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VCFL Sciences Journal ISSN: 2231-9522 Vol. 4 Issue 1

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ISSN: 2231-9522

Vol.4, Issue 1

April 2014

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ISSN: 2231-9522

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Contents

STUDY OF CERTAIN BIOCHEMICAL INDICES TO ASSESS LIVER FUNCTIONAL STATUS IN SICKLE CELL DISEASE PATIENTS WITH ANAEMIC CRISES ................................................. 215

A STUDY OF DIGIT RATIO (2D:4D) COMPARISON IN MALE AND FEMALE HUMAN BEINGS. .................................................................................................................................... 224

INDIAN PERSPECTIVE OF INFLAMMATORY GRANULOMA IN A TERTIARY CARE HOSPITAL .................................................................................................................................... 232

BOMB BLAST INJURIES – NEW FACE OF TERROR: RADIOLOGISTS' PERSPECTIVES BASED ON THE EXPERIENCE IN INDIA ............................................................................................. 248

STRANGULATED INTERNAL HERNIA .............................................................................. 266

A RARE CASE PRESENTING WITH ACUTE SMALL BOWEL OBSTRUCTION. ........................ 266

DIAGNOSTIC EFFICACY OF ENDOSCOPY IN EVALUATION OF DYSPHAGIA ....................... 271

STUDY OF SELLAR BRIDGES IN DRY HUMAN SKULLS OF NORTH INTERIOR KARNATAKA . 275

STUDY OF VARIATION IN HIP JOINT ANGLES AND MEASUREMENTS AMONG REGIONAL URBAN POPULATION OF SOUTH INDIA- A CONTRIBUTION TO TRIBOLOGY .................... 286

USEFULNESS OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE EVALUATION OF THE NODULAR GOITER WITH HISTOPATHOLOGICAL CORRELATION ...................................... 298

IMPACT OF STANDARDIZED FEEDING REGIME ON INCIDENCE OF NECROTIZING ENTEROCOLITIS IN LOW BIRTH WEIGHT BABIES ............................................................ 305


215

Study of certain biochemical indices to assess liver functional

status in sickle cell disease patients with anaemic crises

Prashant Nigam1, Purnima Dey Sarkar2

1Dept. of Biochemistry, Chhattisgarh Institute of Medical Sciences, Bilaspur (C.G.),

2Dept. of Biochemistry, MGMC, Indore (M.P.).

Corresponding Author

Prashant Nigam E mail: [email protected]

Abstract

Sickle cell disease is characterized by

presence of HbS in RBC. It is a genetic

disorder in which substitution of glutamate

by valine produces abnormal hemoglobin.

Multi-organ failure is often occurred in SCD

if it is not managed well. Liver is one of the

most important organ affected in sickle cell

disease. Due to multi-factorial causes,

pathophysiology of liver is not easy to

understand. The manifestation of

biochemical parameters related to liver are

very useful to understand to severity of

liver damage as well as its pathophysiology.

Hemolysis, transfusion management,

vasoocclusion, and other defects which are

not associated with sickle cell disease can

cause hepatic complications in Sickle cell

disease. In this study we were investigated

biochemical findings of patients with sickle

cell disease in order to determine the

extent of liver damage.

Key Words

Liver Function, Sickle Cell Disease, Crises,

Steady State.

Introduction

Initially sickle cell was believed to be

familial until it was later found that sickle

cell anaemia was an autosomal recessive

inheritable disease associated with the

sickling of the red blood cell as a result of

oxygen depletion (Davis et al 1997). The

incidence of liver disease in sickle cell

disorders is difficult to ascertain despite

being a component of the multi-organ

failure that occurs in sickle cell disease. The

clinical manifestations of different causes of

liver failure is also similar and inter related

thus making the pathophysiology complex.

The liver function abnormalities may be due

to hemolytic anaemia of sickle cell disease,

complications to the liver due to the part of

mailto:[email protected]


216

treatment in sickle cell disease such as

transfusion management, hepatobiliary

abnormalities due to the consequences of

sickling and vaso occlusion and

abnormalities of the liver not related to the

sickle cell disease mainly viral hepatitis.

Abnormalities of liver function tests have

been reported to be common and relatively

mild in sickle cell patients in steady state.

Hepatomegaly as a common symptom

observed both in disease and trait groups.

The clinical manifestation of sickle cell in

India seems to be milder than in Africa and

Jamaica (Mohanty et al 2002). The clinical

spectrum of SCD ranges from mild to severe

liver function and clinical crises with

marked hyperbilirubinemia and liver failure.

Multiple factors may contribute to the

aetiology of the liver disease, including

ischemia, transfusion related viral hepatitis,

iron overload, and gallstones (Banerjee S. Et

al 2001).

Materials & Methods

This study included 50 patients with an

established diagnosis of SCD. All are

homozygous sickle cell disease patients. All

the patients were in crisis state of the

disease. The diagnosis of disease was

confirmed by Hb electrophoresis in alkaline

pH using fully automatic electrophoresis

instrument, Genio, Italy. A general

examination was done on all the patients

before blood sampling were taken for

biochemical studies.

Statistical Analysis

Data were analyzed by using SPSS version

16.0 software. Association between clinical

data was assessed by cross tabulation and

two tailed T – test was used for laboratory

parameters. Analysis of Variance (ANOVA)

was then used to compare the parameters

of each group. Level of significance for all

tests was set at 95% confidence interval.

Result

In this study we included patients under age

of 16 years. The mean age was 12 year

(Range 4 – 16 year), 62% were male & 38%

were female. All patients were presented

with crisis. The level of SGPT as well as

SGOT was increased. ALP level was also

present beyond its normal reference

interval. The level of GGT also observed

elevated (Table No. 1). There was no

significant correlation found between these

enzymes, age and sex. Total protein and

albumin level was observed within normal

limit or higher side of normal reference

interval. The level of total bilirubin was

higher in all patients without any

correlation with age and sex (Table No. 2).


217

Discussion

Liver abnormality release SGPT and SGOT,

which makes useful test for detecting liver

damage. Hemolysis also raises SGOT and

SGPT levels in SCD. Nsiah K et al (2011)

reported higher activity of SGOT and SGPT

in sickle hepatopathy with various crises

associated with sickle cell disease. In the

present study levels of SGPT and SGOT were

found higher in haemolytic crisis when

compared to other two groups (I & II

p<0.001). Level of ALP also found highly

significant in group – III when compared to

other groups (p<0.001). Oparinde DP et al

(2006) conducted biochemical assessment

regarding severity of sickle cell anemia with

reference to role of hepatic enzyme and

found that a significant increase in serum

ALT, ALP and GGT levels in SCA with

persistent hepatomegaly over those

without hepatomegaly (p < 0.05, p < 0.05

and p < 0.01 respectively). All the index

scores and the final aggregate severity

scores were also significantly higher in SCA

subjects with persistent hepatomegaly.

Only GGT demonstrated a fairly positive

and significant correlation (r = 0.46, P <

0.05) with increased clinical severity among

the hepatic enzymes. Yahaya et al (2012)

conducted a study in which activities of

alkaline phosphatase, alanine

aminotransferase and aspartate

aminotransferase were significantly higher

(P<0.05) in the HbSS patients than the

control subjects. This study made a

conclusion that level of total protein and

albumin is not very much altered in sickle

cell crises. Our study was also in agreement

with above study although we were found

statistically significant difference between

group I and Group III as the level of total

protein and albumin fall higher side of the

normal reference interval. However in

present study group III shows highly

significant mean difference when compared

to group I, it may be due to the

inflammatory response against viral

infection, induced over production of

antibody. Statistically insignificant

difference of albumin in above group

supports this study. Same findings were

also reported by U. P. ISICHEF (1979). The

protein patterns seen in his study are

interesting in many respects. A comparison

of the serum protein values shows definite

evidence of relative hyperproteinaemia as

well as hyperglobulinaemia in sickle cell

disease. Whereas the albumin levels were

almost the same in all groups, the globulin

values in sicklers were significantly greater

than in normal children of the same age,

showing that the globulin fraction is largely

accountable for the high total protein.


218

Marked hyperbilirubinemia of up to 57

mg/dL, in most cases predominantly

conjugated with only a mild elevation in ALT

levels, has been described by Buchanan et

al. (1977) in 6 children with minimal or no

symptoms. In the present study we found

highly significant Bilirubin mean differences

among all the groups (p<0.001). Similar

pattern was also observed by Ebert EC et al

(2010), reported the most common

laboratory abnormality is an elevation of

unconjugated bilirubin level. Bilirubin and

lactate dehydrogenase levels correlate with

one another, suggesting that chronic

hemolysis and ineffective erythropoiesis,

rather than liver disease, are the sources of

hyperbilirubinemia. Highly significant

bilirubin level may be due to combination of

ongoing hemolysis, intra hepatic cholestasis

and renal impairment encountered in sickle

cell hepatopathy in comparison with

remaining disease groups. Abdominal pain

is very common in SCD and is usually due to

sickling, even in the steady state Bilirubin is

significantly high with the asymptomatic

jaundice. In the present study the total

serum bilirubin concentration was also

significantly increased in haemolytic crisis

(mean 18.95, p<0.001) above the steady

state level. Bilirubin concentration in

haemolytic crisis was much more higher

when compared to other groups(Group I &

II), is due to access hemolysis of RBC in the

crisis which is not present up to that extent

steady state SCD. Ojuwa et al (1994) studied

thirty children with SCA and assayed serum

alanine aminotransferase, alkaline

phosphatase, total protein, albumin and

bilirubin, during vaso-occlusive crisis and at

recovery. Alanine aminotransferase,

alkaline phosphatase and bilirubin levels

were significantly higher during crisis than

at recovery, (p < 0.005) especially in the

young patient. However, the total protein

and albumin levels were not significantly

different in crisis and at recovery. A

transient hepatic functional derangement

during vaso-occlusive crisis is a probable

explanation for the reported changes.

Bone changes are common in SCD but the

pathogenesis is not fully understood

(Nouraie M et al 2011). The level of alkaline

phosphatase indicates severity of bone

damage and is a useful guide of progress in

the management of bone pains in sickle

cell(Afonja OA et a 1986). Bone disease with

osteoporosis and osteomalacia are common

in SCD. Some patients have vitamin D

deficiency and low bone mineral density.

Delayed growth and bone destruction may

contribute to the elevated levels of alkaline

phosphatase. Higher levels of alkaline

phosphatase may be due to associated

vasoocclussive crises involving the bones


219

rather than pathology of the liver (Kotila T

et al 2005, Mohammed SM et al 1991). The

level of the heat-labile alkaline phosphatase

indicates severity of bone damage and is a

useful guide of progress in the management

of bone pains in sickle cell. In the present

study we found highly significant level of

alkaline phosphatase in group II & III when

compare with normal (p <0.001), which is

similar to a study conducted by Isichei UP

(1980). Brody JI et al (1975) studied

behaviour of ALP in sickle cell anemia

patients and found Physical and

biochemical criteria identified bone alkaline

phosphatase as the principal, although not

necessarily the sole, enzyme fraction that

increases during

symptomatic sickle cell crises. Moreover,

there appeared to be concordance between

crisis severity, serum levels of alkaline

phosphatase, and isoenzyme patterns;

electrophoretic and biochemical

abnormalities could be detected even when

the patients were asymptomatic. GGT is

another useful enzyme to assess hepatic

function in SCD. In our study we found

statistically highly significant raised level of

GGT among all the group when compared

to normal (p <0.001). Similar findings were

obtained by Oparinde DP et al (2006)

concluded, Only GGT demonstrated a fairly

positive and significant correlation (r = 0.46,

P < 0.05) with increased clinical severity

among the hepatic enzymes. It shows,

serum alkaline phosphatase level may be an

additional marker of the degree, frequency,

and persistence of tissue injuries that occur

in sickle cell anemia.

Conclusion

The present data suggest that abnormalities

in liver functions have been assumed to be

common and mild in steady state and to

become more severe in crisis. Liver function

tests are normal in majority of the sickle cell

disease patients, who progressed to

hepatobiliary complications they shown

significant elevated levels of hepatobiliary

enzymes.


220

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11. Nouraie M, Cheng K, Niu X, Moore-King

E, Fadojutimi-Akinsi MF, Minniti CP, et al

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doi:10.3324/haematol.2011.042499.

12. Nsiah K, Dzogbefia VP, Ansong D, Osei

Akoto A, Boateng H, Ocloo D (2011).

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13. Ojuawo A, Adedoyin MA, Fagbule D

(1994). Hepatic function tests in

children with sickle cell during vaso

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14. Oparinde DP, Oghagbon EK, Okesina

AB, Olatunji PO, Ojuawo AO (2006). Role

of hepatic enzymes in the biochemical

assessment of the severity

of sickle cell anemia. Trop

Gastroenterol. Jul-Sep;27(3):118-21.

15. U. P. Isichef (1979). Serum protein

profile in sickle cell disease. Journal of

Clinical Pathology, 32, 117-121

16. Yahaya IA (2012). Biochemical features

of hepatic dysfunction in Nigerians

with sickle cell . Niger Postgrad Med J.

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Tables

Table No.1 Various enzymes level in study groups (Mean ± SD)

S. No. Parameter Control

(Group - I)

Steady State

(Group - II)

Hemolytic Crises

(Group - III)

1. SGPT (IU/L) 21.66 ± 5.31 39.23± 5.87 151.78 ± 30.36

2. SGOT (IU/L) 22.98 ± 4.94 32.98 ± 4.15 65.76 ± 4.8

3. ALP (IU/L) 76.06 ± 16.36 112.36 ± 90.09 365.72 ± 8.3

4. GGT (IU/L) 22.92 ± 6.67 39.49 ± 12.33 168.00 ± 4.39

Table No. 2 Various Biochemical Parameters’ level in study groups (Mean ± SD)

S. No. Parameter Control

(Group - I)

Steady State

(Group - II)

Hemolytic Crises

(Group - III)

1. Total Protein (g/dl)

7.26 ± 0.33 7.46 ± 0.42 8.43 ± 0.39

2. Albumin (g/dl) 4.10 ± 0.28 3.89 ± 0.40 3.30 ± 0.35

3. Bilirubin(T) (mg/dl) 1.09 ± 0.15 1.76 ± 0.30 18.95 ± 3.69

4. Bilirubin(D) (mg/dl) 0.56 ± 0.13 0.63 ± 0.16 8.81 ± 1.89

5. Bilirubin (I) (mg/dl) 0.52 ± 0.18 1.13 ± 0.27 10.14 ± 2.54


224

A Study of Digit Ratio (2d:4d) Comparison in Male and Female

Human Beings.

