation of bronchi and
bronchioles caused by destruction of smooth muscle and
elastic tissue, resulting from chronic necrotizing infections.
Williams-Campbell syndrome is a rare developmental
disorder of familial occurrence which results absence or
deficiency of cartilage in the bronchial walls distal to first
divisions of subsegmental bronchi and associated with
diffuse cystic bronchiectasis. This uncommon entity should
not be confused with congenital bronchiectasis which are
those of hereditary conditions, such as cystic fibrosis,
primary ciliary dyskinesia or immunodeficiency states; that
predispose to subsequent development of bronchiectasis.
On chest radiograph large thin walled cysts are found;
while high resolution computed tomography (HRCT) scan
characteristically shows central, cystic, thin-walled airways
that collapse upon expiration. Microscopic studies
document, dilated airways having thin walls, absent or
[1]
deficient cartilage with minimal inflammation. Although
most cases presented in childhood, some sporadic
[2,3]
subclinical cases maybe diagnosed in adults as well. .
Here we report such a rare case that had typical clinicoradiological presentation as well as histopathological
features of congenital bronchiectasis.
CASE REPORT

investigation reports. The patient was presented with


severe breathlessness and had history of recurrent
episode of productive cough with low grade fever since
childhood for which he was admitted in hospital and
treated symptomatically with oxygen, mucolytics,
bronchodilators and antibiotics. But, he had no history of
hemoptysis, joint pain or chronic gastrointestinal
symptoms. He smoked five cigarettes per day for last
twelve year and had no family history of lung disease.
Despite manifestation he declined medical evaluation until
the age of 24 year. On admission, he had coarse
crepitations with rhonchi and decreased air entry in left
lung field and clubbing. His routine investigations were
normal and serum was negative for Human
Immunodeficiency Virus 1 and 2 antibodies. Sputum was
negative for acid-fast bacilli (AFB) on multiple occasions
but culture was positive for Klebsiella species.
Chest roentgenogram revealed right hyperlucent lung,
deviation of trachea towards left; while the left lung
showed multiple scattered large thin walled cysts along
with elevation of left dome of diaphragm (Figure 1A). High
resolution computed tomography (HRCT) revealed
multiple cystic thin walled airways in the left hemithorax,
suggestive of bronchiectasis with collapse of left lung and
compensatory hyperinflation of right lung along with
herniation of right upper lobe to the left (Figure 1B).
Echocardiography was normal.

We received pneumonectomy specimen of left lung of a


40 years old male patient from the department of
cardiothoracic and vascular surgery of our hospital and
retrospectively collected the clinical history and

913
SuklaMitra et al.,

Int J Med Res Health Sci. 2015;4(4):913-915

DISCUSSION

Fig 1: (A) Chest roentgenogram showed hyperlucent right


lung with multiple scattered cystic spaces in left lung
field and elevation of left dome of diaphragm (arrow). (B)
HRCT shows cystic spaces in left hemithorax suggestive
of bronchiectasis with collapse of left lung and herniation
of right upper lobe to left.

Spirometry showed severe restrictive type of lung function


and sera was positive for Aspergillus allergen specific
antibodies (IgE) recently, but it was negative on previous
occasions. Other serum immunoglobulins were within
normal limits. Culture of broncho-alveolar lavage (BAL)
was negative for AFB, but positive for methicilin sensitive
Staphylococcus aureus.
He underwent left pneumonectomy. Gross specimen
revealed a small non-expansile fibrotic lung measuring 12
x 8 x 5 cm and weighing 150 g. The cut section revealed a
dilated bronchial system (Figure 2A & 2B). Microscopic
findings shows, dilated airways having thin walls with
minimal inflammation and deficient cartilage (Figure
3A&3B).

Fig 2: Pneumonectomy specimen of left lung shows: (A)


Pleural surface (B) Cut section shows dilated bronchial
system (arrow).

Williams-Campbell syndrome is a rare form of familial


disorder in which deficiency of bronchial cartilage is
associated with diffuse cystic bronchiectasis without other
[1,4-6]
recognized predisposing factors.
Cartilage is absent or
deficient from fourth to eighth divisions of subsegmental
bronchi; while normal amount of cartilage present in first
and second order bronchi or other body parts. The cause
[1]
of this cartilage deficiency is still uncertain. Symptoms
like cough, dyspnea on exertion, cyanosis and clubbing
[1,7]
appears from infancy.
The prognosis varies from rapid
clinical deterioration and death in some, while prolonged
[4]
survival in others. The survived patients may developed
recurrent pulmonary infections; often present acutely
necessitating emergent evaluation and requires lung
[8,9]
transplantation.
However, Williams-Campbell syndrome
remains a controversial entity, and its congenital origins
[10-12]
have yet to be proven beyond question.
Chest radiograph of this patient shows large thin walled
cysts, while HRCT scan characteristically reveals central,
cystic, thin walled airways that collapse upon
[2,13,14]
expiration.
Microscopic findings shows, dilated
airways having thin walls with minimal inflammation and
[1]
deficient cartilage.
In 1960, Williams and Campbell reported five unusual
cases of bronchiectasis, with soft, compliant bronchi
having deficient cartilage, which dilated and collapsed
[5]
respectively during inspiration and expiration.
The diagnosis of Williams Campbell Syndrome requires an
appropriate clinical history, characteristic expiratory
collapse of airways and exclusion of other causes of
congenital or acquired bronchiectasis such as cystic
fibrosis, allergic bronchopulmonary aspergillosis (ABPA),
[7,9]
immune deficiency, tracheobronchomegaly.
The patient was presented with destruction of left lung with
cystic changes, but trachea and main bronchi were
normal, which rules out tracheobronchomegaly. The
differential diagnosis includes ABPA or cystic fibrosis. The
antibodies against aspergillus allergen were negative on
previous results, but became positive for short duration
and that may be due to the result of recurrent pulmonary
infection which is a major complication of this entity.
Absence of gastrointestinal symptoms during the course of
illness ruled out possibilities of cystic fibrosis and lastly,
the extent and distribution of the bronchial abnormalities
[15]
are not consistent with that of cystic fibrosis and ABPA.
The case discussed in this article was managed medically
for long duration, which developed complications and
required pneumonectomy. These scenarios can be
prevented by early diagnosis and more importantly by
recognizing the existence of these lesions as a separate
entity.
CONCLUSION

Fig 3: Histopathological sections (A) & (B) dilated,


irregularly shaped airway lumen shows absence of
cartilage throughout the airway walls with minimal
inflammation; Hematoxylin-Eosin stain with magnification
100x.

Congenital lung disorders are increasingly diagnosed in


adults. Williams Campbell Syndrome, although a rare
congenital anomaly; it should be recognise as a separate
entity and needs to be considered in the differential
diagnosis of bronchiectasis.

914
SuklaMitra et al.,

Int J Med Res Health Sci. 2015;4(4):913-915

Conflict of interest: None of the author has any conflict


of interest or any funding support.
REFERENCE
1.

2.
3.

4.

5.

6.
7.

8.

9.

10.

11.

12.
13.

14.
15.

Tomashefski J F, Dail D H.Aspiration, Bronchial


Obstruction, Bronchiectasis, and Related Disorders.
In: Tomashefski J F, editor. Dail and Hammars
pulmonary Pathology, Nonneoplastic lung Disease
vol 1.Third Edition. New York: Springer; 2008.p: 99146.
Newman KB, Beam WR. Congenital bronchiectasis
in an adult. Am J Med 1991;91:198-201.
Przerwa KB, Bestry I, Gawryluk D, Wiatr E. Case
report: Williams Campbell syndrome. Pol J Radiol
2009;74:7678.
Jones VF, Eid NS, Franco SM, Badgett JT, Buchino
JJ. Familial congenital bronchiectasis: WilliamsCampbell syndrome. Pediat Pulmonol 1993;16:2637.
Williams H, Campbell P. Generalized bronchiectasis
associated with deficiency of cartilage in the
bronchial tree. Arch Dis Child 1960;35: 182-191.
Davis PB, Hubbard VS, McCoy K, et al. Familial
bronchiectasis. J Pediatr 1983;102:177-185.
Williams HE, Landau LI, Phelan Po. Generalized
bronchiectasis due to extensive deficiency of
bronchial cartilage. Arch Dis Child 1972;47:423-428.
Palmer SM Jr, Layish DT, Kussin PS, et al. Lung
transplantation for Williams-Campbell syndrome.
Chest 1998;113:535-537.
Wayne KS, Laussig LM. Probable familial congenital
bronchiectasis due to cartilage deficiency. Am Rev
Resp Dis 1976;114:15-22.
Hayward J, Reid LM. The cartilage of the
intrapulmonary bronchi in normal lungs, in
bronchiectasis, and in massive collapse. Thorax
1952;7:98-110.
Ogrinc G, Kampalath B, Tomashefski IF Jf.
Destruction and loss of bronchial cartilage in cystic
fibrosis. Hum Pathol1998;29:65-73.
Whitwell E Study of pathology and pathogenesis of
bronchiectasis. Thorax 1952;7:213-239.
Gupta N, Pulinilkunnathil JG, Dixit R, Gupta R. A
rare case of congenital bronchiectasis Williams
Campbell Syndrome. DiagTher Stud 2012;1(1):1-6.
McAdams HP, Erasmus I. Case 4: WilliamsCampbell syndrome. AJR 1995;165:190-19l.
Hartman TE, Primack SL, Lee KS, Swensen SJ,
Muller NL. CT of bronchial and bronchiolar
diseases. Radiographics 1994;14:991-1003.