Ravi P Bangalore1, Vinod A2, Prashanth S3, Praveenkumar I. Inamadar4

1Assistant Professor, Department of Psychiatry, SSIMS&RC, Davangere, Karnataka.

2Senior Resident, Department of Psychiatry, S Nijalingappa Medical College, HSK (Hanagal

Shree Kumareshwar) Hospital and Research Centre Bagalkot. Karnataka

3Associate Professor, Department of Neurology, SSIMS&RC, Davangere, Karnataka

4Professor and Head - Dept. of Forensic Medicine & Toxicology, HIMS & RC, Hassan,

Karnataka


Dr Ravi P Bangalore

Email: [email protected]

Abstract

The digit ratio is the ratio of the lengths of

different digits, fingers or toes, typically as

measured from the bottom crease where

the finger joins the hand to the tip of the

finger. It has been suggested that the ratio

of two digits in particular, the 2nd (index

finger) and 4th (ring finger) is affected by

exposure to androgens such as testosterone

while in the uterus. This study was

conducted with objective of comparing the

digit ratio (2D:4D) in males & female human

beings. The subjects included 30 males and

30 females who met the inclusion and

exclusion criteria and were assessed with

measurement of digit ratio in both the

hands by transperancy method. The results

were analysed by applying chi square test

for categorical variables and independent T

test for continuous variables. We found that

men have longer ring finger (4D) than index

finger (2D), where as in females both are of

nearly equal length. The digit ratio was

higher in females compared to males in

both the hands but the difference was not

statistically significant.

Keywords

Digit ratio; 2D:4D.

Introduction

The digit ratio is the ratio of the lengths of

different digits, fingers or toes, typically as



225

measured from the bottom crease where

the finger joins the hand to the tip of the

finger. It has been suggested by some

scientists that the ratio of two digits in

particular, the 2nd (index finger) and 4th

(ring finger) is affected by exposure to

androgens such as testosterone while in the

uterus and that this 2D:4D ratio can be used

as a crude measure for prenatal gonadal

exposure.

2D:4D is sexually dimorphic: in men, the

second digit tends to be shorter than the

fourth, and in females the second tends to

be the same size or slightly longer than the

fourth.1 Several studies have shown that

the length of the second digit in adults is

directly proportional to the average plasma

estrogen concentration in the individual. In

the same fashion, the length of the fourth

finger is directly proportional to the average

plasma concentration of androgens.2, 3, 4

The fact that the proportion between the

length of the above two digits (second:

fourth) is already fixed around the

thirteenth week of intrauterine life5 has led

to the conclusion that the length of the two

digits is also representative of the foetal

concentrations of oestrogens and

androgens. Their measurements therefore

represent a “smoking gun” of what were

the concentrations of an individual’s sexual

hormones in utero.2, 3, and 4

Smaller ratio reflects higher foetal

testosterone and lower estrogen,6 the

relationship between the gonad

differentiation and formation of fingers and

toes led to suggestion that patterns of digit

and toe morphology may correlate with

gonad function in the fetus and adult.3

According to hypothesis of manning and

Bundred (2000), the2D: 4D may be used as

an indicator and predictive factor in a

variety of disorders associated with a

disturbed testosterone/estrogen hormone

balance like gender identity disorder7,4

dyslexia, migraine, stammering, immune

dysfunction. There are some studies which

have thrown light on testosterone/estrogen

hormonal imbalance in schizophrenia.

According to Mihaly arato et al, 2004 low

fetal androgen/estrogen ratio may have a

predisposing role in development of

schizophrenia.8 More feminized digit ratio

have been demonstrated in schizophrenia

compared to same sex controls.9

Materials and Methods

The study was based on the hypothesis that

digit ratio is sexually dimorphic trait with

females having higher digit ratio than the

males.


226

Aim of the study

To compare the second to fourth digit

length ratio between male and female

participants

Methodology:

The study group comprised male (n= 30)

and female (n=30) who were selected from

NIMHANS staff, their families and the

neighbourhood of local guardian of the

main investigator provided -

1. They did not have any medical and

surgical conditions that would lead to

errors in measuring 2D:4D ratio like

syndactaly, polydactaly, trauma,

amputation, contracture etc.

2. They were ready to give informed

consent.

After obtaining informed consent, subjects

who met the above said criteria were

assessed. Digit ratio (second finger to fourth

finger lengths) measurement was taken

using a vernier calliper by transparency

method, in which the hand in straight

continuation position of forearms was

placed over the table with dorsum of hand

facing table. A transparent sheet was placed

over the palm. The proximal crease and tip

of the second and fourth finger was

marked. Digit lengths (2Dand 4D) was

obtained by measuring the distance

between proximal crease and tip of the

finger using simple scale by three different

raters blind to the gender of subject. The 2D

and 4D lengths were measured for both

hands. This 2D: 4D ratio was compared

between males and female participants.

Statistical analysis was done using the

Statistical package for social sciences (SPSS)

version-13. Continuous variables were

assessed using the t-test and categorical

variables were assessed using the chi-

square test

Results

In this study 60 participants (males=30,

females=30) were participated. There was

statistically significant difference between

two groups in terms of marital status,

education, occupation, socio economic

status and place. These were of lesser

significance as the digit ratio not affected by

these parameters.

Comparison of digit lengths showed that

length of 2D and 4D was more in males

than females and the difference was

statistically significant(p=0.00). The

comparison of digit ratio (2D:4D) showed

that the ratio is higher in females than

males but the difference was not

statistically significant (p=0.415 for right

side and p=0.500 for left side).


227

Discussion

Our study replicated the finding that men

have longer ring finger (4D) than index

finger (2D), where as in females both are of

nearly equal length which is consistent with

findings from the previous studies.3

In our study the digit ratio was higher in

females than males in both the hands but

the difference was not statistically

significant. The earlier studies have found

that the digit ratio was higher in females

than males3, 8, and 9 which was partly

supported by this study. This could be

because of the racial differences in digit

ratio which need to be explored.

Sexual differences in 2D:4D are mainly

caused by the shift along the

common allometric line with non-zero

intercept, which means 2D:4D necessarily

decreases with increasing finger length, and

the fact that men have longer fingers than

women, 10 which may be the basis for the

sex difference in digit ratios and/or any

putative hormonal influence on the ratios.

The 2D:4D ratio in mice is controlled by the

balance of androgen to estrogen signaling

during a narrow window of digit

development.11 The formation of the digits

in humans, in utero, is thought to occur by

13 weeks, and the bone-to-bone ratio is

consistent from this point into an

individual’s adulthood.5 During this period if

the fetus is exposed to androgens, the exact

level of which is thought to be sexually

dimorphic, the growth rate of the 4th digit

is increased, as can be seen by analyzing the

2D:4D ratio of opposite sex dizygotic twins,

where the female twin is exposed to excess

androgens from her brother in utero, and

thus has a significantly lower 2D:4D ratio.12

Hox genes responsible for digit

development13 have been implicated in

affecting these multiple traits such as

otoacoustic emissions and arm-to-trunk

length ratio (pleiotropy). Direct effects of

sex hormones on bone growth might be

responsible, either by regulation of Hox

genes in digit development or

independently of such genes. Further

studies with large number of subjects are

required to throw some more lights in this

aspect.

The strengths of study being the method

used for the measurement of digits was

direct (transparency method) than the

photocopies of the hands, measurement

was done using vernier callipers which is

more sensitive than ruler and

measurements were done by 3 raters blind

to the gender of participants which

increases the inter rater reliability.

Limitation of the study may be lesser

number of subjects.

http://en.wikipedia.org/wiki/Hox_genes

http://en.wikipedia.org/wiki/Otoacoustic_emissions


228

References

1. George R. Human finger types.

Anatomical Record. 1930; 46:199–

204.

2. Manning JT, Bundred PE. The ratio

of 2nd to 4th digit length: a new

predictor of disease predisposition?.

Med Hypotheses. 2000; 54:855-7.

3. Manning JT, Scutt D, Wilson J. The

ratio of 2nd to 4th digit length: a

predictor of sperm numbers and

concentrations of testosterone,

luteinizing hormone and oestrogen.

Hum Reprod. 1998; 13:3000-4.

4. Williams T, Pepitone ME,

Christiansen SE, Cooke BM,

Huberman AD, Breedlove TJ, Jordan

CL, Breedlove SM. Finger-length

ratios and sexual orientation.

Nature. 2000; 404:455–6.

5. Garn S, Burdi AR, Babler WJ, Stinson

S. Early prenatal attainment of adult

metacarpal-phalangeal rankings and

proportions. Am J Phys Anthropol.

1975; 43:327–332.

6. Manning JT, Barley L, Walton J et al.

The 2nd:4th digit ratio, sexual

dimorphism, population differences,

and reproductive success. Evidence

for sexually antagonistic genes

Evolution and Human

Behavior. 21(3); 2000163–183.

7. Green ED, Yan WL, Guan XY.

Childhood-onset

schizophrenia/autistic disorder and t

(1; 7) reciprocal translocation:

identification of a BAC contig

spanning the translocation

breakpoint at 7q21. Am J Med

Genet. 2000;96:749-53

8. Arato M, Frecska E, Beck C, An M,

Kiss H. Digit length pattern in

schizophrenia suggests disturbed

prenatal hemispheric lareralization.

Prog Neuropsychopharmacol Biol

Psychiatry. 2004; 28(1):191-4.

9. Walder DJ, Seidman LJ, Cullen N,

SuJ, Tsuang MT, Goldstein JM. Sex

differences in language dysfunction

in schizophrenia. Am J Psychiatry.

2006; 163(3):470-7.

10. Kratochvíl L, Flegr J. Differences in

the 2nd to 4th digit length ratio in

humans reflect shifts along the

common allometric line. Biology

Letters. 2009; 5(5): 643–6.

11. Zhengui Z., Cohn MJ. Developmental

basis of sexually dimorphic digit

ratios. Proceedings of the National

Academy of Sciences of the United

States of America. 2011;

108(39):16289–16294.

12. Van Anders SM, Vernon PA, Wilbur

CJ. Finger-length ratios show


229

evidence of prenatal hormone-

transfer between opposite-sex

twins. Hormones and Behavior.

2006; 49(3): 315–9.

13. Dickman S. HOX gene links limb,

genital defects. Science. 1997;

275 (5306):1568–9.


230

Tables showing comparison of absolute digit lengths and digit ratio (2D:4D) in

participants.

Participants

Right 2D

Males Females P value

Rater 1 73.62 66.19

Rater 2 73.66 66.25

Rater 3 73.78 66.20

Mean right 2D 73.6878 66.2111 0.000

Participants

Right 4D


Rater 1 75.86 67.62

Rater 2 75.95 67.57

Rater 3 75.96 67.69

Mean right 4D 75.9233 67.6256 0.000

Participants

Left 2D


Rater 1 72.91 65.45

Rater 2 73.07 65.40

Rater 3 73.06 65.41

Mean Left 2D 73.0133 65.4189 0.000


231

Participants

Left 4D


Rater 1 76.18 67.67

Rater 2 75.99 67.52

Rater 3 76.14 67.73

Mean Left 4D 76.1033 67.6389 0.000

Participants

Male female P value

Rt 2D:4D 0.9715 0.9803 0.415

Lt 2D:4D 0.9606 0.9687 0.500


232

Indian perspective of inflammatory granuloma in a Tertiary Care

Hospital

Dr. Rajkumar S Y1, Dr. Pavitra2, Dr. Dipu Bhuyan3, Dr. Gautam Goswami4

1Assistant professor, Department of Radiology, S.S.I.M.S & R.C., Davangere, Karnataka,

India; 2Postgraduate resident, Department of Pharmacology, JJM medical college,

Davangere, Karnataka, India; 3Associate professor, Department of Radiology, Gauhati

Medical College and Hospital, Guwahati-32, Assam, India; 4Professor and Head, Department

of Radiology, Gauhati Medical College and Hospital, Guwahati-32, Assam, India.


Dr. Rajkumar S. Y.


Abstract

Central nervous infections presenting as

episode of seizure is frequently

encountered in clinical scenario.

Neurocysticerosis and Tuberculoma

constitutes majority of inflammatory

granuloma is a public-health problem,

especially in developing countries including

India. Systematic population-based studies

are lacking in most parts of the country;

hence it is difficult to estimate the disease

burden in India. It becomes difficult in some

cases where infective conditions with

similar clinical and radiological conditions

with low sensitivity and specificity in

serological and immunological screening.

With recent advances in computed

tomography (CT) and magnetic resonance

imaging (MRI) technology, our study was

aimed to study incidence, various stages of

neurocysticercosis, location, enhancement

pattern, to differentiate neurocysticercosis (

NCC) and tuberculomas based on imaging

findings and in difficult cases magnetic

resonance spectroscopy and clinical

response to medical therapy with interval

follow up helped us to come to conclusion.

This study helps in the early medical

intervention, decrease morbidity and

improves quality of life in the endemic and

high prevalence disease population in

developing countries especially in India.

Key Words

Central nervous infections (CNS),

Neurocysticerosis (NCC), Computed

tomography (CT), Magnetic resonance

Imaging (MRI), Magnetic resonance

spectroscopy (MRS), Fluid attenuated



233

inversion recovery sequence (FLAIR),

Diffusion weighted images (DWI).

Introduction

Epilepsy is a largely unrecognized but

increasing burden on the welfare and

economies of developing countries like

India. Poor hygiene, living conditions,

immune status, poor nutrition are some of

risk factors. Neurocysticerosis and

tuberculomas are the major cause of

inflammatory granuloma frequently

presenting as partial or generalized tonic

clonic seizures. Neurocysticercosis is caused

by the encysted larval stage, 'cysticercus

cellulosae' of the pork tapeworm Taenia

solium. The parenchymal cysts may remain

dormant for many years, and symptoms

(e.g. seizures) usually coincide with larval

death and subsequent intense

inflammatory reaction induced by larval

antigens. Subsequently, the cyst then

shrinks and granuloma eventually calcify or

more frequently disappear completely1.

Imaging and clinical features of

tuberculoma are exceedingly similar to that

of neurocysticercosis and it is difficult to

differentiate between these two conditions

1. This distinction is an important issue

because cysticercus granuloma is a benign,

self-limiting condition which is preventable

and potentially eradicable, whereas

tuberculoma is an active infection that

requires prolonged therapy with potentially

toxic drugs 2. Due to the scarcity of relevant

literature about the incidence, various

stages and differentiating features on CT

and MRI, wherein the case load is

enormous which inspired us to take up this

prospective study in northeastern part of

India.


This prospective study was carried out in

the department of Radiology, Gauhati

Medical College and Hospital, Guwahati

from July 2007 to November 2009.

Inclusion criteria:

Our study was carried out in 90 consecutive

patients presenting with seizure and

clinically high suspicion of CNS infection,

particularly common types of inflammatory

granulomas- neurocysticercosis and

tuberculoma from neurology referral and

out patients. Out of which 80 cases were

studied, 10 cases were excluded due to

exclusion criteria.

Exclusion Criteria:

Hypoxic ischemic encephalopathy, trauma,

congenital CNS abnormalities, metabolic

disorders, stroke, drug abuse and brain

tumors.


234

Data Analysis: Were done using rate,

ratios and statistical percentage of different

diagnoses and outcome is computed.

CT evaluation was carried out using a

SIEMENS SPIRIT DUAL SLICE SPIRAL

SCANNER. Axial 4 mm slices, plain followed

by contrast with intravenous 50-60 ml of

non-ionic contrast media.

MRI evaluation was carried out using

SIEMENS TIM AVANTO 1.5T SCANNER.

Multiplanar T1W, T2W, Fluid attenuated

inversion recovery (FLAIR), Diffusion

weighted (DWI), Apparent diffusion

coefficient (ADC) and Post Gadolinium T1W,

SWI and Magnetic resonance spectroscopy

(MRS) in selected cases.

Results and Discussion:

Out of 80 patients, 55 cases on CT and 25

cases on MRI was studied. 16 cases (29 %)

were 21-30 age group followed by 13 cases

(24%) in 11-20 age groups on CT. 12 cases

(48 %) were 21-30 age group and 6 (24 %) in

41-50 age groups on MRI. Single enhancing

CT lesions, seen in India, are common in

children and younger patients. Chopra et al

3 observed that 78 % of 122 patients of their

series were between 11 and 20 years of

age. Sethi et al 4 noted that approximately

46 % of 186 patients were below 15 years

of age and only one patient was over 60

years of age. Male were three times more

common than female (75: 25).

Neurocysticerosis (NCC) comprises of 69 %

on CT and 72 % on MRI and Tuberculomas

comprises of 31 % on CT and 28 % on MRI.

Our study showed 66 % and 60 % solitary

NCC on CT and MRI respectively of total

cases. Vedantam Rajashekhar et al5 stated

that solitary cerebral cysticercus granuloma

(SCCG) is one of the commonest causes of

seizures in Indian patients.

Rajshekhar et al, in a prospective study of

210 patients, observed that single

enhancing lesions completely resolved at

different time intervals. At 3 months 19%

had completely resolved; at 1 year

approximately 63% had disappeared.

Our study showed 40 % granular nodular

stage, followed by 31 % calcified nodular

and 8 % disseminated neurocysticercosis on

CT images and 39 % colloidal vesicular, 33

% granular nodular and 6 % disseminated

stages of neurocysticercosis on MRI images.

The presence of cystic lesions

demonstrating the scolex can be considered

pathognomonic from a diagnostic

standpoint in a NCC. The scolex is visualized

as a bright nodule within the cyst,

producing the so-called "hole-with-dot"

imaging that is seen in some vesicular cysts


235

located in the brain parenchyma, the

subarachnoid space, or the ventricular

system 6. Our study showed 26 cases on CT

(84%) and 5 cases (16 %) on MRI. The scolex

was frequently observed in vesicular stage

of neurocysticercosis with high percentage

detected on CT. On MRI FLAIR and proton

density (PD) sequences were useful in

detecting the scolex.

According to D Kishore et al7 in a study of

100 patients with NCC, majority of the cases

had a ring like enhancement 88 out of 100

(88%) patients. Only 12% had disc- like

enhancement. An eccentric dot inside the

ring representing the cysticercus larva was

seen in only 19 out of 88 (21.6%) patients.

In our study 76 % cases had ring enhancing

lesion, 24 % had nodular enhancement and

39 % had scolex.

According to D Kishore et al7, the most

favored site was the parietal lobe (52%)

followed by fronto-parietal (19%), later

either at parieto-occipital region or

temporo-parietal region. These regions

form the watershed areas of cerebral

circulation and hematogenous spread of

infective agents are more likely to lodge in

these regions, because of the end arteries 7.

In this study, the maximum number of

lesions was seen in the parietal lobe (40%)

followed by the frontal lobe. Moreover

85% of the granulomas were at the grey

matter or the grey-white matter junction.

Diagnosis of NCC was greatly improved by

the introduction of CT and MR imaging.

These imaging techniques depict the

location and number of lesions and their

stages and the degree of inflammatory

response to the parasite (perilesional

edema and blood-brain barrier breakdown).

In a study by HR Martinez et al 8, inactive

forms were observed better with CT (23%

vs 14%). Our study showed, the inactive

form, i.e. calcified nodular stage was seen

better on CT than MRI (31 % vs 6 %).

MRI is considered the best neuro-imaging

tool for the detection of degenerating and

innocuous (viable) cysticerci, while CT is the

best for calcified lesions 11. The added

advantage of MRI is that it can differentiate

the stages of the parasite, which CT fails to

do. Moreover, MRI with gradient echo

sequence phase imaging has been reported

as good as CT for the detection of the scolex

in cystic lesions and also the calcified stage

of the parasite10. Although MRI allows

better detection of the active parasites but

some calcified parasites may be missed,

especially in absence of gradient echo

sequence.

The incidence of tuberculoma varies from

3.3% to 40.5% in different studies by Dastur


236

and Desai et al 9. Our study showed the

incidence of tuberculomas was 31% on CT

and 28 % on MRI. 57 % cases with liquefied

center and 14 % with nodular

enhancement. Few of the cases are

associated with meningitis and tubercular

abscess.

The distinction between cysticercal

granuloma & tuberculoma is controversial,

often associated with single enhancing CT-

documented lesions. This is because the

clinical and imaging features are quite

similar; both diseases are common in

endemic areas and may coexist in the same

patient. Rajshekhar et al, have attempted to

differentiate between the two entities on

the basis of clinical and imaging features.

Based on these findings and their

experience, Rajshekhar V, Prakash and

Chandy 5, suggested that cysticerci are

usually round in shape, 20mm or smaller in

size, with ring enhancement or a visible

scolex; cerebral edema severe enough to

produce midline shift or focal neurological

deficit is not seen. Tuberculomas by

contrast are usually irregularly shaped, solid

and greater than 20mm in size. They are

often associated with severe perifocal

edema and focal neurological deficit.

Various metabolites were studied using

magnetic resonance spectroscopy (MRS) in

neurocysticercosis and tuberculoma. On

MR spectroscopy, neurocysticercosis (NCC)

shows Lactate 1.33, Alanine 1.47, Acetate

1.92, Succinate 2.4 ppm(parts per million) 10

and tuberculoma shows high lipid lactate

peaks, doublet lactate peak at 0.9 and 1.3

ppm10.

Whenever, in a difficult case on

conventional magnetic resonance imaging,

we sort the help of MR spectroscopy

findings and follow up cases with good

clinical response after medical treatment of

albendazole or antitubercular therapy.

Conclusion

In this part of India, NCC and tuberculomas

are alarming high in communities with low

socioecomic status, lack of basic education,

decreased environmental awareness and

high HIV prevalence. Since cysticercosis is a

preventable and eradicable disease,

appropriate measures like health education,

mass awareness, better medical facilities,

mass treatment of T. solium carriers, and

restriction on sale of measly pork may help

to reduce the disease burden in the

endemic areas. Tuberculoma is an active

infection that requires prolonged therapy

with potentially toxic drugs in a high HIV

prevalence population. With recent

advances in CT and MRI technology, NCC

and tuberculoma are better localized,

characterized and differentiated.


237

Background knowledge helps in the early

medical intervention, decrease morbidity

and improves quality of life in the endemic

and high prevalence disease population in

developing countries especially in India.

Acknowledgement

To my parents for constant support and

care.

To technical staff and patients.

Fund Support: None

Conflict of Interest: None


238

REFERENCES:

1. Shah GV. Central nervous system

tuberculosis. Neuroimaging Clin North

Am 2000; 10:355-74.

2. Garg RK. Diagnostic criteria for

neurocysticercosis: Some modifications

are needed for Indian patients. Neurol

India 2004; 52:171-7.

3. Chopra JS, Sawhney IMS, Suresh N, et al.

Vanishing CT lesions in epilepsy. J

Neurol Sci 1992; 107:40-9.

4. Sethi PP, Wadia RS, Kiyawat DP et al.

Ring or disc enhancing lesions in

epilepsy in India. J Trop Med Hyg 1994;

97:347-53.

5. Rajshekhar V, Haran RP, Prakash GS et

al. Differentiating solitary small

cysticercus granuloma and tuberculoma

in patients with epilepsy. Clinical and

computerized tomographic criteria. J

Neurosurg 1993; 78:402-7.

6. RA Suss, KR Maravilla and J Thompson

MR imaging of intracranial cysticercosis:

comparison with CT and

anatomopathologic features. , American

Journal of Neuroradiology, Vol 7, Issue 2

235-242.

7. Short course of Oral Prednisolone on

disappearance of lesion and seizure

recurrence in patients of Solitary

Cysticercal Granuloma with Single small

enhancing CT lesion: An Open Label

Randomized Prospective Study, D

Kishore, S Misra; JAPI • VOL. 55 • JUNE

2007.

8. HR Martinez, R Rangel-Guerra, G

Elizondo, J Gonzalez, LE Todd, J Ancer

and SS Prakash MR imaging in

neurocysticercosis: a study of 56 cases.

(American Journal of Neuroradiology,

Vol 10, Issue 5 1011-1019).

9. Dastur H.M., and Desai A.D:1965; Brain,

88: 375-396.

10. Rakesh K. Gupta and Robert B. Lufkin et.

al, MR Imaging and Spectroscopy of

Central Nervous System Infection, book:

Kluwer Academic Publishers, 2001.

11. García HH, Del Brutto OH, Imaging

findings in neurocysticercosis. Acta

Trop. 2003 Jun; 87(1):71-8.


239

Tables

Table 1: Age distribution of inflammatory granulomas CT and MRI cases in various age groups.

AGE (years) No of CT cases No of MR cases % of CT cases % of MR cases

1- 10 07 02 13 08

11- 20 13 01 24 04

21- 30 16 12 29 48

31- 40 10 04 18 16

41- 50 05 06 09 24

>50 04 - 07 -

Table 2: Sex wise distribution of total cases.

SEX No of cases ( CT + MRI cases) Percentage (%)

CT MRI TOTAL

MALE 42 18 60 75

FEMALE 13 07 20 25

Table 3: Distribution of Inflammatory granuloma on CT images.

INFLAMMATORY GRANULOMA

No of cases ( CT) Percentage (%)

Neurocysticerosis ( NCC) 38 69

Tuberculomas 17 31

Table 4: Distribution of various stages of Neurocysticercosis on CT images

STAGES No of cases ( CT) Percentage (%)

Vesicular 03 08

Colloid vesicular 05 13

Granular Nodular 15 40

Calcified Nodular 12 31

All stages 03 08


240

Table 5: Distribution pattern of inflammatory granuloma on MRI images.

INFLAMMATORY GRANULOMA No of cases ( MRI) Percentages (%)

Neurocysticerosis ( NCC) 18 72

Tuberculomas 07 28

Table 6: Distribution pattern of various stages of Neurocysticercosis (NCC) on MRI images.

STAGES No of cases ( MRI) Percentages (%)

Vesicular 03 17

Colloid vesicular 07 39

Granular Nodular 06 33

Calcified Nodular 01 5.5

All stages 01 5.5

Table 7: Identification of scolex in Neurocysticercosis (NCC).

Imaging modalities No of cases Percentages (%)

CT 26 84

MRI 5 16

Table 8: Distribution pattern of enhancement in Neurocysticercosis (NCC).

Pattern of Enhancement No of cases Percentages ( %)

CT MRI Total

Ring enhancement ( RE) 25 13 38 76

Nodular enhancement ( NE) 11 01 12 24

Table 9: Distribution of Caseous and Noncaseous Tuberculomas and associated Meningitis and abscess in Total MRI cases.

Tuberculomas T2WI No of cases Meningitis Tubercular Abscess

Central liquefaction Hyperintense 4 3 2

Nodular Hypointense 1 1 -


241

Photos

Figure 1: Contrast enhanced CT brain reveals Colloid vesicular stage of Neurocysticercosis

Figure 2:Contrast enhanced CT brain reveals granular nodular stage of Neurocysticercosis.


242

Figure 3:Plain CT brain reveals calcified nodular stage of Neurocysticercosis.

Figure 4: Contrast enhanced CT brain reveals disseminated NCC


243

CECT T2W T1W

FLAIR MR Post Gd MR Post Gd

Figure 5: CT & MRI images of a NCC case with enhancing granular nodular and non-

enhancing cystic vesicular stages.

Figure 6: Plain and Contrast CT brain shows nodular and ring enhancing

Tuberculomas


244

Figure 7: Contrast enhanced CT brain shows Ring enhancing tuberculoma – Target sign.