915
SuklaMitra et al.,

Int J Med Res Health Sci. 2015;4(4):913-915

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00186.1
Open Access

PRIMARY SQUAMOUS CELL CARCINOMA OF KIDNEY: REPORT OF TWO CASES


1

Samanta DR , Bose Chaitali , Panda Sasmita , Upadhaya Ashis , Das Abhijit , Senapati SN

ARTICLE INFO
Received: 6th Jul 2015
Revised: 17th Aug 2015
Accepted: 16th Sep 2015
Author details: 1Assistant Professor,
Department of Medical Oncology,
Acharya Harihara Regional Cancer
centre, Cuttack, Odisha, India
2
Senior resident, 4Post graduate,
5
Professor and Head, Department of
Radiation Oncology, Acharya Harihara.
Regional Cancer centre, Cuttack,
Odisha, India
3
Assistant Professor Department of
Oncopathology,
Acharya
Harihara
Regional Cancer centre, Cuttack,
Odisha, India

ABSTRACT
Primary squamous cell carcinoma of renal pelvis is rare clinical entity with
only few cases have been reported in the literature. It is usually
associated with long standing renal calculi. Insidious onset of symptom
and inconclusive clinical and radiological features leads to locally
advanced or metastatic disease at presentation; resulting in poor
prognosis. Here we are reporting two cases of squamous cell carcinoma
of kidney having renal calculi to highlight its clinical presentation and to
document the association of squamous cell carcinoma in longstanding
nephrolithiasis due to its rarity.
Keywords: Carcinoma, Kidney, Renal stone, Squamous cell

Corresponding author: Bose Chaitali,


Department of Radiation Oncology,
Acharya Harihara Regional Cancer,
Cuttack, Odisha, India.
Email: dr.chaitalibose@gmail.com

INTRODUCTION
Primary carcinoma of the renal pelvis accounts for only 4[1]
5%of all the urothelial tumor. Transitional cell carcinoma
is the most common histopathological type followed by
[2]
squamous cell carcinoma and adenocarcinoma.
Primary squamous cell carcinoma of renal pelvis is a rare
clinical entity that constitutes only about 0.5-8% of renal
[3]
tumors. The lack of definite clinical presentation and
inconclusive imaging features result in advanced stage of
presentation.
Solid
mass,
hydronephrosis,
and
calcification are common but nonspecific radiological
finding that explain why this tumor is not diagnosed
before histopathological examination of resected surgical
[4]
specimen.
These tumors are high grade, highly
aggressive tumors with poor prognosis. Very few cases
of primary squamous cell carcinoma of kidney have been
reported in the literature. Here we present two cases of
squamous cell carcinoma of renal pelvis due to its rarity
and also to highlights the silent presentations of these
tumors and the need to keep in mind the association of
malignancies in patients having nephrolithiasis. This
report highlights the rarity and aggressiveness of
squamous cell carcinoma.
CASE SERIES

dull aching pain in right flank of last six months. There


was no significant past medical history as well as family
history. Physical examination of the patient revealed mild
tenderness in right renal angle. A lump of about 128cm
was palpable in the right lumbar and hypochondrial
region, which was firm, and moving with respiration.
Routine haematology revealed leucocytosis and
thrombocytosis. Biochemical test and chest radiograph
were normal. Plain x-ray abdomen revealed multiple
radiopaque shadows in the right kidney (Figure-1).
Ultrasonography
of
whole
abdomen
showed
hydronephrosis of right kidney with multiple renal calculi
and multiple hepatic metastases. Normal architecture of
right kidney was lost. Patient had undergone right
nephrectomy. On gross examination right kidney was
enlarged measuring 1485.5cm. Cut surface revealed
loss of architecture of right kidney. Medulla and cortex
could not be differentiated.
Whole kidney was converted into multiple lobules with
thickened septa. Multiple black hard stones were present
(figure-2). Histopathology of the renal pelvis revealed
moderately differentiated squamous cell carcinoma
(figure-3). Patient was in low general condition and was
treated symptomatically. He died due to disease 6
months after.

CASE: 1
A 65 years old male clinically presented in the
Department of Radiation oncology of our institute with
lose of weight, fever, vomiting on and off and intermittent

916
Chaitali et al.,

Int J Med Res Health Sci. 20015;4(4):916-918

Rest of the clinical examination was insignificant. Routine


haematological and biochemical investigations were
within normal limits. Intravenous pyelograpy showed nonfunctioning right kidney with a calculi in the right renal
pelvis. Ultrasonography of abdomen and pelvis showed
large calculi in right renal pelvis, hydronephrosis and
cortical thinning of right kidney. Left kidney was normal.
He underwent right nephrectomy. Grossly the right kidney
was irregular, brownish, and oval shaped of 1897 cm
in size. Cut section showed a large brownish calculus in
pelvis with surrounding whitish tissue of size 221 cm.
Rest of kidney appeared cystic and distorted (figure-4).
Histopathology revealed well differentiated squamous cell
carcinoma and thyroidisation of renal tubules (figure-5)
Patient was in regular follow up without any evidence of
disease since 1 year.

Fig 1: Plain x-ray abdomen showing


radiopaque shadows in the right kidney

multiple

Fig 4: Gross specimen of nephrectomy showing


large brownish calculi in pelvis and surrounding
whitish tissue.
Fig 2: Gross specimen of nephrectomy

Fig
3:Photomicrograph
showing
Transitional
epithelium of renal pelvis and underlying stroma with
tumour tissue showing moderately differentiated
squamous carcinoma cells.(H & E ,10x]
CASE: 2
A 67 years old male patient presented in Radiation
oncology Department of our institute with history of
intermittent right flank pain of 6 months duration. There
was no history of hematuria, fever or dysuria. Clinical
examination showed mild tenderness in right renal angle.
A mass of about 169 cm was palpable in right
hypochondrium. It was firm and moving with respiration.

Fig 5: Photomicrograph showing squamous


metaplasia, squamous carcinoma in situ and foci of
invasion.stroma
shows
inflammation
and
thyroidisation of renal tubules. (H & E 100)
DISCUSSION
Squamous cell carcinoma of urinary tract more frequently
reported in urinary bladder and urethra. It rarely occurs in
renal pelvis. Transitional cell carcinoma is the most
common tumor originating from renal pelvis followed by
squamous cell carcinoma and adenocarcinoma. The
median age of presentation is 57, with slight female
[5]
preponderance. In the present case one patient was
65years,another was 67years, and both are male. Due to
lack of pathognomonic sign they present in advanced

917
Chaitali et al.,

Int J Med Res Health Sci. 20015;4(4):916-918

stage resulting in poor prognosis. Common etiologic


factors are renal stone, infection, chemicals; hormone
imbalance, vitamin A deficiency, schistosomiasis and
[6]
smoking. Chronic irritation and infections are thought to
induce metaplasia of urothelium which subsequently
leads to squamous cell carcinoma. Li MK et. al in their
study found coexisting renal stone in 100%
[4 ]
cases. Staghorn calculi being the most frequent variant.
In both the reported cases patient had calculi in renal
pelvis producing chronic irritation leading to squamous
cell carcinoma which correlated with data given in
literature.
Hypercalcemia,
leukocytosis
and
thrombocytosis have been reported as Para neoplastic
syndrome in renal squamous cell carcinoma. One of our
patients also had leucocytosis and thrombocytosis.
Histopathology is the hallmark of diagnosis because of
lack of characteristic clinical and imaging feature.
Squamous cell carcinoma of renal pelvis is diagnosed
histopathologically by extensive squamous differentiation.
The histologic hallmark of pearl formation, intercellular
bridges and keratotic cellular debris are like those of
squamous cell carcinoma at any site. Most of these
carcinomas are moderately differentiated or poorly
differentiated and more deeply invasive than the
[7]
transitional cell carcinoma. Detail work up to exclude
secondary renal squamous cell carcinoma should be
done. Lee et. al in their study classified squamous cell
carcinoma into two groups based on the location of the
[8]
tumor, central and peripheral. Central one has more
intraluminal component with lymph node metastasis.
Peripheral variant has prominent renal parenchymal
thickening invading perirenal fat tissue before lymph node
or distant metastasis. Central variant has worse
prognosis. One of our cases was moderately
differentiated central type who had hepatic metastasis.
However another patient had peripheral variant of
squamous cell carcinoma.
Nephroureterocystectomy is considered the primary
treatment. Surgery is the standard of care even in the
faces of metastasis to establish a histological diagnosis,
to control symptoms or to eliminate the source of
[9]
infection. In one of our case nephrectomy was done
even in the presence of liver metastasis. Adjuvant
treatment is considered in case of metastasis.
Cisplatinum based chemotherapy and radiotherapy are
usually given in advanced cases but failed to show any
survival benefit. However, because of less number of
cases no fixed treatment guideline is present.
It is highly aggressive tumor with unfavorable outcome. In
one series 84% of tumor was locally advanced or had
[10]
metastasis at the time of operation.
In the present
study one patient had hepatic metastasis at diagnosis
due to central variety. He died 6 months after the surgery.
The other patient had peripheral type of lesion and
surviving for last one year without any evidence of
disease. Nativet. al in their study reported locally invasive
renal squamous cell carcinoma had 1 and 2 year survival
[11]
rate of 33% and 22% respectively. They also found that
treatment modalities like nephrectomy, nephrourectomy,
adjuvant chemotherapy or radiotherapy did not affect
survival of patients irrespective of tumor stage.

CONCLUSION
Primary squamous cell carcinoma of renal pelvis is a rare
aggressive tumor with poor prognosis. Due to no definite
pathognomic sign and symptoms, most of the patients
presented with advanced stage. As these tumors are
strongly associated with renal stones, patient with renal
stones and non-functioning kidney should be evaluated
with newer imaging technologies for early detection of the
tumor that may lead to a better outcome for the patients.
Conflict of Interest: The authors declare that there is no
conflict of interests
REFERENCES
1.

Busby JE, Brown GA, Tamboli P, Kamat AM,


DinneyCP,Grossman HB, etal.Upper urinary tract
tumors withnontransitional histology: A single-center
experience. Urology2006;67:518-23.
2. P Kaur, AChauhan, G Singh, S Kataria, R Kalra.
Primary Squamous Cell Carcinoma Of Kidney - A
Case Report And Review Of Literature.. The Internet
Journal of Nephrology. 2009; 6(1).
3. Jain A, Mittal D, Jindal A, Solanki R, Khatris S,
Parikh A et al Incidentally Detected Squamous Cell
Carcinoma of Renal Pelvis in Patients with Staghorn
Calculi: Case Series with Review of the Literature
ISRN Oncol. 2011; 2011: 620574.
4. Li MK, Cheung WL.Squamous cell carcinoma of the
renal pelvis.J Urol. 1987; 138(2):269-71.
5. Singh V, Sinha RJ, Sankhwar SN, Mehrotra B,
Ahmed N,MehrotraS.Squamous Cell Carcinoma of
the Kidney Rarity Redefined: Case Series with
Review of Literature. J Cancer SciTher.2010;2: 087090.
6. Tyagi N, Sharma S, Tyagi SP, Maheshwari V, Nath
P, Asharf SM, et al. A histomorphologic and
ultrastructural study of the malignant tumors of the
renal pelvis. J Postgrad Med 1993;39:197-201.
7. Reuter VE. The urothelial tract: Renal pelvis, ureter,
urinary bladderand urethra. In: Mills SE, Carter D,
Greenson JK, Oberman HA, Reuter V, Stoler MH,
Sternbergs
Diagnostic
Surgical
Pathology,
Philadelphia Lippincott Williams and Wilkins
th
;2004;4 edition: p. 2058-9.
8. Lee TY, Ko JF, Wan YL, Wan YL, Cheng YF, Yang
BYet al. Renal squamous cell carcinoma: CT
findings and clinical significance. Abdom Imaging
1998;23:203-8.
9. Blacher EJ, Johnson DE, Abdul-Karim FW, Ayala AG
Squamouscellcarcinoma
of
renal
pelvis.
Urology.1985; 25: 124-26.
10. RosaiJ..Urinary tract, surgical pathologyMOSBY,
stlouis USA 2004; 9th ed. Vol I, PP-1274.
11. Nativ O, Reiman HM, Lieber MM, Zincke H.
Treatment of primary squamous cell carcinoma of
the upper urinary tract. Cancer. 1991;68:2575-8.