Figure 8:Axial T2 weighted image shows multiple tuberculomas with hypointense center.

Post IV gadolinium axial T1 weighted images shows multiple ring enhancing

tuberculomas


245

Figure 9:Plain and Contrast CT brain shows tubercular basal meningitis with mild communicating

hydrocephalus.

Figure 10:Postgadolinium enhanced axial T1 weighted image show nodular tubercular basal

leptomeningeal enhancement


246

Figure 11:40 year old gentleman with seizure- Neurocysticercosis. Axial FLAIR image shows well defined

round ring lesion in right parietal region (Right). Post-gadolinium sagittal T1 weighted image show ring

enhancement (Left). MR spectroscopy shows lactate 1.33, Alanine 1.47, Acetate 1.92, Succinate 2.4 ppm

(Bottom).


247

Figure 12:24 year old lady with seizure – Tuberculoma. Axial T2 weighted image shows solitary lesion

with central liquefaction in left capsuloganglionic region (Right). MR spectroscopy shows doublet lactate

peak at 0.9 and 1.4 ppm. No evidence of elevated choline and NAA peak (Left).


248

Bomb blast injuries – New face of terror: radiologists' perspectives

based on the experience in India Rajkumar S Yalawar1, Pavitra2, Ramesh Desai3, Dipu Bhuyan4

1Department of Radiology, S.S.I.M.S & R.C., Davangere, Karnataka, India.

2Department of Pharmacology, JJM medical college, Davangere, Karnataka, India.

3Department of Radiology, Gauhati Medical College and Hospital, Guwahati-32, Assam,

India.


Dr. Rajkumar S Yalawar

Email: [email protected].

Abstract

Objectives: To understand the nature and

patterns of bomb blast injuries, to

familiarize with the imaging the radiologist

might expect to see in a mass casualty

terrorist, the role of radiology in the

management and planning for a mass

casualty terrorist incident.

Materials and Methods: A prospective

study of 126 bomb blast victims, 100

patients were included due to imaging and

26 patients were excluded due to critical

conditions and brought dead. Study

conducted in the department of Radiology,

Gauhati Medical College and Hospital at

Guwahati from July 2007 to January 2010.

Results: Males were more common to

female (70 / 30), 53% in young productive

15-29 years, followed by 21 % in 30-44

years. Multiple complex injuries of head

and neck, chest and abdomen, skeletal and

vascular injuries are noted. 23 % patients

shifted to ICU care for ventilation and

priority nursing care, 62 % victims

underwent surgical procedures and 19 were

reported dead.

Conclusion: Imaging should be fast, in order

to help identify major injuries that need

immediate management and to help in the

triage of injured individuals. With the

limited hospital resources, tailored

protocol for patient evaluation, triage,

training to doctors and supporting staff,

better management and optimal outcome



249

in victims during terrorist attack in any

region of the world.

Keywords

Mass Casualty Incidents (MCI), Intensive

care unit (ICU), Focused assessment with

sonography for trauma (FAST), Extended

FAST (eFAST), Computed tomography (CT)

Introduction

After the horrific mass-casualty terror

attack on the United States on September

11, 2001, Israel bomb blast injuries of 2000-

2003 and London Underground tube blasts

of 7 July 2005, the world has changed.

Bomb blast injuries was a part of

emergency department in the hospital

when I was training my residency in the

northeastern part of India. I share my

experience, owing to the complexity of

injuries and mass casualty incidents

encountered in terror attack victims. New

challenges, skills, clinically inapparent cases

where fast and accurate imaging plays an

essential role in triage and identification of

abnormalities associated with injuries. The

radiologist becomes a crucial part of the

first-line team of doctors treating these

patients. A need to understand the nature

and patterns of bomb blast injury,

particularly in confined spaces. We highlight

the value of using a standardized imaging

protocol to find clinically undetected

multisystem and complex injuries

encountered in the bomb blast victims.

Knowledge and skills in managing the

victims by using optimal imaging facilities

can enhance the strength and endurance of

society against terror.


This prospective study was carried out in

the department of Radiology, Gauhati

Medical College and Hospital at Guwahati

from July 2007 to January 2010.

Inclusion criteria: Total of 126 patients of

bomb blast victims referred to our hospital

for tertiary care and management, 100

patients were sent for imaging. 26 patients

were excluded due to critical conditions and

brought dead.

Exclusion Criteria: Critical and unstable

patients, brought dead, severe burns.

Data Analysis: Were done using rate,

statistical percentage and outcome is

computed.

Imaging Protocols:

1. Fluoroscopy: To screen out any metallic

objects.

2. Spine, chest, abdomen and extremity

radiographs: To screen out metallic


250

objects, fractures, pneumothorax,

pneumomediastinum,

pneumoperitoneum – life threatening

conditions.

3. Ultrasonography of abdomen: FAST to

exclude solid organ injuries and

hemoperitoneum.

4. CT evaluation using SIEMENS spirit dual

slice spiral scanner and 16 slice Toshiba

CT scanner. Plain CT scan for brain or

whole body single venous phase CT scan

including head, neck, chest and

abdomen using 100-150 ml of non-ionic

contrast media.

Results

Out of 126 bomb blast victims, 100 were

included due to imaging workup. Males

were more common to female (70 / 30),

53% in young productive 15-29 years,

followed by 21 % in 30-44 years. Multiple

complex body injuries: Traumatic brain

injuries (79%) - Countercoup injury,

Subdural hematoma, extradural hematoma,

Faciomaxillary complex fractures, nasal and

temporal bone fractures, Spine and cord

injuries (19%)- Multilevel compression and

burst fractures, shrapnel’s in bony canal,

Chest injuries (39%) – Multilevel rib

fractures, tension pneumothorax,

pneumomediastinum, lung contusions,

surgical emphysema , vascular injury,

Abdominal and pelvic injuries ( 43%)- liver,

splenic and pancreatic lacerations, blunt

and penetrating injury to kidneys, hemo-

pneumoperitoneum, mesenteric /bowel

injuries, extremities (62%) – comminuted

fractures and open wounds. Depending

upon severity, internal and external body

injuries patients were triaged and

categorized to mild, moderate and severe.

Urgent attention and care to severe

category shifting to ICU care, surgical

theatre, minor procedures, hospitalization.

23 % patients shifted to ICU care for

ventilation and priority nursing care. Most

of the patients 60% were discharged within

7 days, 19% within 2 week and 21 % longer

duration. 62 % victims underwent surgical

procedures esp. liver and splenic

lacerations, bowel / mesenteric injury,

pelvic and femoral bone fractures, aortic

injury in 2 cases and minor procedures in

causality like suturing, repair. 23 cases had

severe burns were isolated and treated, 1

patient after a week died. Out of

hospitalized victims, 19 deaths was

reported, 72 % died within a week, 11%

within 2 week.

Discussion

Terror-related injuries have become a

threat for populations all over the world [1].

As long as gunpowder and explosives are


251

used to solve disagreements between

nations, ethnic groups and individuals,

victims of blast injury continue to arrive at

trauma centers around the world [5]. Bomb

blast injuries are often more complex but

easiest and least costly methods of

achieving the terrorist goals of large-scale

casualties. This explains why

multidisciplinary team including Radiologist,

Surgeons, Paediatrians, Orthopedics

surgeons and supporting staffs must be

integrally involved in the field of disaster

management, local hospitals and tertiary

care centers. We must develop the

necessary expertise that we now tend to

lack in the biology of explosive injury, its

known patterns of severity and the unique

principles of mass casualty management

that are so different from our routine

approaches to trauma [3].

Only lifesaving procedures should be

performed during the initial phase. Later,

medical care is directed at patients moved

to ICUs. Prompt evacuation after necessary

lifesaving procedures in the field, proper

triage and distribution, prudent hospital

triage and surgical care and last but not

least, expert critical care provide the best

possible outcome in such circumstances.

The mortality among critically injured

survivors of terrorist bombing disasters is

directly related to the magnitude of

overtriage [4]. Therefore rapid and accurate

triage is essential to minimize mortality

among survivors.

During a detonation, the explosive

substance transforms from a solid state to a

gaseous one, creating the blast wave. When

the explosion occurs in a closed space, the

blast damage is amplified owing to

reflection of the blast wave ranging from

wind velocity of 125 mph (201 km/h) to the

velocity of a hurricane, because of the low

density of air, high-velocity winds can be

produced even by small changes in

pressure. The objects that can be found at

a local hardware store such as nails, screws,

bolts, and ball bearings; the included

metallic objects may add up to 10 kg to a

single bomb[1]. The large number of

metallic objects, along with the complex

internal injuries they may inflict requires a

multimodality imaging approach. Places

like crowded markets, shops, bus stops and

railway station are targeted. These places

are difficult to access for hospitals, first-aids

and fire stations.

The clinical presentation depends on

whether the blast occurs in open or

confined quarters, open air or water, the

pattern of injury inflicted on the body is

relatively consistent [5]. Injury from

explosion may be due to the direct cussive

effect of the blast wave (primary), being


252

struck by material propelled by the blast

(secondary), to whole-body displacement

and impact (tertiary) or to miscellaneous

effects from burns, toxic acids and so on6.

Three systems are prone to injury. The first

is the auditory system, with damage to the

eardrum in milder cases and inner-ear

injury in more severe cases. Second is

alimentary tract with contusions,

hematoma and less frequently perforation

of a hollow viscus. Solid organs injuries are

noticed in survivors of blast injury but the

hallmark of blast injury is the involvement

of the respiratory system. Pulmonary injury

is characterized by pneumothorax,

parenchymal hemorrhage, and alveolar

rupture where later is responsible for the

arterial air embolism that is the principle

cause of early mortality [6]. Close proximity

to the blast can impose traumatic

amputation of limbs (i.e., arms and legs)

and ear lobes [5]. The most common fatal

injury is brain damage [7].

The heart of every hospital is the

emergency department - core of decision

makers whose choices determine how the

emergency response will evolve. The

radiologist becomes a crucial part of the

first-line team of doctors in mass casualty

incidents and in disaster management. The

workflow pattern is described in the given

chart [⁴].

Radiologic examinations including plain

radiography, fluoroscopy, Computed

tomography (CT), sonography, and

angiography are used to assess the site,

extent of injuries and can help determine

which patients will be triaged to immediate

surgery and which will be followed up

conservatively. Large numbers of casualties

whose complicated injuries are due to blast

and shrapnel’s require the most

sophisticated imaging but are often

admitted with no or minimal early warning

to the radiology department during a brief

period.

As in any trauma / blast victims, chest,

cervical spine, and pelvic radiographs are

routinely obtained as part of the initial

work-up. The role of conventional

radiography in localizing foreign objects is

limited when shrapnel’s are multiple,

scattered in body parts and therefore

helping detect which parts of the body need

further imaging usually with Computed

tomography (CT). The radiographs are

requested to exclude any metallic density

shrapnel’s, fractures, live threatening

pneumothorax, pneumomediastinum,

pneumoperitoneum, hollow viscus injuries.

Chest radiological findings from pulmonary

contusions, chest wall injury including bony

fractures and soft tissue injury to

pneumothorax, hemothorax,


253

hemopericardium and vascular injury.

Abdominal radiographs to look for free air

under diaphragm. However with best

possible, internal injuries cannot be

excluded from radiographs. It warrants

computed tomography for detailed and

precise information and guides further

surgical management.

The primary function of the radiologist is to

perform focused abdominal sonography in

trauma or FAST, in order to evaluate for

free peritoneal fluid and to exclude

hemodynamically significant abdominal

injuries. This quick study takes 1–2 minutes

per patient. To provide rapid reports that

could be used instantly, we have developed

colored stickers that are attached the

patient’s chart: red when positive for free

peritoneal fluid, green when negative, and

yellow when indeterminate, which will alert

the staff as to whether the patient needs

prompt further evaluation1.

The extended FAST (eFAST) [10] allows for

the examination of both lungs by adding

bilateral anterior thoracic sonography to

the FAST exam. This allows for the

detection of a pneumothorax with the

absence of normal ‘lung-sliding’ and

‘comet-tail’ artifact. Compared with supine

chest radiography with CT or clinical course

as the gold standard, bedside sonography

has superior sensitivity (49–99 versus 27–

75%), similar specificity (95–100%) and can

be performed in under a minute [10].

Immediate bedside detection of a

pneumothorax confirms, often ambiguous

physical findings in unstable patients and

guides immediate chest decompression. In

addition, in the patient undergoing positive-

pressure ventilation, the detection of an

otherwise ‘occult’ pneumothorax prior to

CT scanning may hasten treatment and

subsequently prevent development of a

tension pneumothorax, a deadly

complication if not treated immediately and

deterioration in the radiology suite (in the

CT scanner) [11].

FAST is most useful in trauma patients who

are hemodynamically unstable. A positive

result suggests hemoperitoneum; often CT

scan will be performed if the patient is

stable [12] or a laparotomy if unstable. In

those with a negative FAST result, a search

for extra-abdominal sources of bleeding

may still need to be performed [12]

Computed tomography (CT) is a superior

modality for demonstrating the course a

penetrating object has traveled and the

resulting injuries. Radiologist should be

stationed at every CT console to aid in

planning the best protocol and to give real-

time interpretations of the scans. On arrival

at the CT suite, a whole body scout image

should be obtained initially. This may depict


254

additional unsuspected sites of shrapnel

that were not detected on the emergency

department. Shrapnel in the pelvis may

warrant rectal administration of contrast

material prior to CT to aid in evaluating

injuries to the colon. Then dedicated region

of interest was planned with single venous

contrast and later multiplanar and

reformatted images was performed.

Angiography is a minimally invasive

examination that should be reserved for

patients in whom there is a clinical

suspicion of vascular injury. Angiography

has the added benefit of allowing for

therapy in certain cases, such as the

treatment of active bleeding by means of

embolization.

Males were more common to female (70 /

30), 53% in young productive 15-29 years,

followed by 21 % in 30-44 years. Multiple

complex body injuries- brain, chest and

abdominal, skeletal and vascular injuries.