918
Chaitali et al.,

Int J Med Res Health Sci. 20015;4(4):916-918

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00187.3
Open Access

RECURRENT CORNUAL ECTOPIC PREGNANCY A CASE REPORT


Velayudam DA, Radha Bai Prabhu T, Dipenty Devi L, Meenalochani P, Isha Gutgutia

ARTICLE INFO
th

Received: 14 Jul 2015


th
Revised: 27 Aug 2015
th
Accepted: 25 Sep 2015
details: Department of
Obstetrics
&
Gynaecology.,
Meenakshi
Medical college and
Research Institute, Kancheepuram,
Tamilnadu, India
Authors

Corresponding author: Radha Bai

Prabhu T
Department
of
Obstetrics
&
Gynaecology., Meenakshi
Medical
college and Research Institute,
Kancheepuram, Tamilnadu, India
Email: radhaprabhu54@ymail.com
Keywords: Recurrent cornual ectopic,

ABSTRACT
Cornual ectopic gestation is one of the causes of Maternal near miss
cases. In the modern era of IVF treatments and better imaging techniques,
more number of cases of cornual ectopic pregnancies is being diagnosed
and treated both by conservative and radical methods. Here, we report a
case of a recurrent cornual ectopic pregnancy in the early second trimester,
which was managed by hysterectomy due to uncontrolled haemorrhage.
Thirty five year old Mrs. S, Gravida 4, para2, with one previous ectopic
pregnancy presented to the obstetric casualty with acute abdominal pain at
15 weeks +2 days of gestation. On vaginal examination, there was right
fornicial fullness and both the fornices were tender. Cervical motion
tenderness was also present. On review of her previous records, dating scan
done at 8 to 9 weeks showed normal intrauterine pregnancy. An emergency
scan was carried out which revealed an empty uterine cavity with gestational
sac measuring 3.64.44.6 cms seen outside the uterus just above the
fundus with absent cardiac activity. There was evidence of
haemoperitoneum, therefore she was diagnosed with recurrent ruptured
ectopic pregnancy.

maternal near miss, hysterectomy


INTRODUCTION
Ectopic pregnancy occurs in 1-2 % of all sexually active
[1]
reproductive women , of which cornual ectopics account
[2]
for 2-4% . Cornual or interstitial region is that part of the
fallopian tube that lies within the muscular wall of the
uterus. It measures 1-2cm with a diameter of 0.7 mm with
a slightly tortuous course extending obliquely upwards and
outwards from uterine cavity. Though less common,
cornual ectopic pregnancy is of major concern because of
[2]
the risk of high mortality rate of 2.0% to 2.5% and
[3].
accounts mainly for maternal near miss cases
Cornual
pregnancies pose a significant diagnostic and therapeutic
challenge as they are diagnosed relatively late, at 7 to 12
weeks of pregnancy, as myometrial distensibility allows
the pregnancy to grow. Sudden rupture imposes a medical
emergency due to significant maternal haemorrhage
[2]
leading to hypovolemia and shock .
CASE REPORT
Thirty five year old Mrs. S, Gravida 4, para2, with one
previous ectopic pregnancy presented to the obstetric
casualty with acute abdominal pain at 15 weeks +2 days
of gestation. She complaint of severe abdominal pain for
the previous two hours associated with giddiness, profuse
sweating, breathlessness and palpitation. In her past
obstetric history, in her first pregnancy she had a full term
normal vaginal delivery and the baby died in the neonatal
period. In her second pregnancy, emergency caesarean
section was done at term 4 years back, delivering a
healthy baby. It was found from her previous records that
in her third pregnancy 3 years ago, she had a right cornual

ectopic pregnancy which was managed by laparotomy


with right cornual resection.
On general examination, she was drowsy, but responded
to verbal stimuli, afebrile, there was severe pallor, her
blood pressure was 70/50 mm Hg and pulse was not
recordable. On abdominal examination, uterus was
enlarged to 16 to 18 weeks size and there was abdominal
distension with generalised tenderness. On vaginal
examination, there was right fornicial fullness and both the
fornices were tender. Cervical motion tenderness was also
present. On review of her previous records, dating scan
done at 8 to 9 weeks showed normal intrauterine
pregnancy. An emergency scan was carried out which
revealed an empty uterine cavity with gestational sac
measuring 3.64.44.6 cms seen outside the uterus just
above the fundus with absent cardiac activity. There was
evidence of haemoperitoneum, therefore she was
diagnosed with recurrent ruptured ectopic pregnancy. Her
immediate laboratory investigations were as follows: Hb8.6%, BT/CT were within normal limits, blood group was A
positive. In view of recurrent ruptured ectopic pregnancy,
emergency laparotomy was proceeded with. Intra
operatively, a large 7.56 cm rupture was noted in the
right cornual region with an intact gestational sac along
with the embryo freely floating in the peritoneal cavity.
[Fig1]. Decision for hysterectomy was taken in view of
recurrent cornual ectopic pregnancy and heavy bleeding
from the ragged margins of the ruptured cornual area.
Total hysterectomy was preceded after obtaining the
consent from the relatives. Intra operatively she was
transfused with 3 units of packed cells and another 3 units
of packed cells and fresh frozen plasma were given
postoperatively. Patient had a speedy recovery and was
th
discharged well on the 10 post-operative day.

919
Radha Bai Prabhu et al.,

Int J Med res Health Sci. 2015;4(4):919-920

cornual resection,
salpingostomy or salpingectomy.
Radical surgery is necessary in cases where the
[8]
haemorrhage is life-threatening . Cornual pregnancy if
diagnosed early can be managed by systemic
[9]
methotrexate in accordance with RCOG guidelines .
Selective uterine artery embolization will be useful in
cases where there is methotrexate failure, to decrease the
[8]
vascularity and to prevent catastrophic haemorrhage .
Early diagnosis and appropriate management form the
mainstay in the conservative management.
CONCLUSION
Fig 1: Right ruptured cornual ectopic pregnancy 7.56
cms
DISCUSSION
Diagnosis of a cornual pregnancy poses great difficulty
especially in early trimesters, as the gestational sac will be
seen in an eccentric position, giving the appearance of an
eccentric intrauterine pregnancy. However the diagnosis
can be improved with transabdominal or transvaginal
[4]
ultrasound, using the following criteria: An empty uterus,
a gestational sac seen separately and <1cm from the most
lateral edge of the uterine cavity, the myometrial layer
surrounding the sac would be thin and a thin echogenic
line extends directly up to the centre of the gestational sac
representing either the interstitial portion of the fallopian
tube or the endometrial cavity. This is called the interstitial
line sign.
The incidence of recurrent cornual ectopic pregnancies is
unknown; nevertheless, this finding has already been
[5, 6]
reported
. Tubal pathology, together with assisted
conception and conservative management of cornual
pregnancy contributes to a higher risk of recurrence of
[5]
cornual pregnancy . Other factors associated with an
increased risk of ectopic pregnancies include prior
abdominal surgery, a ruptured appendix and uterine
developmental abnormalities. Proper diagnosis is
mandatory so as to avoid misdiagnosis of a normal
intrauterine pregnancy as a cornual pregnancy which can
happen in pregnancy occurring in an anomalous uterus
(bicornuate/ septate). 3D and 4D transvaginal ultrasound
is a valuable tool in making a correct diagnosis in these
situations , as well as will help in differentiating between
angular pregnancy and cornual pregnancy. In angular
pregnancy, the embryo is implanted in the lateral angle of
the uterine cavity, medial to the uterotubal junction and
round ligament while in cornual pregnancy; the embryo is
implanted lateral to the round ligament.
Cornual ectopic pregnancies are usually managed by the
conventional technique i.e hysterectomy. However in
recent years more conservative approaches have been
introduced into practice, but all conservative surgical
approaches have been associated with decreased fertility
rates and increased rates of uterine rupture in future
[7]
pregnancies . Conservative surgical approach consists of

Cornual ectopic pregnancy is one of the most important


causes of Maternal Near Miss cases and is associated
with high risk of massive intra peritoneal bleeding. Early
diagnosis by ultrasound and timely action are important to
avoid catastrophic events. Though can be managed
conservatively, because of recurrent cornual ectopic
pregnancy, this case was managed by hysterectomy as a
life saving procedure.
Conflict of interest: Nil
REFERENCES
1.
2.
3.
4.

5.

6.

7.

8.

9.

Jurkovic D, Wilkinson H. Diagnosis and management


of ectopic pregnancy BMJ 2011: 342: d3397
Faraj R, Steel M. Review management of cornual
(interstitial)pregnancy. ObstetGynaecol 2007;9:249-55
1
Say L , Souza JP, Pattinson RC; WHO working group
on Maternal Mortality and Morbidity classifications.
Shiragur SS, Gobbur RV, Tehalia JM, Doshi R, Kori
S. Ruptured cornual ectopic pregnancy at 8 weeks
gestation- successful conservative approach: a case
report.
Int
J
ReprodContraceptObstetGynecol
2013;2:671-3.
VanderWeiden RM, Karsdorp VH. Recurrent cornual
pregnancy after heterotopic cornual pregnancy
successfully treated with systemic methotrexate. Arch
GynecolObstet 2005;273:1801.
Wittich AC: Recurrent cornual ectopic pregnancy in a
patient with leiomyomata uteri. J Am Osteopath Assoc
1998, 98:332-333.
Ross R, Lindheim SR, Olive DL, Pritts EA. Cornual
gestation: a systematic literature review and two case
reports of a novel treatment regimen. J Minim
Invasive
Gynecol
2006;13:748.
doi:10.1016/j.jmig.2005.11.005
Grimbizis GF, Tsalikis T, Mikos T, Zepiridis L,
Athanasiadis A, Tarlatzis BC, Bontis JN. Case report:
laparoscopic treatment of a ruptured interstitial
pregnancy. Reprod Biomed Online 2004; 9:44751.
[PubMed 15511347]
Royal College of Obstetricians and Gynaecologists.
The Management of Tubal Pregnancy. Green Top
Guideline No. 21. London: RCOG; May 2004
[www.rcog.org.uk/index.asp?PageID=537]

920
Radha Bai Prabhu et al.,

Int J Med res Health Sci. 2015;4(4):919-920

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00188.5
Open Access

PRIMARY GASTRIC ACTINOMYCOSIS: A RARE CASE REPORT


1

Mohit Bhatia , Archana Thakur , Bibhabati Mishra , Vinita Dogra

ARTICLE INFO
th

Received: 26 July 2015


th
Revised: 20 Aug 2015
th
Accepted: 20 Sep 2015
1

Authors details: Senior Resident,


2,4
3
Director
Professor,
Director
Professor & Head,
Department of
Microbiology, Govind Ballabh Pant
Institute of Post Graduate Medical
Education and Research, New Delhi,
India
Corresponding author: Mohit Bhatia
Department of Microbiology, Govind
Ballabh Pant Institute of Post
Graduate Medical Education and
Research, New Delhi, India.
Email: docmb1984@gmail.com

ABSTRACT
Actinomycosis is a chronic disease characterized by abscess formation, tissue
fibrosis, draining sinuses and ulcers caused by the filamentous, gram-positive
anaerobic or microaerophilic bacterial species of the genus Actinomyces.
Actinomycosis mainly presents in three forms namely cervicofacial (31-65%),
abdominopelvic (20-36%) and thoracic (15-30%) respectively. Primary gastric
actinomycosis is extremely rare, with only 24 cases reported till date. We
present a case report of a thirty five years old female patient who was admitted
in a super specialty hospital with complaints of low grade intermittent fever,
abdominal pain and two discharging sinuses on anterior abdominal wall.
Clinical, radiological, microbiological and pathological evaluation revealed
findings suggestive of primary gastric actinomycosis with underlying gastric
adenocarcinoma in this patient. To the best of our knowledge, this is the first
ever report of primary gastric actinomycosis from India.

Keywords:
Actinomyces
spp.,
Primary gastric actinomycosis, Gastric
adenocarcinoma
INTRODUCTION
Actinomycosis is a chronic disease characterized by
abscess formation, tissue fibrosis, draining sinuses and
ulcers. It is caused by the filamentous, gram-positive
anaerobic or microaerophilic bacterial species of the
[1]
genus Actinomyces.
Actinomycosis mainly presents in
three forms: cervicofacial (31-65%), abdominopelvic (20[2,3]
36%) and thoracic (15-30%).
Abdominal actinomycosis
has often been called one of the greatest imitators in
[4]
clinical practice. It often presents as an indolent chronic
suppurative process with atypical symptoms that are
misdiagnosed as neoplasms and other inflammatory
[5]
diseases like tuberculosis or Crohns disease. There is a
predilection for appendix and ileocecal region of the bowel
and thus, it can easily mimic colonic adenocarcinoma,
intestinal tuberculosis, chronic appendicitis or regional
[6]
enteritis.
When outside the intestine, abdominal
actinomycosis generally grows by local spread with rare
incidences
of
haematogenous
or
lymphatic
[7]
dissemination.
Primary gastric actinomycosis is
[8-14]
extremely rare, with only 24 cases reported till date.
The rarity of gastric involvement by Actinomyces spp. has
been attributed to the high luminal acidity of stomach, as a
result of which, the organisms are either killed or their
[11]
growth is inhibited.
We hereby present a case of
primary gastric actinomycosis, which to the best of our
knowledge, is the first ever report from India.

patient revealed that one month prior to the appearance of


discharging sinuses, she had abdominal swelling. There
was also history suggestive of loss of appetite and
significant weight loss. Although, there was no significant
past history suggestive of use of Intra Uterine
Contraceptive Device (IUCD), however, this patient had
undergone cholecystectomy for cholelithiasis at a private
nursing home six months ago. On examination, the patient
was febrile and had pallor. No icterus, cyanosis, clubbing,
lymphadenopathy or edema were observed. Systemic
examination revealed no abnormality except for the
presence of two sinuses discharging frank pus on anterior
abdominal wall. Sinus openings were raised, inflamed and
flared up [Figures 1a & 1b].

A thirty five years old female patient was admitted in a


super specialty hospital with complaints of low grade
intermittent fever, abdominal pain and discharging sinuses
on anterior abdominal wall of one week duration. The

Fig 1:(a & b). Discharging sinuses on anterior


abdominal wall
The following investigations were carried out, the results of
which are as follows: Complete haemogram revealed
anaemia (hemoglobin: 5.5 gram%) and leucocytosis (total
leucocyte count: 20,400/cu.mm of blood) respectively.

Mohit et al.,

Int J Med Res Health Sci. 2015;4(4):921-924

CASE REPORT

921

Ultrasonography of abdomen revealed eccentric


asymmetric wall thickening of gastric antro-pyloric region
of maximum thickness 3 cm with loss of mural
stratification. Few enlarged perigastric lymph nodes of size
12 mm10 mm each were also seen. Contrast enhanced
computerized tomography (CECT) of abdomen revealed
thickening of gastric mucosa with formation of a mass
extending to anterior abdominal wall and present up to
transverse colon. Upper gastro intestinal endoscopy
revealed the presence of a large area of elevated surface
of size 4 cm5cm near lesser curvature of stomach. Two
openings each of size 1cm1cm with smooth margins
probably containing some necrotic material were
visualized in this area. The overlying mucosa of elevated
surface appeared to be slightly nodular and abnormal.
Gastric biopsy samples collected during this procedure
were subjected to histopathological examination which
revealed the presence of neoplastic glands (present in
lamina) lined by cells showing nuclear pleomorphism,
stratification, high Nuclear: Cytoplasmic ratio and
moderate amount of eosinophilic cytoplasm suggestive of
moderately differentiated gastric adenocarcinoma.
Pus and necrotic material collected from sinuses was
subjected to Gram stain, Ziehl-Neelson stain and aerobic
culture and sensitivity. On macroscopic examination, the
pus was yellow to brown in color, thick, fowl smelling with
presence of numerous granules which were yellow to
white in color and approximately 0.5-1mm in size. Gram
stain of pus sample revealed the presence of numerous
pus cells, occasional Gram negative bacilli and numerous
Gram positive non-fragmented, non-branching, thin
filamentous bacteria [Figure 2].

Fig 2: Gram stain of pus sample showing Gram


positive, non-branching, thin filamentous bacteria and
Gram negative bacilli (1000X)
No acid fast bacilli were seen on Ziehl-Neelson stain using
3% acid-alcohol as decolorizer. Taking all sterile
precautions, the granules present in pus sample of this
patient were transferred to several glass slides and
crushed with the help of cover slips and wooden handle of
inoculating wire. Potassium hydroxide mount examination
of crushed granules revealed the presence of numerous
aseptate filamentous structures approximately 0.5 to 1m
in size [Figure 3]. Gram stain and modified Ziehl-Neelson
stain (using 1% sulfuric acid as decolorizer) of crushed
granules respectively revealed the presence of numerous
Gram positive and non-acid fast, non-fragmented, nonbranching, thin filamentous bacteria without any chains of
spores suggestive of Actinomyces spp [Figures 4 & 5].

Fig 3: KOH mount of crushed granules showing


aseptate, non-branching, thin filamentous structures
suggestive of Actinomyces spp. (400X)

Fig 4: Gram stain of crushed sulfur granules revealing


Gram positive non-branching, thin filamentous
bacteria (1000X)

Fig 5: Modified Ziehl-Neelson stain showing non acid


fast
structures
morphologically
resembling
Actinomyces spp. (1000X)
Escherichia coli sensitive to amikacin, imipenem,
meropenem and ertapenem was isolated after twenty four
hours of aerobic incubation of pus sample. In lieu of the
clinical picture, aforementioned macroscopic and
microscopic findings, special requisition was sent from the
laboratory to the clinicians for sending some more pus and
necrotic debris, collected from sinuses of this patient, for
performing anaerobic culture for confirmation of
actinomycosis. However, by the time this requisition was
received by the clinicians, the patient had deteriorated

922
Mohit et al.,

Int J Med Res Health Sci. 2015;4(4):921-924

clinically and finally expired due to cardiac arrest owing to


which a second sample could not be collected.
Suggestive history, predisposing factors in the form of
surgery and presence of gastric adenocarcinoma,
endoscopic findings and presence of discharging sinuses,
macroscopic and microscopic microbiological findings
suggest that it was a case of primary gastric
actinomycosis.
DISCUSSION
Actinomyces spp. are often found as saprophytes in the
oral cavity, gastrointestinal and female genital tract. The
destruction of the muscular barrier by trauma in the form
of
surgeries,
endoscopic
manipulation,
immune
suppression as in leukemia, lymphoma and other
malignancies, renal insufficiency, renal transplant,
diabetes and chronic inflammatory diseases are
recognized as predisposing factors for penetration
[15]
by these organisms.
Upon penetration, these
organisms in turn result in characteristic clinical
manifestations in different parts of the body at varying
frequencies. Primary gastric actinomycosis frequently
presents as low-grade fever, epigastric pain, weight loss,
upper GI bleeding and rarely symptoms of gastric outlet
[3,12,14]
obstruction.
The patient under study presented with
similar clinical features suggestive of actinomycosis. She
had undergone cholecystectomy six months ago and was
diagnosed on histopathological examination as a case of
gastric adenocarcinoma later on, both of which are
predisposing
factors
for
acquiring
abdominal
actinomycosis.
There are no specific radiological or endoscopic findings
suggestive of this condition. CT findings mostly
demonstrate an infiltrative lesion with diffuse gastric wall
thickening suggestive of gastric adenocarcinoma or
[2,14]
lymphoma.
Endoscopic findings of the disease may
simulate a gastric neoplasm and include submucosal
tumor-like or infiltrative lesions and occasionally, mucosal
ulceration. In the present case, endoscopic findings
revealed elevated surface and two openings containing
necrotic material near the lesser curvature of stomach.
Because of the submucosal localization of the
inflammatory process, endoscopic biopsy specimens
[14]
usually reveal nonspecific inflammatory changes. Out of
the twenty four reported cases of primary gastric
actinomycosis, only three cases have been diagnosed
pre-operatively by histopathological examination of
[9,10,14]
endoscopic biopsy specimens.
In a case reported by
Khaleel Al-Obaidy et al, the patient was subjected to upper
gastrointestinal endoscopy twice, carried out one week
apart. Actinomycosis was detected by histopathological
examination only in the second biopsy which was obtained
from an area containing brownish fibrinopurulent
[14]
inflammatory exudate.
In the present case also it is
possible that biopsy samples may not have been obtained
from the necrotic area and therefore, the diagnosis of
actinomycosis was missed. However, histopathological
examination revealed gastric adenocarcinoma as the most
probable underlying cause of acquiring this infection in
contrast to most reported cases of gastric actinomycosis,

in which it was impossible to trace the mechanism by


[14]
which Actinomyces spp. had reached the gastric wall.
Actinomycosis is often but not always characterized by the
presence of sulfur granules which occur in 50% of the
cases. Although the presence of sulfur granules strongly
suggests a diagnosis, these are not pathognomonic for the
[16,17]
disease.
The differential diagnosis of sulphur granules
includes nocardiosis, streptomycosis, chromomycosis,
[18]
eumycetoma and botryomycosis.
In the case under
study, preliminary microbiological examination of pus and
necrotic material obtained from discharging sinuses
revealed the presence of organisms morphologically
resembling Actinomyces spp and largely ruled out the
aforementioned conditions.
Culture is negative in >76% cases of gastric
[14]
actinomycosis.
In our case, aerobic culture of pus and
necrotic material obtained from discharging sinuses
yielded Escherichia coli. Generally typical actinomycotic
lesions contain one to ten bacterial species in addition to
the pathogenic actinomycetes. These bacteria are
responsible for early symptoms of the disease and
treatment failures in addition to acting as probable
synergistic pathogens that strengthen the comparatively
[19]
low
invasive
power
of
Actinomyces
spp.
Whether Escherichia coli, which is known to cause
[20]
botryomycosis , had contributed to the development of
mycetoma in our case remains unclear. Unfortunately,
anaerobic culture for isolation and speciation of
Actinomyces spp. could not be attempted due to early
death of the patient.
CONCLUSION
Primary gastric actinomycosis is an extremely rare
disease and often missed by routine diagnostic tests if the
sample is not specifically collected from the affected area.
A high level of suspicion is required both by
gastroenterologists and pathologists in order to correctly
diagnose this condition. Actinomycosis should be
considered in the differential diagnosis of radiological and
upper gastrointestinal endoscopic findings of gastric wall
thickening, particularly in patients with history of
abdominal surgery, trauma or immune compromised
status. In order to avoid the possibility of missing the
diagnosis, the pathologists should be more vigilant and
employ appropriate staining techniques when gastric
endoscopic biopsy samples reveal the presence of subtle
changes such as inflammatory exudates.
ACKNOWLEDGEMENTS
Department of Gastroenterology, Govind Ballabh Pant
Institute of Post Graduate Medical Education and
Research, New Delhi
Conflict of Interest: Nil
REFERENCES
1.