Depending upon severity, internal and

external body injuries patients were triaged

and categorized to mild, moderate and

severe. Urgent attention and care to severe

category shifting to ICU care, surgical

theatre, minor procedures and

hospitalization. In damage control for

abdominal trauma, bail-out laparotomy for

achieving hemostasis and preventing

uncontrolled spillage of intestinal contents

or urine [8]. 23 % patients shifted to ICU

care for ventilation and priority nursing

care. 62 % victims underwent surgical

procedures esp. liver and splenic

lacerations, bowel / mesenteric injury,

pelvic and femoral bone fractures, aortic

injury in 2 cases and minor procedures in

causality like suturing, repair and wound

debridement. 23 cases had burns were

isolated and treated, 1 patient after a week

died. Out of hospitalized victims, 19 deaths

was reported, 72 % died within a week, 11%

within 2 week. Deaths were due to third

space volume loss, septicemia and in some

victims without obvious external injuries,

cardiac dysrhythmia or air emboli caused

cardiac arrest and eventual death [9].

Conclusion

Take home message, there are four

components of knowledge are required as

critical to master by medical teams

intending to treat victims admitted

following explosions. a) detonation- the

physics of the explosion, b) wound ballistics

- understanding the resultant injury

patterns, c) triage - the art of sorting

patients according to the severity of injury

and d) medical concerns - treating multiple

patients with multidimensional injuries and

special injury patterns [9].


255

In Mass Casualty Incidents (MCI), imaging

should be fast, in order to help identify

major injuries that need immediate

management and to help in the triage of

injured individuals.

The observations in this article have

implications for treatment, preparedness of

hospital resources, tailored protocol for

patient evaluation and training to treat

patients after a terrorist attack in any

region of the world. Disaster management

plans should include the possibility of

terrorist bombing, and medical

preparedness should anticipate that a large

proportion of the injuries will be nonfatal.

Fund Support: None

Conflict of Interest: None


256

References

1. Kobi Peleg, Limor Aharonson-Daniel,

Michael Stein. Gunshot and Explosion

Injuries: Characteristics, Outcomes and

Implications for Care of Terror-Related

Injuries in Israel. Ann Surg. 2004 March;

239(3): 311–18.

2. Jacob Sosna, Tamar Sella, Dorith

Shaham. The role of radiology in terror

attacks. Radiology 2005; 237:28–36.

3. Eric R. Frykberg. Principles of Mass

Casualty Management Following

Terrorist Disasters. Ann Surg. 2004

March; 239(3): 319–21.

4. Frykberg ER. Medical management of

disasters and mass casualties from

terrorist bombings. How can we cope? J

Trauma. 2002; 53:201–12.

5. Stein M, Hirshberg A. Medical

consequences of terrorism: the

conventional weapon threat. Surg Clin

North Am. 1999; 79:1537–52.

6. Philips YY. Primary blast injuries. Ann

Emerg Med. 1986; 15:1446–50.

7. Cooper GJ, Maynard RL, Cross NL.

Casualties from terrorist bombings. J

Trauma. 1983; 23:955–67.

8. Hirshberg A, Walden R. Damage control

for abdominal trauma. Surg Clin North

Am. 1997; 77:813–20

9. Kluger Y. Bomb explosions in acts of

terrorism-detonation, wound ballistics,

triage and medical concerns. Isr Med

Assoc J. 2003; 5:235–40.

10. Kirkpatrick AW, Sirois M, Laupland KB. J

Trauma, 2004; 57(2):288–95.

11. Davis JA. Critical Diagnosis in Bedside

Ultrasonography. Diagnostics & Imaging

2007.

12. Scalea T, Rodriguez A, Chiu W,

Brenneman F (1999). "Focused

Assessment with Sonography for

Trauma (FAST): results from an

international consensus conference".

Journal of Trauma 46 (3): 466–72.


257

Chart


258

Tables Table 1: Age and gender distribution in bomb blast victims

Age groups (years) No. of victims Percentage (%)

0-14 07 07

15-29 53 53

30-44 21 21

45-59 06 06

>60 13 13

Table 2: Region-wise distribution of injuries in bomb blast victims.

Region wise distribution Percentage (%)

Traumatic brain injury 79

Spine and Cord injury 19

Chest injury 39

Abdomen and pelvis injuries 43

Extremities and Joints 62

Table 3: Distribution pattern of bomb blast victims for Hospital care.

Distribution pattern of bomb blast victims for Hospital care

Duration of Stay (Hospitalization) Percentage (%)

<7 days 60

7-14 days 19

>15 days 21

ICU stay

Yes 23

No 73

Surgical procedures

Yes 62

No 38

Hospital Deaths 19


259

Figures

Figure 13:: Chest radiograph reveals right side tension pneumothorax (thick arrow), minimal

pneumomediastinum (thin arrow) and subcutaneous emphysema

Figure 14:Chest radiograph reveals multiple ribs fractures, right side hydro-pneumothorax (arrow) and

chest drain tube insitu.


260

Figure 15: Lateral chest radiograph reveals multiple radio opaque foreign bodies (arrow) in chest wall of

bomb blast victim.

Figure 16: Chest and abdominal radiographs – Free air under diaphragm (arrow).


261

Figure 17: Pelvic radiograph reveals comminuted intertrochanteric fracture of right femur

Figure 18: Radiograph of right leg reveals comminuted fractures of tibia and fibula.


262

Figure 19: Plain CT brain reveals multiple calvarial fractures, right temporal bone fracture (thick arrow)

with right ear bleed, hemorrhagic cortical contusions, hemosinus (thin arrow) and minimal subdural

hemorrhage.

Figure 20: SSD CT of skull reveals multiple comminuted calvarial fractures, bilateral lacrimal, nasal

bones, medial orbital wall, mandible and right tripod fractures.


263

Figure 21: Plain CT chest reveals multiple pulmonary contusions with right side hemothorax (arrow).

Figure 22: CT abdomen in bomb blast victim, scout and axial images reveals multiple metallic density

splinters (arrows) in chest and abdominal wall.


264

Figure 23: Plain CT abdomen in bomb blast victim. Axial and sagittal reformatted images reveals

multiple density splinter (arrow) in the spinal canal at L5 vertebra.

Figure 24: Contrast enhanced CT abdomen. Axial and coronal reformatted images reveals multiple

splenic lacerations (arrow), subscapular hematoma, hemoperitoneum, left side hemothorax and

pulmonary contusion


265

Figure 25: SSD (Surface Shaded Display) images reveals (R) comminuted fractures in right half of

sacrum and right superior pubic ramus (thick arrow), (L) anterior wedge compression fracture of L1

vertebral body (thin arrow).

Figure 26: USG abdomen reveals liver laceration with hematoma (arrow).


266

Strangulated internal hernia

A rare case presenting with acute Small bowel Obstruction.

Thulasivasudevaiah1, Manjunath shenoy2, Thrishuli P.B3, Shivanand Reddy K.V4

Department of Surgery, JSS Medical College & Hospital, Mysore-570015, India


Dr. Thulasivasudevaiah


Abstract

Acute small bowel obstruction is the

commonly seen surgical abdominal

Emergencies. Strangulated intestinal

obstruction due to idiopathic internal

Hernia is rare. Our patient presented with

features of small bowel obstruction for 3

days duration &strangulated internal hernia

in the Mesenterico-parietal fossa of

Waldeyer immediately below the

Duodenum was diagnosed per- operatively.

Early surgical intervention prevented him

from complications of bowel gangrene.

Key Words

Internal Hernia, Strangulation, Small bowel

obstruction. Mesentericoparietal fossa of

Waldeyer

Introduction

Internal abdominal Hernias rarely presents

with strangulated Small bowel obstruction.

Strangulated Small bowel obstruction is

easily diagnosed in painful, irreducible

external hernia. Pre-operative suspicion of

bowel strangulation due to congenital

internal herniation should be kept in mind

in a patient who has not undergone any

Previous Intra-abdominal surgery. Internal

hernia can be secondary to some intra

abdominal surgery. (Trans-mesenteric -

acquired, common type) Internal Hernia can

occur in left or right para-duodenal,

Diaphramatic (congenital) region& into

Mesentericoparietal fossa of Waldeyer. CT

scan can identify the herniated bowel loops

in internal hernia.

Case Summary

A 60 year old male patient was admitted to

ER at JSS hospital with history of abdominal

distension, constipation & vomiting of 7-8

episodes of 3 days duration. Vomitus was

bilious in nature.

His vital signs were normal at the time of

admission except for dehydration. Per-

abdominal examination showed uniform



267

distension with generalised tenderness &

guarding with absent bowel sounds. Naso-

gastric aspiration showed 600ml of bile

stained fluid. Initial diagnosis of acute Small

bowel obstruction was made & erect

abdominal X-ray showed multiple air fluid

Levels in distended small bowel loops.

Abdominal ultrasound revealed prominent

bowel loops with sluggish peristalisis with

minimal ascitis.

Blood investigations were normal except for

mild neutrophilia. (TC- 6800, DC N-87%)

His chest x-ray showed COPD changes.

Serum electrolytes were of normal range.

Emergency laparotomy revealed

haemorrhagic peritoneal fluid with

congested and distended

Loops of ileal coils leading to

retroperitoneal region. There were

collapsed coils emerging from

infraduodenal area. The constricting lower

border of hernia window was incised to

reduce the herniated small bowel (Fig: 2) &

an area of circumferential strangulated ileal

loop identified, which was buried with

Polyglycolic seromuscular sutures. (Fig: 3)

The congested bowel loops regained its

Pink colour after correction of partial

mesentry twist.

Post operative period was uneventful.

Patient had a bout of malena on second

post-operative day. He was treated with IV

antibiotics, analgesics & blood transfusion.

Discussion

Primary internal herniation of small bowel

with early strangulation is difficult to

diagnose pre-operatively. Internal hernia

into the Mesentericoparietal fossa of

Waldeyer is a rarecondition. This fossa lies

behind the superior mesenteric artery &

below the diaphragm, withits orifice looking

to the left. Intermittent colicky abdominal

pain with features of small bowel

obstruction can be presenting features in

suspected cases of acquired internal

hernia.& can be diagnosed by CT scan.

Primary (Idiopathic) Internal hernias are

rare & knowledge of Paraduodenal fossae

and the relation of the mesenteric vessels

during release of strangulated bowel is

necessary for the Clinicians & Surgery

residents while treating a case of Acute

Small bowel Obstruction.


268

References

1. Internal hernia- An increasingly

common cause of SBO. –Blachar.A

FederleMP,Division of abdominal

imaging, Dept of radiology, University

of Pittsburgh medical center

2. Lee McGregor`s synopsis of surgical

Anatomy.-Duodenal fossae-page 33-35.

3. Congenital & acquired internal hernia-

Unusual causes of small bowel

obstruction- NewsomBD,Kukora JS Dept

of Surgery ,University of Mississipi chool

of medicine,Jackson MS USA

4. Internal hernia –a brief review, Hernia

Vol17,issue 3June 201

5. Right paradudenal hernia in an adult

patient ,diagnostic approach & surgical

management.Case reports in

Gastroenterology 2011 may-Aug 5(2)

www.karger.com


269

Figures

Figure 27: Reduction of herniated coils of ileum from retroperitoneum after transecting the constricting

band

Figure 28: Reduction of herniated bowel loops


270

Figure 29: Circumferential strangulated region


271

Diagnostic Efficacy of Endoscopy in Evaluation Of Dysphagia

Zameerulla T1, Praveen Devarbhavi2

1Associate professor, Department of general surgery, SSIMSRC, Davanagere 2Associate professor, Department of Medicine, SSIMSRC, Davanagere


Dr. Zameerulla T


Abstract

Background: Dysphagia is a common

complaint in the patients attending the

surgical OPD. It is common especially in the

elderly population and more so in females.

Many investigative modalities have been in

use in the evaluation of this complaint

including barium swallow and more

recently with the invention of flexible

endoscopy it has become the gold standard

of investigations in dysphagia owing to its

advantages over others.

In the present retrospective study, data was

collected and evaluated from the registry of

endoscopy department of SSIMSRC,

regarding the cases of upper GI endoscopy

done by the author for the evaluation of

dysphagia from January 2008 to December

2013. Patients with known diagnosis or who

have come for repeat endoscopy were

excluded from the study.

Conclusion: Dysphagia being a common

complaint, yet could be a symptom of

malignancy, has to be evaluated properly.

Upper gastro intestinal endoscopy is of

immense value in the initial evaluation of

the same.

Key words

Efficacy, Dysphagia, Endoscopy.

Introduction

Dysphagia is defined as Difficulty in

swallowing or inability to swallow1.

Dysphagia is a common complaint

especially in ageing persons. Approximately

7 to 10 percent of adults above 50 years

have dysphagia, although this number may

be lower in comparison to the reality

because many patients may never seek

medical care2, 3. About 25 percent of

patients in hospitals and 30 to 40 percent of

patients in nursing homes experience

swallowing problems.4, 5. Before the advent



272

of endoscopy physicians had rely upon

barium studies for the evaluation of

dysphagia. In 1988, the first published

description of the use of flexible

laryngoscopy to evaluate oropharyngeal

dysphagia was published by Langmore,

Schatz, and Olsen6. Now fibreoptic

endoscopy is in common use and in

combination with barium swallow the

diagnostic accuracy of this is reported to be

85%7.


The data was collected from the registry

maintained in the department of endoscopy

at SSIMSRC Davangere regarding the cases

of upper gastro intestinal endoscopy done

by the author in the patients with

predominant complaint of difficulty in

swallowing from January 2008 to December

2013. Both outpatient and admitted

patients were included in the study.

Patients with known diagnosis and

previously done endoscopy cases were

excluded.

The data collected was evaluated regarding

the pre procedure clinical diagnosis, the

endoscopy findings, weather biopsy was

taken and the pathological diagnosis.

Statistical analysis was done using SPSS

statistical tool. The results were compared

with the other international studies.

Results

In the present study, total of 187 patients

were included, out of which 106 were males

and 81 were females. Endoscopy was able

to find some pathology in 122 patients

(65%) and was normal in 65. The most

common diagnosis was malignancy of the

esophagus , 46% of the total number of

patients, out of this malignancy of upper,

middle and lower third of esophagus

constituted 14(), 15() and 57() patients

respectively. Among 14 patients of upper

third malignancy, 6 patients were found to

have carcinoma of post cricoid region and

among 57 patients of lower third

malignancies, 6 patients were found to

have carcinoma of Gastro Esophageal

junction. Other lesions discovered were

carcinoma of posterior pharyngeal wall in 6

patients, stricture of the esophagus in 6,

carcinoma of pyriform fossa in 4, reflux

esophagitis in 3, hiatus hernia in 3,

esophageal candidiasis and erosive gastritis

in 2 patients each, carcinoma of

paraepiglottic region, pyloric stenosis and

esophageal web was found in one patient

each.

Discussion


273

Dysphagia is a common symptom in the

patients attending the surgical and ENT

outpatient departments. Cause for such a

symptom can be minor disorders such as

pharyngitis or laryngitis in some. But the

cause can also be dreaded diseases such as

malignancy of the upper gastrointestinal

tract such as esophagus and gastro

esophageal junction and can also be a

symptom of malignancy of upper aero

digestive tract.

The most common cancer of the gastro

intestinal tract in southern India is that of

esophagus8. Esophageal cancer is one of the

least treatment responsive cancers all over

the world9. In India, Squamous cell

carcinoma of the esophagus is the third

leading cancer in men and fourth in

women10, 11, and 12. Males are more

commonly affected13, 14. In the present

study also there is male preponderance

noted.

In our study, about 65% of the patients

evaluated for dysphagia were found to have

some or the other pathological lesion as a

cause for their complaint, majority of them

were found to have malignancy, mainly of

the esophagus and the gastro esophageal

junction. This finding may not reflect with

the general population and this alarming

percentage of patients with malignancy can

be because of the fact that a significant

percentage of the patients were referred to

the author from the department of

oncosurgery.

Our study demonstrated that although

majority of the patients with dysphagia will

either be have some clinically diagnosed

disease or will be normal, there are some

‘diagnostic surprises’ possible such as we

found esophageal candidiasis, GERD, pyloric

stenosis, esophageal web and erosive

gastritis as a cause for the patients’

complaints.

Conclusion

Upper gastro intestinal endoscopy is an

important tool in the initial evaluation of

patients with dysphagia. Being an

outpatient procedure and done without any

form of sedation or anesthesia in most of

the patients and being safer even in elderly

patients, it can be considered even with

slightest suspicion of malignancy. Multiple

biopsies can be taken from any suspected

areas and subjected for histopathology. If

found to be normal patient can be safely

evaluated further with other investigative

tools.


274

Reference

1. The American Heritage® Medical

Dictionary Copyright © 2007, 2004 by

Houghton Mifflin Company.

2. Lindgren S, Janzon L. Prevalence of

swallowing complaints and clinical findings

among 50–79-year-old men and women in

an urban population. Dysphagia. 1991;

6:187–92.

3. Tibbling L, Gustafsson B. Dysphagia and

its consequences in the elderly. Dysphagia.

1991; 6:200–2.

4. Brin MF, Younger D. Neurologic disorders

and aspiration. Otolaryngol Clin North Am.

1988; 21:691–9.

5. Layne KA, Losinski DS, Zenner PM, Ament

JA. Using the Fleming index of dysphagia to

establish prevalence. Dysphagia. 1989;

4:39–42.

6. Langmore SE, Schatz K, Olsen N.

Fiberoptic endoscopic examination of

swallowing safety: a new procedure.

Dysphagia 1988; 2:216–219.

7. Wilkins WE, WalkerJ, McNulty MR,

Britton DC, Gough K.

The organisation and evaluation of an open

access dysphagia

clinic. Ann R Coll Surg Engl 1984; 66:115-6.

8.Chitra S, Ashok L, Anand L, Srinivasan V,

Jaynath V. Risk factors for esophageal

cancer in Coimbatore;SouthernIndia;A

hospital based care control study. Indian J

Gastroenterology 2004; 23:19-21.

9. Kamangar F, Malekzadeh R, Dawsey SM,

Saidi F.et al Esophageal cancer in North

Eastern Iran: A review. Arch Iran Med 2007;

10:70-82.

10. Malkan G, Mohandas KM.

Epidemiology of digestive tract cancers in

India. Gut 1997; 16:98-101.

11. Malhotra SL. Geographical

distribution of gastrointestinal cancers in

India with special reference to causation.

Gut 1967; 8:376-72.

12. Ansari MM, Haleem S, Beg MH.

Clinicopathological profile of carcinoma

esophagus at Aligarh. J Indian Med Assoc

1991; 89:217-19.

13. Farin K, Graca MD, William FA. Patterns

of cancer incidence, mortality and

prevalence across five continents: Defining

priorities to reduce cancer disparities in

different geographic regions of the world. J

Clin Oncol 2006; 24:2137-50

14. Sankaranarayanan R, Duffy SV, Padma

Kumaray G, Nair SM, Day NE, Pandanabhan

TK. Risk factors for cancer of the esophagus

in Kerala, India. Ind J cancer 1991; 49:485-

89


275

Study of Sellar Bridges in Dry Human Skulls of North Interior

Karnataka

P.S.Bhusaraddi1, S. D. Desai2, sunkeswari sreepadma3

1Associate Professor, Department of Anatomy, KIMS, Hubli, India

2Principal, Sridevi Institute of Medical Sciences & RH, Tumkur, India

3Department of Anatomy, S D M Medical College, Dharawad, India

Corresponding Author Dr P.S.Bhusaraddi Introduction

The ossified interclinoid ligament forms a

bony bridge between the anterior, middle

and posterior clinoid processes of the

sphenoid bone. These bony bridges are

known as sellar bridge.

The microsurgical and radiological anatomy

of the clinoid processes and their bridging

structures give neurosurgeons more details

about the anterior, middle and the

posterior clinoid processes and their

relations to the vascular and nervous

relations during intradural and extradural

clinoidectomy, thus making the operatives

procedures successful and safer.

Excision of the anterior clinoid process may

be required for many skull based surgical

procedures and the presence of the

carotico clinoid foramen may pose

problems. The study of these structures

around the sella is immensely beneficial and

especially related to neurosurgeons and

radiologists

Objectives

To know the prevalence of Sellar bridges

among the skull samples studied.

To study the Different types of Sellar

bridges in relation to unilateral or bilateral

Methodology

Source of data:

For the present study, dry unknown human

skulls were obtained from North interior

Karnataka region collected in the

department of Anatomy of Shri B. M. Patil

Medical College Hospital and Research

Centre, BLDE University Bijapur.

Method of Data Collection

Sample size- 223 dry unknown human

skull were taken for the study.

Sampling procedure- Skulls were

observed for different types of sellar

bridges.

Type 1

Type 2


276

Type 3

Type 4

Statistical analysis:

The data was analyzed statistically with chi

square test. Graphs and tables were

generated using Microsoft office word and

excel software

INCLUSION CRITERIA:

For the present study dry unknown human

skull which were well ossified were taken

EXCLUSION CRITERIA:

Fragmented, Broken skull bones were

excluded from the study.

Discussion

Ossification of the ligaments around the

sella turcica may give rise to bony bridges

that connect the clinoid processes and

other surrounding structures.

The interclinoid ligament joins the anterior

and posterior clinoid processes while the

caroticoclinoid ligament connects the

anterior and middle clinoid processes.

Frazer did not mention the caroticoclinoid

ligament as a separate entity. According to

him, the anterior, middle and posterior

clinoid processes are connected by

interclinoid ligaments.

The ossified interclinoid ligament forms a

bony bridge between the anterior, middle

and posterior clinoid processes of the

sphenoid bone. These bony bridges are

known as sellar bridge.

These sellar bridges can develop unilaterally

or bilaterally and which can be complete or

incomplete and may vary in frequency.

Sellar bridges are significant in surgical

management while dealing with the

vascular, neoplastic or traumatic lesions

giving rise to various clinical symptoms

Presence of ossified interclinoid bars not

only poses difficulty in removal of anterior

clinoid process but also enhances the risk of

damage to the adjacent important

structures.

Anomalies of sellar region may result in

confusion in the evaluations of MRI or CT

and also in the regional surgery planning.

Sellar bridges may compress surrounding

structures like hypophysis cerebri, trochlear

and the abducens nerve & leads to cause

several endocrinological and neurological

disorders.

Bridge formation between the anterior and

middle clinoid processes could cause

pressure on the internal carotid artery that

lies in the cavernous sinus.

Aneurysms of the proximal carotid

(paraclinoidal) artery is an interesting family

of the aneurysms arising from the proximal

part of the internal carotid artery.

Conclusion


277

The variations in clinoid processes of the

sphenoid bone should be carefully studied

by all neurosurgeons.

Complete or partial removal of the anterior

clinoid process is an important step in the

superior approach to the cavernous sinus.

Knowledge of the prevalence sellar bridges

will help the neurosurgeons for pre-

operative scanning and precautions to be

taken implications in surgical procedures to

assess the pituitary gland, cavernous sinus

and internal carotid artery to prevent fatal

complications during surgery.

The osseous carotico clinoid foramen is an

underestimated structure which has

important neuronal and vascular relations

and is both clinically and surgically

important.

Knowledge of the detailed anatomy of the

carotico clinoid foramen and its content can

increase the success of diagnostic

evaluation and surgical approaches to the

region.


278

References

1. Avci E, Bademci G, Ozturk A.

Microsurgical Landmarks for Safe

Removal anterior clinoid

process.Minim Invas Neurosurg

2005; 48: 268-72.

2. Seoane E, Rhoton AL, Oliveira E

.Microsurgical anatomy of the dural

collar (carotid collar) and rings

around the clinoid segment of the

internal carotid artery.

Neurosurgery 1998;42:869–86.

3. Archana R, Anita R, Jyoti C, Punita

M, Rakesh D. Incidence of osseous

interclinoid bars in Indian

population.Surg Radiol Anat

2010;32:383–7.

4. Ozdogmus O, Saka E, Tulay C, Gurdal

E, Uzun I, Cavdar S. Ossification of

interclinoid ligament and its clinical

significance. Neuroanatomy 2003;

2:25–7.

5. Peker T, Anıl A , Gülekon N, Turgut

HB, Pelin C , Karaköse M.The

incidence and types of sella and

sphenopetrous bridges. Neurosurg

Rev 2006;29: 219–23.

6. Bilodi AKS. Study of sella turcica and

associated anomalies in human

skulls, Journal of Institute of

Medicine 2005;27: 3-6.

7. Erturk M, Kayalioglu G, Govsa F

.Anatomy of the clinoidal region

with special emphasis on the

caroticoclinoid foramen and

interclinoid osseous bridge in a

recent Turkish population.

Neurosurg Rev 2004; 27:22–6.

8. Dyke CG, DavidoV LM

Demonstration of normal cerebral

structures by means of

encephalography: choroid plexus.

Bull Neurol Inst NY 1932;2:331–46

9. Rengachari SS, Ellenbogen RE

.Intracranial aneurysm. In: Principles

of Neurosurgery. 2nd ed. USA:

Elsevier Mosby; 2005.p 222-5.

10. Narolewski R. Significance of

anatomic variants of bony

surroundings of the internal carotid

artery and their significance for

lateral surgical approaches to the

cavernous sinus. Ann Acad Med

Stetin 2003; 49:205-29.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Narolewski%20R%22%5bAuthor%5d


279

Figures

Figure 30: Normal Anatomy of Sellar Region


280

Figure 31: Type 1 Sellar Bridges



281




282




283


Figure 38: Type 4 Sellar Bridges Tables

Table showing percentage of type 1 sellar bridges


284

Bilateral Unilateral (Right)

Unilateral (Left)

Total

Complete 8 (3, 58%) 0 0 8 (3.58%)

Total 8 (3, 58%) 0 0 8 (3.58%)

Table showing percentage of type 2 Sellar bridges


Unilateral (Left)

Total

Complete 15 (6.73%) 9 (4.03%) 7 (3.13%) 31 (13.90%)

Total 15 (6.73%) 9 (4.03%) 7 (3.13%) 31 (13.90%)



Unilateral (Left)

Total

Complete 15 (6.73%) 9 (4.03%) 7 (3.13%) 31 (13.90%)

Total 15 (6.73%) 9 (4.03%) 7 (3.13%) 31 (13.90%)


Bilateral Unilateral (Right) Unilateral (Left)

Complete 2 (0.85%) 0 0

Incomplete 0 0 0 Total 2 (0.85%) 0 0

Comparisons of present study with other studies

Type of sellar bridge

Present study Rani archana Bilodi AKS

Type 1 8 (3.58%) 14 (5.6%) 1

Type 2 31 (13.90%) 9 (3.6%) 3

Type 3 44 (19.73%) - 4

Type 4 2 (0.85%) - 2

Graphs

Graph 1showing different types of sellar bridges & their percentage


285

Graph 2 showing Bar Chart Representing sellar bridges by sides

0

2

4

6

8

10

12

14

16

18

20

Complete Incomplete

Right side

Left side

0907

20

17


286

Study of variation in hip joint angles and measurements among regional

urban population of south India- A Contribution to Tribology

Prashanth Nagaraj1, Gautham T Kiron2, Dinesh Golla3, Raghavendra Rao Dharmavaram4

1Assistant Professor, Department of Orthopaedics, M S Ramaiah Medical College, Bangalore

2Resident, Apollo Hospitals, Chennai

3Post graduate, Department of Orthopaedics, M S Ramaiah Medical College, Bangalore 4Assistant

Professor, Department of Orthopaedics, M S Ramaiah Medical College, Bangalore


Dr. Prashanth Nagaraj


Abstract:

Background: Anatomical parameters of bony

components of the hip joint are essential for

better understanding of diseases and their

etiopathogenesis like primary osteoarthritis of

the hip joint.

Aims/Objectives: This study is planned to analyze

the outcome of various measurements and

geometrical angles around the normal hip joints

of representative sample size. It will help us to

know the same in our native population in terms

of averages creating a new insight into whether

any change in these parameters will help us to

better understand tribology and its application.