Ferrari TC, Couto CA, Murta-Oliveira C, Conceicao


SA, Silva RG. Actinomycosis of the colon: A rare
presentation. Scand J Gastroenterol, 2000;35:108-9

923
Mohit et al.,

Int J Med Res Health Sci. 2015;4(4):921-924

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.
13.
14.

15.

16.

17.

18.

Isik B, Aydin E, Sogutlu G, Ara C, Yilmaz S,


Kirimlioglu V. Abdominal actinomycosis simulating
malignancy
of
the
right
colon. Dig
Dis
Sci. 2005;50:131214
Choi MM, Beak JH, Lee JN, Park S, Lee WS. Clinical
features of abdominopelvic actinomycosis: report of
twenty cases and literature review. Yonsei Med
J. 2009;50:55559
Dayan K, Neufeld D, Zissin R, Bernheim J, Paran H,
Schwartz I et al. Actinomycosis of the large bowel:
Unusual presentations and their surgical treatment.
Eur J Surg,1996;162:657-60
P. Acquaro, F. Tagliabue, G. Confalonieri, P. Faccioli,
and M. Costa. Abdominal wall actinomycosis
simulating a malignant neoplasm: case report and
review of the literature. The World Journal of
Gastrointestinal Surgery, 2010;2(7):24750
Richards RJ, Grayer D. Actinomycosis: A rare cause
of vesicocolic fistula. Am J Gastroenterol, 1989;84:
677-9
Meyer P, Nwariaku O, McClelland RN, Gibbons D,
Leach F, Sagalowsky AI, et al. Rare presentation of
actinomycosis as an abdominal mass: report of a
case. Dis Colon Rectum, 2000;43:872-5
Oksz M, Sandiki S, Culhaci A, Egesel T, Tuncer I.
Primary gastric actinomycosis: a case report. Turk J
Gastroenterol, 2007;18:4446
Lee SH, Kim HJ, Kim HJ, Chung IK, Kim HS, Park
SH, et al. Primary gastric actinomycosis diagnosed by
endoscopic
biopsy:
case
report. Gastrointest
Endosc., 2004;59:58689
Minamino H, Machida H, Tominaga K, Kameda N,
Okazaki H, Tanigawa T, et al. A case report on
primary gastric
actinomycosis. Gastroenterol
Endosc., 2011;53(2):26269
Skoutelis A, Panagopoulos C, Kalfarentzos F,
Bassaris H. Intramural gastric actinomycosis. South
Med J.,1995;88:64750
Lee CM, Ng SH, Wan YL, Tsai CH. Gastric
actinomycosis. J Formos Med Assoc., 1996;95:6668
Mazuji MK, Henry JS. Gastric actinomycosis: case
report. Arch Surg., 1967;94:29293
Khaleel
Al-Obaidy, Fatimah
Alruwaii, Areej
Al
Nemer, Raed Alsulaiman, Zainab Alruwaii, Mohamed
A Shawarby. Primary gastric actinomycosis: report of
a case diagnosed in a gastroscopic biopsy.BMC Clin
Pathol., 2015; 15: 2
D. C. Dominguez, S. J. Antony. Actinomyces and
nocardia infections in immunocompromised and non
immunocompromised patients. Journal of the National
Medical Association, 1999; 91(1): 3539
Yeguez J.F., Martinez S., Sands L.R., Hellinger M.D.
Pelvic actinomycosis as malignant large bowel
obstruction: A case report and a review of the
literature. Am Surg, 2000;66(1):85-90
Cintron J.R., Del Pino A., Duarte B., Wood D.
Abdominal
actinomycosis.
Dis
Colon
Rectum,1996;39(1):105-8
Omsby AH, Bauer TW, Hall GS. Actinomycosis of the
cholecystic duct: case report and Review Pathology,
1998;30:65-7

19. Schaal KP, Lee HJ. Actinomycete infections in


humans -- a review. Gene, 1992;115:201-11
20. B Devi, B Behera, ML Dash, MR Puhan, SS Pattnaik,
S Patro. Botryomycosis. Indian J Dermatol., 2013
Sep-Oct; 58(5): 406

924
Mohit et al.,

Int J Med Res Health Sci. 2015;4(4):921-924

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00189.7
Open Access

RARE PRESENTATION OF RUPTURED RUDIMENTARY HORN PREGNANCY


1

Shergill Harbhajan K , Grover Suparna , Chhabra Ajay

ARTICLE INFO
Received: 13th Aug 2015
Revised: 23rd Sep 2015
Accepted: 28th Sep 2015
1
Authors details:
Professor,
Department
of
Obstetrics
and
Gynaecology,
Government
Medical
College, Amritsar; 2Assistant Professor,
Department
of
Obstetrics
and
Gynaecology,
Government
Medical
College, Amritsar; 3 Assistant Professor,
Department of Medicine, Government
Medical College, Amritsar
Corresponding author: Ajay Chhabra,
Assistant
Professor
Medicine,
Government Medical College, Amritsar
Address: 429, Akash Avenue, Amritsar
Email: drajaychhabra@gmail.com

ABSTRACT
It is a rare occurrence for the rudimentary horn of uterus to harbour a
pregnancy and the usual outcome is devastating leading to a spontaneous
rupture in second trimester with the patient presenting in shock with
massive intra-peritoneal haemorrhage and if appropriate management is
not instituted in time it may lead to high rate of mortality. We report an
unusual case of rupture rudimentary horn pregnancy who presented as a
chronic ectopic with an adnexal mass and surprisingly with no sign of
shock. Diagnosis is often difficult in such a situation which puts the treating
gynaecologist in dilemma. High clinical suspicion supplemented with
radiological findings helped clinch the diagnosis and laparotomy was
performed followed by resection of the rudimentary horn to prevent future
complications.
Keywords:

Rudimentary
uterus,Mullerian anomaly

INTRODUCTION
The incidence of mullerian duct anomalies in general
.population is estimated to be 0.5%-3.2%.[1,2]Noncommunicating rudimentary horn is one of these
mullerian anomalies. A pregnancy implanting in this horn
is a rare event but when it happens, the implications can
be catastrophic. The incidence as reported by Johnsen is
1 in 100,000 patients making it an extremely rare
[3]
presentation. It usually ruptures in second trimester
leading to immediate fetal demise, massive intraperitoneal haemorrhage and shock. The clinical picture
mimics a ruptured tubal ectopic and a diagnosis is often
made at laparotomy only. Pre-rupture diagnosis is rare
and radiological. We report a rare case of ruptured
rudimentary horn pregnancy mimicking a chronic ectopic
[3]
with no features of shock.

horn,

ectopic

pregnancy,

unicornuate

General examination: Patient was conscious, cooperative


and her vitals were within normal range. Pallor was
present.
Abdominal examination: abdomen was soft and nontender.
Pelvic examination: Soft non tender 5x5 cm mass was
felt on the left of the uterus which was 8 weeks in size.
Clinically it appeared to be a case of chronic ruptured
ectopic of left adnexa.
USG pelvis showed a 15 weeks 3 days dead fetus in
abdominal cavity just below the abdominal wall. Uterus
was bicornuate with placenta in left horn. A hypoechoic
area was seen in the fundal region of left horn which
appeared to be a dent in uterine wall and showed
continuity with fetus. Right horn of the uterus was normal
and cervix was closed. (Fig 1 & 2)

CASE REPORT
A 25 year old gravida three and para two was referred to
Guru Nanak Dev Medical College and Hospital, Amritsar
with three months amenorrhoea and pain in abdomen for
a week. Pain was acute and severe before one week and
was relieved with analgesics. There was history of
fainting sensation at the same time. Over one week pain
had persisted but was dull and aching type. Patient had
no complaint of per vaginal bleed.
Obstetric history: Patient was G3P2L2A0 with history of
two term normal deliveries and last birth was 8 months
prior.
Menstrual history: Her past menstrual cycles were
regular, painless with normal blood flow. She was not
sure about her last menstrual period but vaguely
remembered her pregnancy to be of 3 months duration.

Shergill Harbhajan et al.,

Fig 1: Showing ascites and left uterine horn with rent in


fundal region

925
Int J Med Res Health Sci. 2015;4(4):925-927

Fig 2: Fetus surrounded by ascitic fluid lying in the


abdominal cavity

Fig 3: Showing rent in the rudimentary horn on the left side

Operative findings: on entering the peritoneal cavity,


there was altered blood and clots in the pelvis. There was
a rudimentary non-communicating horn on left side
measuring about 6x6 cm with a rent on its anterior and
superior aspect with a cord like structure coming out of it
which was traced to a dead fetus wrapped up in the
omentum. ( Fig 3)
Ovaries and tubes were normal on both sides. Excision of
rudimentary horn with ipsilateralsalpingectomy was done,
hemostatic stitches taken and right sided partial
tubectomy was done. Peritoneal lavage was done and
abdomen closed in layers. Postoperative period was
uneventful.
DISCUSSION
During embryogenesis, the uterus is normally formed by
the fusion of the two Mllerian ducts. Defective fusion or
absorption of these ducts leads to congenital uterine
abnormalities. In 1988, American Fertility Society (AFS)
classified mullerian duct abnormalities on the basis of
[4]
magnitude of failure of normal uterine development.
Unicornuate uterus is a result of incomplete development
of one of the mllerian ducts. As per AFS classification, it
is a type 2 mullerian anomaly. A unicornuate uterus can
be present alone [Type 2a] or with a rudimentary horn or
[4]
bulb on the opposite side [Type 2b].
Unicornuate uterus occurs in 1 in 4020 women in the
general population and a rudimentary horn is present in
[5,6]
about 84% of the cases.
Heinonen et al reported a
case series of 13 unicornuate uteri of which 11 had a