Design: prospective analytical observer non

population based study

Main outcome measures: acetabular

inclination ,Acetabular depth ,center edge

angle, neck length ,neck width, Neck shaft

angle, Distance from tip of greater

trochanter to center of head ,Tear drop to

femoral head distance and their averages.

Materials and methods: 80 Pelvic

radiographs of adult patients were

taken,32(64hips) were analyzed in 18 men

and 14 women, we measured the acetabular

inclination , Acetabular depth ,center edge

angle, neck length ,neck width, Neck shaft

angle, Distance from tip of greater

trochanter to center of head ,Tear drop to

femoral head distance using goniometer and

scale. The radiographs were taken from

patients with no underlying bone disease

between June 2011 and June 2012.

Conclusion: Sex and Age influences the

measurements of parameters around a

normal hip joint. Males had significantly

longer neck length in comparison to females

(p=0.001) .For neck diameter towards right

side .Males had significantly longer neck

diameter in comparison to females (p=0.004)

(report mean and SD as appropriate. Towards

left side Males had significantly longer neck

diameter in comparison to females

(p=0.011).Regarding Acetabular inclination,

Acetabular depth, Center edge angle ,Neck



287

shaft angle and Tear drop to head distance

there were no observable differences but for

Distance GT to center of femoral head

towards left hip Males had significantly

longer distance GT center head measurement

in comparison to females (p=0.041)This

information will assist clinicians in the region

to interpret analyze and design appropriate

implants to native Indian patients.

Key words

Hip joint, acetabulum, femur, measurements,

radiographs

Introduction

There has been an ongoing interest in degree

and patterns of variation of the medial

inclination of the femoral head and neck,

relative to its diaphysis at least since Charpy

(1885) and Humphry (1889), And with the

extreme vertical and horizontal positions

normally characterized as coxa valga and

coxa vara according to John. Y Anderson

1997. The hip joint is functionally a three-

dimensional ball and socket joint, known

commonly as a cotyloid joint because of its

anatomical feature, enabling movements in

three planes as rotation(Jeremid D,2011 ).

The acetabulum is a cup-shaped socket of the

hipbone that derives its name from its

resemblance to a shallow Roman vinegar cup

(Williams and Wilkins, 1992). In clinical

medicine, measurements of the acetabulum

and proximal femur are crucial in diagnosis,

monitoring of patient recovery,

determination of stability of the hip joint and

in assessment of acetabular dysplasia

(McCarthy, 1996).The decision for type of

operative treatment and the prostheses used

is often based on different radiographic

measurements and scores for which normal

values have been defined (Nelitz, 1999).

Therefore orthopaedic surgeons often use

combinations of measurements when

assessing hip joint parameter.

knowledge about various bony components

of the hip joint will not only help the

radiologists, but will be also of immense

importance to the orthopaedic surgeons and

tribologists to design suitable prosthesis. The

awareness about average dimensions of hip

bones joints in both sexes will also help in

early detection of disputed sex by forensic

experts (Jeremid D,2011).

Materials and Methods A total of 80

anteroposterior bilateral pelvic radiographs

were collected from June 2011 to June 2012

from our Hospital in Bangalore. Of these 48

were excluded: 34 had fractures of hip, 9 had

no clear boundaries, and 5 were out of focus.

32 bilateral pelvic radiographs 18 male and

14 female subjects were studied by

measuring acetabular inclination ,Acetabular

depth ,center edge angle, neck length ,neck

diameter, Neck shaft angle, Distance from tip

of greater trochanter to center of head ,Tear

drop to femoral head distance using a scale

and goniometer. The criteria for choosing

pelvic radiographs taken in neutral position


288

(Tonnis,1976) included: intact pelvis and hip

joint, intact Shenton's line, intact cortices at

the femoral heads, no history of fractures at

femoral necks and no hip or pelvic bone

disease(5). All films were taken at the object-

film distance of 5 cm (5) and focal-film

distance of 100 cm in the antero-posterior

view (Jeremid D, 2011)

Acetabular inclination: The acetabular

inclination is formed between the

intersection of a line joining the superior and

inferior margins of the acetabulum. A line

joining the ischeal tuberosity.

• Acetabular Depth (AD): The acetabular

depth is the length measured along a

perpendicular line after joining the superior

and inferior lips of the acetabulum, from the

midpoint of the lips to the deepest point of

the acetabulum.

• Centre Edge Angle (CEA): The centre edge

angle is formed by the intersection between

a perpendicular line passing through the

centre of the femoral head and the line

joining the centre of the femoral head to the

superior lateral part of the acetabulum

• Neck length: Distance on a line from the

center of the head intersecting the femoral

axis.

• Neck diameter: A perpendicular line to the

line drawn to measure the neck length. At the

most narrowest point of femur neck.

• Tear drop distance/medial joint space: A

vertical line drawn from the most medial

margin of the femoral head to that of the

outer cortex of pelvic tear drop.

Neck shaft angle: Angle formed by a line

drawn through the mid-axis of femoral shaft

and that of the femoral head and neck

Distance from tip of greater trochanter to

center of head. Two independent observers

calculated these measurements. The

measurements were recorded separately for

each sex and side of the hip

Results Analysis tool: SPSS Version 16.0

software Type of analysis: Descriptive &

Bivariate (student t-test; Chi-square test)

only. Multivariate analysis was irrelevant to

this study. Test of normality was done. This

study required parametric tests. Descriptive

statistics for demographics was conducted.

(Number/Percentage was reported). In cases

of continuous variable (age), mean and

standard deviation was reported. Bivariate

analysis using demographic (sex-

male/female) was compared to each of the

parameters being studied. Age was irrelevant

to be compared in this study.

Lau et al., (1995) defined hip dysplasia as

centre edge angle of less than 25° or

acetabular depth of less than 9 mm. Msamati

et al., (2003) explored prevalence of hip

dysplasia using center edge angle and further

investigation on association with gender.

Similar investigation using center edge angle

would be reported in this study. This study


289

could not classify hip dysplasia according to

acetabular depth; no such measurement

cases obtained. To assess association

between categorical variables in dysplasia, in

relation to gender; chi-square test was used

due to two categorical variables involvement.

Discussion

This study has demonstrated variation in

acetabular angles and depth between men

and women, but not the centre-edge angle.

The significant differences observed in

acetabular depth and angles could be due to

the wider pelvis of women that would appear

to reduce the acetabular angle and depth. In

a study of 23 radiographs of normal infants

aged 1-7 days, and 20 radiographs of normal

hips in children aged 11-24 months, Kleinberg

and Lieberman (6) found no sex differences

between them. It is possible that the changes

we have observed in women most likely set

in at puberty when hormonal changes occur

as an adaptation to child bearing in

adulthood. For neck length for right side

Males had significantly longer neck length in

comparison to females (p=0.004) (report

mean and SD as appropriate) Males had

significantly longer neck length in comparison

to females (p=0.001) .For neck diameter

towards right right side .Males had

significantly longer neck diameter in

comparison to females (p=0.004) (report

mean and SD as appropriate. Towards left

side Males had significantly longer neck

diameter in comparison to females

(p=0.011).Regarding Acetabular inclination,

Acetabular depth, Center edge angle ,Neck

shaft angle and Tear drop to head distance

there were no observable differences but for

Distance GT to center of femoral head

towards left hip Males had significantly

longer distance GT center head measurement

in comparison to females (p=0.041) .To

assess association between categorical

variables in dysplasia, in relation to gender;

chi-square test was used due to two

categorical variables involvement. We found

that it was not statistically Significant for both

hip and Findings conformed to the study by

Msamati et al., (2003)

Conclusions

Our study was primarily aimed at analyzing

the statistically significant differences in

various geometric angles around hip joints.

There have been certain demerits in our

study, the sample size is small, and

standardization could be more optimal if CT

scans are done for required sample size,

inter-observational and intra-observational

differences are minimized by choosing only

two observers with less chance of play and

kappa coefficient was not analyzed.

Regression to mean could not be established

due to smaller sample size. However our

study has established new insights to

understand various geometric changes in our

population. We hope this study will assist


290

clinicians in the region to interpret X-ray films

of the hip and to manage orthopaedic

problems of the hip. Further studies are

required, however, to generate more data on

age specific pelvic anthropometry and more

specifically cadaveric anthropometry of the

hip.


291

References

1. Moore, L. The lower limb. In:

Clinically Oriented Anatomy 3rd Ed.

Baltimore: Williams and Wilkins, 1992;

373

2. McCarthy, J.J., Fox, J.S. and Gurd, A.R.

Innominate osteotomy in adolescents

and adults who have acetabular

dysplasia. J. Bone and Joint Surgery.

1996; 78:1455-1461.

3. Nelitz, M., Guenther, K.P., Gunkel, S.

and Puhl. Reliability of radiological

measurements in the assessment of hip

dysplasia in adults. Brit. J. Radiology.

1999; 72:331-334.

4. Tonnis, D. Normal values of the hip

joint for the evaluation of x-rays in

children and

adults. Clinical Orthopaedics and

Related Res. 1976; 119:39-47.

5. Geometric Measurements Of The

Acetabulum In Adult Malawians:

Radiographic Study. East African

Medical Journal Vol. 80 No. 10 October

2003 546 -549

6. Kleinberg, S. and Liberman, H.S. The

acetabular index in infants in relation to

congenital dislocation of the hip. Arch

Surgery. 1932; 32:1049-1054.

7. Sex differences in anatomical

parameters of acetabulum among

asymptomatic Serbian population.

Jeremid D, et al. Vojnosanit Pregl 2011;

volume 68; 935 - 939


292

Figures

Figure 39: Hip Joint

Figure 40: VEC-center edge angle


293

Figure 41: Neck Shaft Angle


294

Tables Significant findings in bivariate analysis

Parameters studied Right Hip Measurement Left Hip Measurement

Neck length Males had significantly longer

neck length in comparison to

females (p=0.004) (report

mean and SD as appropriate)

Males had significantly longer

neck length in comparison to

females (p=0.001) (report


Neck diameter Males had significantly longer

neck diameter in comparison

to females (p=0.004) (report


Males had significantly longer

neck diameter in comparison



Acetabular inclination Not significant Not significant

Acetabular depth Not significant Not significant

Center edge angle Not significant Not significant

Neck shaft angle Not significant Not significant

Distance GT center head Not significant Males had significantly longer

distance GT center head

measurement in comparison



Tear drop to head Not significant Not significant


295

Prevalence of Right hip dysplasia

Frequency Percent Valid

Percent

Cumulative

Percent

Valid dysplasia 6 7.6 15.0 15.0

No

dysplasia

34 43.0 85.0 100.0

Total 40 50.6 100.0

Missing System 39 49.4

Total 79 100.0

Prevalence of Left hip dysplasia

Frequency Percent Valid

Percent

Cumulative Percent

Valid dysplasia 5 6.3 12.5 12.5

No

dysplasia

35 44.3 87.5 100.0

Total 40 50.6 100.0

Missing System 39 49.4

Total 79 100.0


296

Right Hip

Sex * Cross tabulation

Center age RT new Total

Dysplasia No

dysplasia

Sex Male Count 4 18 22

% within Sex 18.2% 81.8% 100.0%

Female Count 2 16 18

% within Sex 11.1% 88.9% 100.0%

Total Count 6 34 40

% within Sex 15.0% 85.0% 100.0%

Chi-Square Tests

Value df Asymp. Sig.

(2-sided)

Exact Sig. (2-

sided)

Exact Sig. (1-

sided)

Pearson Chi-Square .388a 1 .533

Continuity Correctionb .032 1 .859

Likelihood Ratio .397 1 .529

Fisher's Exact Test .673 .435

Linear-by-Linear

Association

.378 1 .538

N of Valid Casesb 40


297

Left Hip

Sex * Crosstabulation

centerageLTnew Total

Dysplasia nodysplasia

Sex Male Count 2 20 22

% within Sex 9.1% 90.9% 100.0%

Female Count 3 15 18

% within Sex 16.7% 83.3% 100.0%

Total Count 5 35 40

% within Sex 12.5% 87.5% 100.0%

Chi-Square Tests

Value df Asymp. Sig.

(2-sided)

Exact Sig. (2-

sided)

Exact Sig. (1-

sided)

Pearson Chi-Square .519a 1 .471

Continuity Correctionb .058 1 .810

Likelihood Ratio .517 1 .472

Fisher's Exact Test .642 .402

Linear-by-Linear

Association

.506 1 .477

N of Valid Casesb 40


298

Usefulness of Fine needle aspiration cytology in the evaluation of

the Nodular Goiter with histopathological correlation Purushotham Krishnappa1, Sowmya Ramakrishnappa2

1Consultant Pathologist & Faculty of Pathology, International Medical University, Kuala

Lumpur.

2Department of Community medicine, University Putra Malaysia, Kuala Lumpur.


Dr Purushotham Krishnappa E mail: [email protected] Abstract

Aim: To assess the usefulness of fine needle

aspiration (FNA) in making a diagnosis of

multinodular goiter by correlating with the

histopathology wherever possible.

Materials & methods: All the patients

presented with multinodular thyroid

swellings at the Karnataka Institute of

Medical Sciences, Hubliunderwent FNAC

procedure. After careful analysis of the

slides, a cytological diagnosis was made.

This diagnosis was compared with

histological diagnosis wherever possible.

Analyses were evaluated using descriptive

statistics.

Results: A total of 41 patients were included

in the study. The mean age was 39 years.

The majority of the patients were females

(85.4%). The results of thyroid FNA revealed

that 7.3% (3) of the samples were

inadequate and did not yield a diagnosis.

Overall, the results of the tests were good,

revealing the diagnostic accuracy of 89%.

Conclusion: Thyroid FNA is a useful test in

the evaluation of multinodular goiter.

Keywords

Fine-needle aspiration, malignancy,

multinodular goiter

Introduction

Thyroid nodules are common clinical

encounters1. Nodular goiter forms an

important group of thyroid lesions which is

a major problem across the globe. The main

challenge in the clinical practice is to

differentiate accurately the malignant

nodules from the more common and

benign nodules so that an accurate pre-

operative tissue diagnosis is made and

allows theappropriatemanagement of the



299

patient2.The incidence of malignancy in

multinodular goiter (MNG) ranges from 1%

to 10%3.