rudimentary horn and the remaining two patients no


rudimentary horn. More than 90% rudimentary horns are
[7]
noncommunicating.
Urinary tract anomalies are
associated with a unicornuate uterus in around 36%
cases and should always be searched for in these
[7]
patients.
A unicornuate uterus is often asymptomatic till a chance
discovery as a result of complications of pregnancy. The
condition favours abortion and premature labour, breech
presentation of the foetus and fundal insertion of the
placenta. Various studies have published a live birth rate
[5,6,8]
ranging from 29%-61%.
The poor obstetric outcome
may be due to the abnormal shape, the insufficient
muscular mass of the uterus, abnormal vasculature,
cervical incompetence and the reduced uterine volume
and inability to expand.
In our patient, previous two vaginal deliveries were term
vaginal deliveries with no complications that could
suggest a uterine anomaly based on the obstetric history
alone. There was no history of dysmenorrhoea or pelvic
pain as is seen sometimes due to any obstruction to
communication between the horn and the main uterine
cavity or the vagina.
Ectopic pregnancy occurring in a non-communicating
rudimentary horn has an estimated incidence of 1 per
[9]
100,000 to 140,000 pregnancies. Pregnancy in the noncommunicating
rudimentary
horn
results
from
transperitoneal migration of sperm or fertilised ovum from
[5]
the opposite side.
If not diagnosed earlier the pregnant rudimentary horn
will eventually rupture and the patient will present with
signs and symptoms mimicking a ruptured ectopic
pregnancy.The highly vascularised wall of the
rudimentary horn may rupture leading on to sudden and
severe intraperitoneal haemorrhage and shock.
Most common outcome of pregnancy in rudimentary horn
is rupture that occurs in the second trimester. It is
associated with serious hemodynamic changes although
a few studies have reported continuation of pregnancy as
secondary abdominal pregnancy after a silent
[10]
rupture. In our patient, in spite of the rupture, patient
was surprisingly not in a state of hypovolemic shock. It
was probably due to no major vessels being involved.
In general, the pregnancy lasts longer than tubal
pregnancy because of the variable musculature of the
horn. 50% of cases rupture usually in second trimester,
[11]
while 30% go to term with a 0-13% fetal salvage rate.
At operation the attachment of the round ligament was
lateral to the gestational sac which was suggestive of
pregnancy in rudimentary horn rather than the tubal
pregnancy. Rudimentary horn had a tube and an ovary
attached to it. The rudimentary horn was removed
together with the corresponding fallopian tube to avoid a
future ectopic pregnancy in a blind residual tube via
[5]
sperm transmigration.
Over last few years, cases of pregnancies in rudimentary
[12,13]
horns have been managed laparoscopically.
Prerupture diagnosis is indeed challenging but when
possible, medical management with methotrexate is an
option although surgical excision of the horn is still
[14]
recommended.

926
Shergill Harbhajan et al.,

Int J Med Res Health Sci. 2015;4(4):925-927

CONCLUSION
Being a rare entity and due to potentially atypical
presentations, diagnosis of rudimentary horn pregnancy
is often delayed and many a times it may surprise a
surgeon operating with provisional diagnosis of ectopic
pregnancy. This possibility should always be considered
in differential diagnosis of a woman presenting with acute
abdomen and/or features of shock in second trimester of
pregnancy. Surgical excision of a non-communicating
horn is always indicated even when diagnosis is
incidental.Ipsilateral fallopian tube should never be left in
such cases as they are a potential site of ectopc
pregnancy in future.
Conflict of Interest- nil

Journal of Reproductive Medicine. 1998; 43(3): 2236.


14. Edelman AB, Jensen JT, Lee DM and Nichols MD.
Successful medical abortion of a pregnancy within a
non-communicating rudimentary uterine horn.
American Journal of Obstetrics and Gynecology.
2003;189:886-7.

REFERENCES
1.

2.

3.

4.
5.

6.
7.

8.

9.
10.

11.

12.

13.

Nahum GG. Uterine anomalies. How common are


they, and what is their distribution among subtypes?
The Journal of Reproductive Medicine. 1998;43:877
87.
Simon C, Martinez L, Pardo F, Tortajada M and
Pellicer A. Mullerian defects in women with normal
reproductive outcome. Fertility and Sterility.
1991;56:11923.
Johnsen K. Pregnancy in a rudimentary horn, two
case
reports.
Obstetrics
and
Gynecology.
1983;62:334-42.
American Fertility Society. Classification of mullerian
anomalies. Fertility and Sterility.1988;49:952.
Reichman D, Laufer MR and Robinson BK.
Pregnancy outcomes in unicornuate uteri: a review.
Fertility and Sterility. 2009; 91(5):1886-94.
Heinanen PK. Unicornuate uterus and rudimentary
horn. Fertility and Sterility. 1997; 168: 224-30.
Jayasinghe Y, Rane A, Stalewski H and Grover S.
The presentation and early diagnosis of the
rudimentary
uterine
horn.
Obstetrics
and
Gynecology. 2005;105:145667.
Akar M, Bayar D, Yildiz S, Ozel M and Yilmaz Z.
Reproductive outcome of women with unicornuate
uterus. Australia New Zealand Obstetrics and
Gynaecology Journal. 2005;45:14850.
OLeary JL and OLeary JA. Rudimentary horn
pregnancy. Obstetrics and Gynecology.1963;22:371.
Shin JW and Kim HJ. Case of live birth in a noncommunicating rudimentary horn pregnancy. Journal
Obstetrics
and
Gynaecology
Research.
2005;31:329-31.
Nahum GG. Rudimentary uterine horn pregnancy.
The 20th century worldwide experience of 588
cases. Journal of Reproductive Medicine. 2002;
47:151-63.
Sharma D, Usha MG, Gaikwad R and Sudha S.
Laparoscopic resection of unruptured rudimentary
horn
pregnancy.
International
Journal
of
Reproduction,
Contraception,
Obstetrics
and
Gynecology. 2013;2:95-8.
Yahata T, Kurabayashi T, Ueda H, Kodama S,
Chihara T and Tanaka K. Laparoscopic Management
of Rudimentary horn Pregnancy: A case report.

927
Shergill Harbhajan et al.,

Int J Med Res Health Sci. 2015;4(4):925-927

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00190.3
Open Access

HOMICIDE BY CERVICAL SPINAL CORD GUNSHOT INJURY WITH SHOTGUN


FIRE PELLETS: CASE REPORT
1,2

3,4

Dana Turliuc , Serban Turliuc , Iustin Mihailov Andrei Cucu , Gabriela Dumitrescu ,Claudia Costea

ARTICLE INFO

ABSTRACT

th

Received: 13 Aug 2015


rd
Revised: 23 Sep 2015
th
Accepted: 29 Sep 2015
1

Author details: PhD, Department of


3
Neurosurgery, PhD, Department of
6
Psychiatry,
PhD, Department of
Ophthalmology, Gr.T. Popa University
of Medicine and Pharmacy, Iasi,
Romania
2
5
MD, Neurosurgery Unit II, PhD,
Department of Pathology, Nicolae Oblu
Emergency Clinical Hospital, Iasi,
Romania
4
MD, Unit II for Female Patients,
Socola Psychiatry Hospital Iasi,
Romania

This case present a rare forensic case of cervical spinal gunshot injury of a
female by her husband, a professional hunter, during a family fight with a
shotgun fire pellets. The gunshot destroyed completely the cervical spinal
cord, without injury to the neck vessels and organs and with the patient
survival for seven days. We discuss notions of judicial ballistics,
assessment of the patient with spinal cord gunshot injury and therapeutic
strategies. Even if cervical spine gunshot injuries are most of the times
lethal for majority of patients, the surviving patients need the coordination
of a multidisciplinary surgical team to ensure the optimal functional
prognostic.
Keywords: cervical spinal cord gunshot injury, shotgun fire pellets, neck
gunshot wounds

Corresponding author: Serban


Turliuc, Associate Professor,
Department of Psychiatry, Gr.T.Popa
University of Medicine and Pharmacy,
16 University Street, Iasi, Romania.
Email: serban_turliuc@yahoo.com

INTRODUCTION
In the last years, due to increasing violence in urban
areas, spinal cord gunshot injuries have became an
important cause of morbidity and mortality, especially in
[1]
the young population .The incidence of spinal cord injury
caused by gunshot wounds varies considerably
[2,3]
depending on the country, with values from 13 to 44%
.
Attacks and aggression are the main causes of spinal
cord gunshot injuries among civilians, while accidental
[1]
[4,5]
shootings are rare . Patients are generally male
[6]
having ages from 15 to 34 years and in most cases of
spinal cord gunshot wounds, there occurs spinal cord
[7]
transection with complete neurological deficit .
Recently, the incidence of shotgun wounds by projectile
weapons with high energy has increased (rifles and
[8,9]
military weapons)
. Currently, the most common are
chest gunshot wounds, and the most devastating are
cervical spinal cord gunshot wounds, having a poor
prognosis,
producing
most
commonly
complete
[7,10,11]
neurological deficit
.
A report of the Statistical Office of the US Justice
Department in 1988 reported that 36% of victims with
gunshot wounds were females. The same report states
that there are twice more women than men victims of
crimes committed by spouses or family members. In 36%

of cases of homicide, the crime weapons were pistols and


[12]
only in 4% of cases shotguns .
We present a rare forensic case of cervical spinal gunshot
wound with a shotgun fire pellets of a female by her
husband, a professional hunter during a family fight. The
peculiarity of this case lies in the fact that the cervical
spinal cord gunshot injury with a shotgun fire pellets is
normally not fatal for a human, but in our case, the
gunshot caused the complete destruction of the cervical
spinal cord, with no other injuries in the neck vessels and
organs, with 7-day survival of the victim.
CASE REPORT
A female patient aged 48 years, from the countryside is
admitted to the Emergency Department, having a cervical
spinal cord gunshot injury. The patient was in druginduced superficial coma, tracheally intubated with
complete neurological deficit (type A, American Spinal
Injury Association classification), hemodynamically stable
and with no other injuries in the neck. From further
examinations, it was found that she was shot by her
husband, a professional hunter, with a shotgun fire pellets
in the right supraclavicular region during a family fight.
Local examination shows projectile entry wound with
irregular edges, involving right latero-cervical deep
regions, with no skin, having a size of approximately 4/8

928
Serban Turliuc et al.,

Int J Med Res Health Sci. 2015;4(4):928-931

cm (Fig.1.A). The exit wound of the projectile consisting of


two contusion wounds of less than1 cm, located in the left
scapular region, accompanied by bruised skin and
underlying subcutaneous hematoma (Fig.1.B). Cervical
spine computed tomopraphy (CT) scan performed in
emergency conditions shows a cervical spinal cord
gunshot injury, highlighting several metal foreign bodies
(pellets) (Fig.2.A.) in latero-cervical soft tissues located
bilaterally and in the right posterolateral spinal canal C6C7, as well in the C7-T3 spinal canal (Fig.2.A and B,
Fig.3.A and B).

Fig 1:Intraoperative images: (A) entry wound with plastic


wadding of cartridge within (box); (B) the two exit wounds of
pellets.

Fig 2: CT scan images: (A) foreign metal bodies (pellets); (B)


presence of pellets in spinal canal in the cervicothoracic
junction.

Fig 3: 3D reconstruction of pellets distribution: (A) anterior


view of cervical spine showing right-left trajectory; (B) right
oblique posterior view showing posterior pellets distribution.

Surgery was performed and during operation there has


been observed an oblique path from right to left, top to
bottom and inside to outside, rear to right
sternocleidomastoid muscle and carotid sheath without
involvement of great vessels of the neck and without
acute hemorrhage, with a cerebrospinal leak in cervical
dural sac. Primary wound toilet and surgical debridement

were performed with the extraction of visible pellets and


blocked plastic wadding in wound lane (Fig. 1. box),
closure of cerebrospinal fluid leak, and cavity lavage and
defect covering with local fasciocutaneous advancement
flaps.
DISCUSSION
For the first time in history, spinal injuries were described
[13]
in 1700 B.C. by Imhotep in Ancient Egypt . Much later,
Galen made the first clinical correlations and showed that
transverse spinal cord lesions are associated with
paraplegia and they are much more serious than
[14]
th
longitudinal lesions . In the 16 -century, Ambroise Pare
first describes spinal cord injuries caused by firearms,
while in the Second World War, front line surgeons
discover first steps of treatment, namely, that debridement
of necrotic tissue, use of antibiotics and surgery greatly
reduce early mortality and morbidity in patients with spinal
[15]
cord gunshot wounds .
In spinal cord gunshot injuries are involved two
mechanisms: ballistic and non-ballistic, that underlay the
understanding of gunshot wounds pathophysiology.
These mechanisms differ among them by the speed of the
projectile at the time of impact. Tissue destruction by
bullet is produced by three mechanisms: direct impact of
the bullet, its shock waves pressure and temporary
[3, 16]
cavitation
. The factors that influence the severity of
spinal cord gunshot injury are: the type of speed, projectile
nature (shape, design, fragmentation), point of entry,
projectile angulation, as well as the features of tissues
involved (bone, muscle, mucosa) anatomical and
neurovascular structures destroyed by the projectile in its
[3, 17]
trajectory
.
Shotgun fire pellets are made of a cartridge containing
pellets. After shooting, plastic wadding of cartridge opens
and pellets are dispersed in a truncated cone, the top
starting from the barrel of a gun and forms in space a
circular field, which is intended to cover the target. The
projectile with pellets is used mainly in hunting weapons
and pellets are lead spheres or lead alloy of different sizes
[13, 18]
between 1 and 5 mm
.
Spinal cord gunshot injuries are classified as transfixed
injuries (when small fragments of projectile are found in
the spinal canal), intra-canal (when the entire projectile is
found in the spinal canal) and intervertebral (when the
[13]
cartridge is inside the intervertebral disc space)
. In
most cases, the wounds are transfixed and only small
fragments (<50% of the projectile) are found in the spinal
[19]
canal .
In the presented clinical case, the hole entrance was
produced only by shotgun fire cartridge because it was
positioned in the supraclavicular region close to skin.
Cartridge exploded in right deep supraclavicular region,
with the creation of a field of dispersion of pellets, oriented
obliquely and down towards the root of the neck, with the
distribution of pellets throughout the right laterocervical
region, the junction region of the cervico-thoracic spine,
laterocervical and left scapular region with the exit of two
pellets through two holes with a diameter of less than 1
cm, located in the left scapular region. Most pellets (about
40) were stuck in the soft tissues located latero-cervically

929
Serban Turliuc et al.,

Int J Med Res Health Sci. 2015;4(4):928-931

bilaterally and in right posterolateral spinal C6-C7 canal


and in C7-T3 spinal canal.
For the survival of patients with spinal cord gunshot
injuries, it is crucial that the overall assessment started
with basic life support techniques. After life support is
[6]
ensured, spinal lesion assessment follows
. It is
recommended that excessive mobilization be avoided due
to risk of aggravation. Therefore, the cervical spine is
[17]
immobilized with a cervical collar
. In case of patients
who are victims of murder, reconstruction and history are
extremely important, accurate information from witnesses
should be collected related to the type of shotgun used,
the proximity of gunshot, number of cartridges and the
direction of shoot. These notions of judicial ballistics can
help the first assessment of injury and could further guide
[20]
the treatment decision .
Also, the entry and exit wound should be evaluated and it
is recommended that bullet trajectory should not be
explored by finger but only after the patient has reached a
hospital. Cervical spine radiography is performed to
assess fractures and locate cartridges.
Once their
positions are identified, a thin section CT is done to allow
a better view of cartridges, as well as the extent of bone
destruction. Magnetic resonance imaging permits a better
visualization of the nerve roots and spinal cord, but is
controversial because of the risk of potential migration of
[21]
cartridges or pellets .
In the case of our patient, ABCDE (airway, breathing,
circulation,
disability,
exposure)
protocol
was
accomplished, cervical spine was immobilized by a collar
and gunshot wound was not explored, leaving the
cartridge in its place. The cervical and thoracic spine CT
scan was performed in emergency which showed
complete destruction of spinal cord of cervico thoracic
junction.
Cervical spinal cord gunshot injuries are usually
associated with damage to the airways that may require
[22]
emergency tracheal intubation
and the main cause of
instant death in case of gunshot wounds is hemorrhage
due to damage of vascular structures in the neck, which is
[23,24]
most often fatal
.
Generally, shotgun fire pellets do not cause death injuries.
In the presented case, the lesion was fatal, since the
gunshot distance was less than 0.5 m from the victim,
which caused major spinal cord injury that later caused
death. Although the cone of dispersion of pellets was very
close to the neck neurovascular bundle and other organs
of the neck, these were not damaged, the patient survived
another seven days after the aggression and died of
complications of spinal cord injury.
Cervical spinal cord gunshot injury are in most cases fatal
[23]
, and patients who survive require guidance of a
multidisciplinary surgical team to optimize the functional
prognosis, still a surgical treatment for complete
[24]
neurological deficit remains controversial .
The only indication for surgical treatment is the dural leak
or progression of neurological deficit associated with
compression of the spinal cord/nerve roots confirmed by
[17]
[25]
imagistics
, the occurrence of spine instability
,
installation of toxicity - poisoning (in case of lead bullets)
and the likelihood of migration of an intracanal cartridge or

pellets. Indications for surgical treatment of spinal cord


[3]
decompression are for the first 24-48 hours .
In this case, emergency surgery consisted of primary
surgical wound toilet with the extraction of visible pellets
and blocked cartridge in the wound lane, cerebrospinal
leak closure, cavity lavage and coverage of defect of
substance with fasciocutaneous advancement flaps.
In spinal cord gunshot injuries, the most important
prognostic factor is the initial neurological examination of
[5, 16]
the patient
. Functional recovery of spinal cord
gunshot injuries with incomplete neurological deficit is
more difficult than in the case of stab wounds or wounds
[5, 26]
caused by road accidents
. In case of cervical spinal
cord gunshot wounds, the neurological deficit is complete
[27, 28]
in about 70% of cases
, lesions are completely in
[29,
approximately 30% of cases in the lumbosacral region
30]
. In our case, the patient's prognosis was unfavorable
due to initial important cervical spinal injury that lead to
respiratory insufficiency, patients death occurring seven
days after hospitalization.
CONCLUSIONS
Therapeutic management of patients with spinal cord
gunshot injuries is an emergency and requires an
interdisciplinary team. Surgical treatment in case of spinal
gunshot wounds with complete neurological deficit is not
recommended in most cases and remains controversial
because there are no therapeutic resources.
Spinal cord gunshot wounds are important forensic events
and it is essential in such cases to know few notions of
judicial ballistics, such as type of weapon used in the
murder, understanding the mechanism of spinal cord
injury and the correct classification of the offense under
the law in force as provided by Criminal Law.
Conflict of interest: Nil
REFERENCES
1.

2.

3.

4.

5.

6.

Cook PJ, Lawrence BA, Ludwig J, Miller TR. The


medical costs of gunshot injuries in the United States.
JAMA. 1999; 282(5): 447454.
Farmer JC, Vaccaro AR, Balderston RA, Albert TJ,
Cotler JM. The changing nature of admissions to a
spinal cord injury center: violence on the rise. J.
Spinal. Disord. 1998; 11(5): 400403.
Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff
KE. Civilian gunshot injuries of the spinal cord: a
systematic review of the current literature. Clin.
Orthop. Relat. Res. 2013; 471(12): 39453955.
Heary RF, Vaccaro AR, Mesa JJ, Northrup BE, Albert
TJ, Balderston RA ,Cotler JM. Steroids and gunshot
wounds to the spine. Neurosurgery. 1997; 41(3):
576583.
Levy ML, Gans W, Wijesinghe HS, SooHoo WE,
Adkins RH, Stillerman CB. Use of methylprednisolone
as an adjunct in the management of patients with
penetrating spinal cord injury: outcome analysis.
Neurosurgery. 1996; 39(6): 11411148.
Yoshida G, Garland D, Waters RL. Gunshot wounds
to the spine. Orthop.Clin. North. Am. 1995;
26(1):109116.

930
Serban Turliuc et al.,

Int J Med Res Health Sci. 2015;4(4):928-931

7.

8.

9.

10.

11.
12.

13.

14.
15.

16.

17.

18.
19.

20.

21.

22.

de Barros Filho TEP, Oliveira RP,De Barros EK, von


Uhlendorff EF, Yutaka AS, Cristante AF,Marcon RM.
Ferimento por projetil de arma de fogo na coluna
vertebral:estudo epidemiologico [Gunshot wounds of
the spine: epidemiological study], Coluna, 2002;
www.plataformainterativa2.com/coluna/html/revistacol
una/volume1/ ferimento_ projetil.htm
Miller CA. Penetrating wounds of the spine. In:
Wilkins RH, Rengachary SS (eds.), Neurosurgery,
McGraw Hill, New York, 1985, pp. 17461748.
Turgut M, Ozcan OE, Gay O, Saglam S. Civilian
penetrating spinal firearm injuries of the spine.
Results of surgical treatment with special attention to
factors determining prognosis. Arch. Orthop.
Trauma.Surg. 1994; 113(5): 290293.
Bishop M, Shoemaker WC, Avakian S, James E,
Jackson G, Wiliams D, Meade P, Fleming A.
Evaluation of a comprehensive algorithm for blunt
and penetrating thoracic and abdominal trauma. Am.
Surg. 1991; 57(12): 737746.
Kupcha P, An HS, Cotler JM. Gunshot wounds to the
cervical spine. Spine. 1990; 15(10):10581063.
U.S. Departament of Justice, Bureau of Justice
Statistics Special Report. Murder in Large Urban
Counties. 1988. U.S.A. G.P.O. 1993-342-471:80004,
on-line.
de Barros Filho TE, Cristante AF, Marcon RM, Ono A,
Bilhar R. Gunshot injuries in the spine. Spinal Cord.
2014; 52(7): 504510.
Ducker TB, Lucas JT, Wallace CA. Recovery from
spinal cord injury. Clin. Neur. 1982; 30: 495513.
Matson DD. Treatment of compound spine injuries in
forward Army hospitals. J Neurosurg. 1946; 3: 114
119.
Klimo P Jr, Ragel BT, Rosner M, Gluf W, McCafferty
R. Can surgery improve neurological function in
penetrating spinal injury? A review of the military and
civilian literature and treatment recommendations for
military neurosurgeons. Neurosurg. Focus. 2010;
28(5): E4.
Kumar
A, Pandey
PN, Ghani
A, Jaiswal
G.
Penetrating spinal injuries and their management. J
Craniovertebr. Junction. Spine. 2011; 2(2): 57-61
Bono CM, Heary RF. Gunshot wounds to the spine.
Spine. J. 2004; 4(2): 230240.
Waters RL, Adkins RH, Yakura J, Sie I. Profiles of
spinal cord injury and recovery after gunshot injury.
Clin. Orthop. Relat. Res. 1991; 267: 1421.
Inaba K, Barmparas G, Ibrahim D, Branco BC, Gruen
P, Reddy S, Talving P, Demetriades D. Clinical
examination is highly sensitive for detecting clinically
significant spinal injuries after gunshot wounds. J.
Trauma. 2011; 71(3): 523527.
Ebraheim NA, Savolaine ER, Jackson WT,
Andreshak TG, Rayport M. Magnetic resonance
imaging in the evaluation of a gunshot wound to the
cervical spine. J.Orthop. Trauma. 1989; 3(1): 1922.
Motamedi MH. Management of firearm injuries to the
facial skeleton: Outcomes from early primary
intervention. J Emerg. Trauma. Shock. 2011; 4(2):
212-216.

23. Abe M, Motani-Saitoh H, Sato Y, Kiuchi M. A fatal


case of shotgun injury caused by one pellet. Leg.
Med. 2002; 4(2):131- 133.
24. Weider L, Hughes K, Ciarochi J, Dunn E. Early
versus delayed repair of facial fractures in the multiply
injured patient. Am. Surg. 1999; 65(8):790-793.
25. Waters RL, Hu SS. Penetrating injuries of the spinal
cord stab and gunshot injuries. In: Frymoyer JW
(eds.), The adult spine: principles and practice,
Raven Press, New-York, 1991, pp. 815826.
26. Hammoud MA, Haddad FS, Moufarrij NA. Spinal cord
missile injuries during the Lebanese civil war. Surg.
Neurol. 1995; 43(5): 432437.
27. Romanick PC, Smith TK, Kopaniky DR, Oldfield D.
Infection about the spine associated with low-velocitymissile injury to the abdomen. J. Bone. Joint. Surg.
Am. 1985; 67(8): 11951201.
28. Schneider RC, Webster JE, Lofstrom JE. A follow-up
report of spinal cord injuries in a group of World War
II patients, J. Neurosurg. 1949; 6(2): 118126.
29. Chittiboina P, Banerjee AD, Zhang S, Caldito G,
Nanda A, Willis BK. How bullet trajectory affects
outcomes of civilian gunshot injury to the spine. J.
Clin. Neurosci. 2011; 18(12): 16301633.
30. Haynes WG. Acute war wounds of the spinal cord.
Am. J. Surg. 1946; 72: 424433.

931
Serban Turliuc et al.,

Int J Med Res Health Sci. 2015;4(4):928-931

Available online at: www.ijmrhs.com


Case report

DOI: 10.5958/2319-5886.2015.00191.5
Open Access

OCCLUSION OF ARTERY OF PERCHERON: A RARE AETIOLOGY OF BILATERAL


THALAMIC INFARCT
1

Mane Makarand , Mane Priyanka , Mohite Rajsinh , Bhattad Prashant , Bangar Kushal , Mahajani Anup
ABSTRACT

ARTICLE INFO
Received: 17th Jul 2015
Revised: 7th Sep 2015
Accepted: 25th Sep 2015
Authors details: 1Assistant Professor,
4
Residents, Dept. of General Medicine,
Krishna Institute of Medical Sciences
Karad, Maharashtra, India
2
Assistant Professor, Dept. of
Microbiology, KIMS, Karad, Maharashtra,
India
3
Assistant Professor, Dept. of
Community Medicine, KIMS, Karad,
Maharashtra, India

Corresponding author:
Mohite
Rajsinh , Assistant Professor, Dept. of
Community Medicine,
Maharashtra, India

KIMS,

Karad,

Email: rajsinhmohite124@gmail.com

The Artery of Percheron, a rare anatomical variant of brain vascularisation,


arises from the posterior cerebral artery. Occlusion of this artery leads to
bilateral paramedian thalamic infarct leads to dysfunction of central nervous
system. Incidence of bilateral thalamic infarct secondary to occlusion of
artery of Percheron is unknown because of its rarity. Here we report a case
of 35 year old female presented with altered state of consciousness and the
underlying cause was occlusion of Artery of Percheron which leads to
bilateral thalamic infarct detected on MRI scanning. It showed
hyperintensities on T2W1 and FLAIR, and hypointensity on T1W1,
restricted to bilateral ventromedial thalami showing corresponding area of
high signal intensity on diffusion weighted images and hypointensity on
apparent diffusion coefficient images indicating diffusion restriction,
suggestive of infarct. On further investigation magnetic resonance
arteriogram (MRA) of the brain demonstrated a single common artery
arising from the left P1 segment which divided into two branches distally
supplying bilateral thalami. Patient became alright after 2 weeks of medical
line of treatment.
Keywords: Artery of Percheron, occlusion, Thalamic infarct

.
INTRODUCTION
Thalamus is a part of midbrain located below
hypothalamus below the ventricles. Thalamus receives
blood supply from both anterior and posterior circulations
of brain. The Artery of Percheron (AOP) is a rare
anatomical variant of brain circulation in which single
central arterial trunk arises from first segment (P1) of the
posterior cerebral artery. The AOP give rise to bilateral
medial thalamic perforants which supplies blood to
[1]
thalamus bilaterally . Occlusion of this artery leads to
sudden breakdown of perfusion of thalamus which leads
to bilateral paramedian thalamic infarct with or without
mesencephalic infarct. Prevalence and incidence of this
[2, 3]
syndrome is unknown,
however few cases were
reported from various parts of world as well as India since
it was first described by Percheron in year 1976 . Here
we report a case of 35 year old lady with acute bilateral
thalamic infarct with underlying cause of occlusion of
Artery of Percheron, as a rare case report from rural area
of Western Maharashtra, India.

involuntary movements, any focal weakness or


hemiparesis. On examination, her vitals were within
normal range and on systemic examination the abnormal
things were state of stupor and bilateral constricted
pupils. All the laboratory investigations were within
normal limits, including hypercoagulable profile. The past
history was of use of oral contraceptives for last few
months for dysfunctional uterine bleeding.
The special diagnostics include non-invasive magnetic
resonance imaging (MRI) of brain was performed. It
showed hyperintensities on T2W1 and FLAIR, and
hypointensity on T1W1, restricted to bilateral
ventromedial thalami showing corresponding area of high
signal intensity on diffusion weighted images and
hypointensity on apparent diffusion coefficient images
indicating diffusion restriction, suggestive of infarct (fig 1).

CASE REPORT
A 35 years old female came with altered state of
consciousness i.e. stuporous state in Krishna hospital,
Karad, a tertiary health care centre loacated in rural
Western Maharashtra, India. Two hours ago of hospital
admission, she felt giddiness which then progressed to
stupour state. She had no history of fever, headache,

Mane Makarand et al.,

Fig 1: MRI of brain showing hyper intensities on T2W1 &


FLAIR in bilateral ventro-medial thalami (arrow heads)

932
Int J Med Res Health Sci, 2015;4(4):932-933

On further investigation magnetic resonance arteriogram


(MRA) of the brain demonstrated a single common artery
arising from the left P1 segment which divided into two
branches distally supplying bilateral thalami.

The medial posterior choroidal artery may arise before


(P1 seg) or after (P2 seg) the origin of the posterior
communicating artery. The inferolateral arteries may
arise individually or from a common pedicle from P2
[6]
segment.

DISCUSSION
CONCLUSION
Thalamus is a large collection of neuronal group within
the diencephalon. It participates in sensory, motor, and
limbic functions. Virtually all information that reaches the
cortex is processed by the thalamus, hence also called
as gateway to the cerebral cortex. Thalamus can be
divided into various nuclei, that project to wide regions of
the neocortex are the midline and intra-laminar nuclei.
The nuclei that project to specific areas include the
specific sensory relay nuclei and the nuclei concerned
with efferent control mechanisms. The specific sensory
relay nuclei include the medial and lateral geniculate
bodies, which relay auditory and visual impulses to the
auditory and visual cortices; and the ventral posterior
lateral (VPL) and ventral posteromedial nuclei, which
relay somato-sensory information to the post-central
gyrus. The ventral anterior and ventral lateral nuclei are
concerned with motor function. They receive input from
the basal ganglia and the cerebellum and project to the
motor cortex. The anterior nuclei receive afferents from
the mamillary bodies and project to the limbic cortex,
[4]
which may be involved in memory and emotion.
Infarction in thalamus may produce symptoms like
seizures, impairment in memory, confusion and
[5]
sometimes coma with vertical gaze palsy.
Thalamus receives blood supply from both anterior and
posterior circulations. The anterior thalamus is supplied
by thalamotuberal arteries arising from posterior
communication artery via anterior circulation. The
paramedian thalamic and rostral midbrain territories are
supplied by thalamoperforators, anterior branches of the
[6]
P1 segments of the posterior cerebral arteries (Fig 2).
Percheron G has described three variations in the blood
[1]
supply of the paramedian thalamus. One of them was
Artery of Percheron which arises from P1 and supplies to
bilateral thalamus and rostral midbrain. Many case series
[7]
like Matheus et al , have shown that occlusion of this
artery leads to bilateral paramedian thalamic infarct with
or without mesencephalic infarct.

The dysfunction of central nervous system in a 35 years


old female due to bilateral paramedian thalamic infarct,
as a result of occlusion of Artery of Percheron, a rare
anatomical variant of brain vascularisation.
Source of Support: Nil.
Conflicting of Interest: None declared
REFERENCES
1.

2.

3.

4.

5.

6.

7.

Percheron G. Arteries of the human thalamus: II.


Arteries and paramedian thalamic territory of the
communicating basilar artery [in French]. Rev Neurol
(Paris) 1976; 132:309-24.
Rodriguez E, Lee J. Bilateral thalamic infarcts due to
occlusion of the Artery of Percheron and discussion
of differential diagnosis of bilateral thalamic
lesions. Journal of Radiology Case Reports.
2013;7(7):7-14.
Lazzaro N, Wright B, Castillo M, Fischbein N,
Glastonbury C, Hildenbrand P, et al. Artery of
Percheron Infarction: Imaging Patterns and Clinical
Spectrum. Am J Neuroradiol 2010; 31: 1283-1289.
Kim E. Barrett, Susan M. Barman, Scott Boitano,
Heddwen L. Ganongs Review of Medical
th
Physiology, 24 Ed.; Tata McGraw Hill Education
Private Limited, India; Ch. 14, p269-270.
Wade S, Joey D, English S, Claiborne J.
Cerebrovascular Diseases; Harrisons Principles of
th
Internal Medicine, 18 Ed.; McGraw-Hill Companies,
Inc.; p3287.
Jeremy D, Schmahmann M. Vascular Syndromes of
the
Thalamus.
http://stroke.ahajournals.org/
content/34/9/2264.full [accessed on 15/06/2015]
Matheus MG, Castillo M.: Imaging of Acute Bilateral
Paramedian Thalamic and Mesencephalic Infarcts.
American Journal of Neuroradiology 2003;
24(10):20058.

Fig 2: Origin of arteries to thalamus from the


vertebrobasilar system.

Mane Makarand et al.,

933
Int J Med Res Health Sci, 2015;4(4):932-933

Das könnte Ihnen auch gefallen