Fine-needle aspiration (FNA) cytology is a

well-established procedure in the primary

diagnosis of thyroid disorders4.However,

the usefulness of FNA in multinodular goiter

is controversial. The study done by Antonio

Rνos et al reported that FNA is not useful

for differentiating MNG with malignant

thyroid lesions, as more than 80% of

carcinomas go unnoticed5, whereas other

study reported the ability to discriminate

11.7% of patients with a 34% probability of

malignancy (suspicious/malignant cytology)

from 81.2% of patients (benign cytology)

with a probability of only 3% of

malignancy6.

The aim of this study was to assess the

ability of thyroid FNA in accurately

diagnosing the multinodular goiter.

Materials and methods

A total of 41 cases presented with nodular

swelling of thyroid to the pathology

department at Karnataka institute of

Medical sciences were included in the

study. After a detailed explanation of the

FNAC procedure, aninformed verbal

consent was obtained from all the patients.

The demographic details and a detailed

history were obtained from the patients.

With the aseptic precautions all the

patients underwent fine needle aspiration

cytology.11 out of 41 cases underwent

surgery with subsequent histopathological

studies. The diagnosis of which was

compared with cytological diagnosis.

Results

The study had majority of the patients as

females 35 (85.4%) and 6(14.6%) cases

were males. Patient’s age ranged from 10

to 80 years. With maximum number of

patients in the age group of 20 – 29 years.

(Table1)

Out of 41 cases, 36 were in euthyroid state

remaining 5 had clinical signs and

symptoms of hyperthyroidism. All of them

presented with thyroid enlargement which

was diffuse, smooth and firm in 8, diffuse

nodular in 7 and remaining 26 had solitary

nodule. Size of the enlarged thyroid varied

from 1to 8 cm with surface smooth to

multinodular. Duration of enlargement

ranged from 4days to 20 years.

Aspirate was hemorrhagic in 7 patients. In

the remaining 34 patients aspirate

consisted of 0.25 - 10 ml of brown /

chocolate brown fluid.


300

Out of 41 samples, 3 samples yielded

inadequate follicular cells to conclude a

diagnosis and were reported as inadequate

samples. The remaining 38 cases were

diagnosed as nodular goiter. Aspirates were

cellular with honeycomb pattern of

follicular cells in 6 (14.6%) cases. Follicular

cells were arranged in small clusters and

singles in 35(73.1%) with few bare nuclei.

Pseudopapillary arrangement was seen in

2(4.8%) cases. Follicular cells showed mild

anisonucleosis in 38(92.6%). Fire flare was

observed in 11(26.8%). Askanazy cells were

present in 10 cases. Majority of these

showed abundant colloid (38 aspirates), in

the remaining 3 scant colloid was seen.

Foamy macrophages, sparse lymphocytes,

hemosiderin laden macrophages were seen

in most of the aspirates (Table 2).

Comparison of diagnosis of nodular goiter

by FNA and histopathology

Histopathological study was available in 11

cases. Cytological diagnosis of nodular

goiter was confirmed in 9 cases. The other

two cases were diagnosed as neoplastic

lesions with follicular adenoma and

follicular carcinoma respectively as shown

in the table 3.

Discussion:

In the current study we compared the

usefulness of FNA to histology results in

evaluating the thyroid nodules. There has

been series of clinical studies made on the

usage of fine needle aspiration cytology in

evaluating the thyroid nodules. However,

the utilization of this technique on the

multinodular goiter is not very much

established.

The study by Antonio Rios et al reports no

significant sensitivity and specificity of FNA

towards the diagnosis of nodular goiter6.

Furthermore this was supported by

Mandreker et al7 and Franklyn et al8. Our

study finds the diagnosis made by cytology

was 82% accurate when correlated with the

tissue diagnosis.

Review of literature has pointed out many

important issues in the varying results of

FNAC accuracy of diagnosing nodular

goiters9. One of the keyissues with MNG is

which nodule is to be aspirated10. A few

researchers claim that it is not

correct/ethical to aspirate all palpable

nodules when the clinical suspicion of

malignancy is minimal and they propose

that the aspiration should be done only

from the one or two of the prominent

thyroid nodules of each thyroid lobe and


301

from the nodules which are suspected to be

malignancy clicnially6.

FNA being a blind technique has limitations

like inadequateyield and false negative

results4. Inadequate samples results when

the lesions are cystic or vascular, yielding a

dilute specimen and few follicular cells.

False negative results occur majorly

because of wrong nodule being sampled11.

Literature also points out with addition of

ultrasound the efficacy of the FNA

technique increases greatly and reduces the

above mentioned limitations12.

Conclusion

FNAC is animportant baseline investigation

of thyroid disease with high specificity and

accuracy. We conclude that FNAC diagnosis

of nodular goiter is significant. However, we

caution about the false negative results

which can miss the possibility of a

neoplastic lesions. Thus, the final should be

based upon histopathology.


302

References

1. TamasSolymosi, GyulaLukacsToth and

MiklosBodo: Diagnostic accuracy of fine

needle aspiration cytology of the

thyroid. Acta cytological 45: 669-674,

2001.

2. Sachmechi I, Miller E, Varatharajah R,

Chernys A, Carroll Z, Kissin E, et al.

Thyroid carcinoma in single cold nodules

and in cold nodules of multinodular

goiters. EndocrPract. 2000;6:5–

3. Vander JB, Gaston EA, Dawber TR. The

significance of nontoxic thyroid nodules.

Final report of a 15-year study of the

incidence of thyroid malignancy. Ann

Intern Med. 1968; 69:537–40. 7

4. P. Krishnappa, S. Ramakrishnappa, M.H.

Kulkarni. “Comparison of Free Hand

versus Ultrasound guided Fine Needle

Aspiration of Thyroid with

Histopathological correlation”. Journal

of Environmental pathology, Toxicology

& Oncology. 2013 Vol.32 Issue 2: 149-

155.

5. Ríos A, Rodríguez JM, Galindo PJ,

Montoya M, Tebar FJ, Sola J, et al. Utility

of fine-needle aspiration for diagnosis of

carcinoma associated with multinodular

goiter. ClinEndocrinol (Oxf) 2004;

61:732–7.

6. Cap J, Ryska A, Rehorkova P, Hovorkova

E, Kerekes Z, Pohnetalova I. Sensitivity

and specificity of the fine needle

aspiration biopsy of the thyroid: Clinical

point of view. ClinEndocrinol

(Oxf)1999;51:509–15

7. Mandreker SR, Nadkarni NS, Pinto RG,

Menezes S. Role of fine needle

aspiration cytology as the initial

modality in the investigation of thyroid

lesions. ActaCytol. 1995; 39:898–904.

8. Franklyn JA, Daykin J, Young J, Oates

GD, Sheppard MC. Fine needle

aspiration cytology in diffuse or

multinodular goiter compared with

solitary thyroid nodules. BMJ. 1993;

307:240.

9. Lopez LH, Canto JA, Herrera MF,

Gamboa-Dominguez A, Rivera R,

Gonzalez O, et al. Efficacy of fine-needle

aspiration biopsy of thyroid nodules:

Experience of a Mexican

institution. World J Surg.1997; 21:408–

11.

10. Gharib H. Fine needle aspiration biopsy

of thyroid nodules: Advantages,

limitations and effect. Mayo Clin

Proc. 1994; 69:44–9.

11. Md. Shafiqul I, Belayat H S, Nasima A,

Kazi S S, Mohammad A. Comparative

study of FNAC and histopathology in the

diagnosis of thyroid swelling.

Bangladesh J Otorhinolaryngol. 16 (1);

April 2010.


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12. E. Papini, R. Guglielmi, A. Bianchini et

al., “Risk of malignancy in non-palpable

thyroid nodules: predictive value of

ultrasound and color-doppler

features,” Journal of Clinical

Endocrinology and Metabolism 2002,

vol. 87(5), 1941–1946,


304

Table No 1: Age and Sex distribution of nodular goiter based on cytological study Age(years) Male Female Total

0-9 - - -

10-19 2 1 3

20-29 - 11 11

30-39 1 7 8

40-49 1 6 7

50-59 2 3 5

60-69 - 4 4

70-79 - 1 1

80-89 - 2 2

Total 6 35 41

Table 2: Cytological features of Nodular goiter

Cytological features No of cases Percentage

Follicular cells in clusters and singles 6 14.6

Follicular cells in honey comb pattern 35 73.1

Papillary cluster 2 4.8

Anisonuleosis 38 92.6

Fire flare 11 26.8

Foamy macrophages 28 68.2

Hurthle cells 15 36.5

Abundant colloid 38 92.6

Scant colloid 3 7.3

Inflammatory cells( lymphocytes) 18 43.9

Table 3: Cytohistopathological correlation of nodular goiter

Cytological diagnosis of nodular goiter

Histological diagnosis

Nodular goiter Others

11 9 2 (1 – follicular adenoma, 1- follicular carcinoma)


305

Impact of Standardized Feeding Regime on Incidence of

Necrotizing Enterocolitis in Low Birth Weight Babies

Manjunatha Sarthi1, Mohamed HaseenBasha2, Chandini K3, Ashoka4, Prasad B S5

Associate professor1, Assistant professor2, Resident3, Associate professor4, Professor5

Department of pediatrics, S.S. Institute of Medical Sciences & Research Center

Davangere 577005, Karnataka, India


Dr.B.S.PRASAD


Abstract

Objective: The objective of this study was

to evaluate the role of standardized feeding

regime in reducing the incidence of

Necrotising Enterocolitis (NEC) in Low Birth

Weight (LBW) babies.

Methods: Prospective study conducted on

all LBW babies admitted to level III NICU

from July 2009 to June 2011.

Results: There were 250 LBW babies

admitted to NICU, out of these 20 were

excluded from the study. The remaining 230

were categorized in to 5 groups based on

the birth weight. In group I, two babies out

of 35 developed NEC (7.1%). In group II, one

baby out of 40 developed NEC (3.1%). In

group III, group IV and group V, none had

NEC.

Conclusion: Implementation of

standardized feeding regime in LBW babies

results in significant reduction in incidence

of NEC.

Keywords: Necrotising Enterocolitis (NEC),

Low Birth Weight (LBW), Feeding

guidelines.

Introduction

Premature birth is defined as birth of baby

before 37 completed weeks of gestation

from 1st day of last menstrual

period1.Premature infants are at greater risk

of short term complications like difficulty in

feeding, feed intolerance, vomiting,

necrotizing enterocolities1 and risk of

infection due to prolong intravenous

catheterization for parentral nutrition. The

long term complications include cognitive

dysfunction2, learning disability3, protein

energy malnutrition and gastro-esophagus

reflux disease and so on.



306

Proper nutrition in postnatal age is essential

for normal growth, immunity, long term

health and optimal neurologic and cognitive

development. Providing adequate nutrition

to preterm infants is challenging because of

immaturity of bowel function, inability to

suck and swallow, high risk of necrotizing

enterocolitis (NEC) 1, illnesses that may

interfere with adequate enteral feeding

(e.g., RDS, PDA), sepsis causing feed

intolerance.NEC may result from initial

mucosal injury secondary to multiple

factors leading to a loss of mucosal integrity

in an immature gut 4, 5, 6. The combination

of bacterial colonization, mucosal injury and

enteral feedings predispose the baby to

develop NEC7.

Currently no single specific preventive

strategy exists for NEC.Many consider NEC

as almost unpreventable given its poorly

understood patho-physiology,and the

difficulties in preventing prematurity, the

single most important risk factor for

development of NEC8. Besides prematurity,

only enteral feeding has a firm association

with NEC, considering that only 10% of the

cases occur in neonates who have never

been fed9. Epidemilogical data strongly

suggest that NEC has an iatrogenic

component related to variations in clinical

practices including feeding strategies10.A

significant and prolonged decline in the

incidence of NEC, nearing virtual

elimination in some countries, has been

reported consistently since implementation

of a standardized feeding regimen (SFR) 11,

12.

Methods

This study was prospective study on LBW

babies from level III NICU of S. S. Institute of

Medical Science and research centre after

implementation of standardized feeding

regime. A standardized feeding regime was

developed through clinical consensus of the

faculty in the department on the basis of

review of literature and other center

feeding protocol. Study was conducted

from July 2009 to June 2011 for a period of

2 years.

All preterm (< 37 completed weeks of

gestation) babies admitted to NICU within

24hrs of life were enrolled in study.

The Exclusion criteria were

1. Congenital anomalies that interfere

with feeding like cleft palate,

esophageal atresia, trachioesophageal

fistula and so on.

2. Those babies admitted to hospital after

24hrs of birth.

3. Babies with respiratory distress due to

any cause.

4. Babies requiring ventilator care.

5. Hemodynamically unstable babies.


307

6. Babies with hypoxic ischaemic

encephalopathy (>/= stage II of sarnat

classification of HIE)13

7. Babies who develops septicemia14

These babies were categorized based on

their birth weight as group I to V after

excluding those babies who met exclusion

criteria.

Assessment of gestation is done by using

modified Ballard`s chart 15. Babies were

weighed at admission and then daily on an

electronic weighing scale of ESSAE model

which has accuracy of ±10gm.

Written informed consent was taken from

parents before inclusion of babies in to

studies.Ethical clearance was taken from

Institute Ethical Committee. After inclusion,

a detailed history was taken for each

neonate to determine the risk factors for

LBW. Babies were categorized to five

groups on the basis of birth weight and

feeding was started according to birth

weight with a standardized feeding regime

through nasogastric tube as shown in table

1. All babies were started with mother`s

milk and in case if mother milk is not

available, Low birth weight formula feed

has been given. The outcome were

measured in the form of necrotizing

enterocolitis, feed intolerance, abdominal

distension and weight gain pattern during

hospital stay.

Babies with <32 weeks postmenstrual age

were given nasogastric tube feeding

intermittently as their sucking and

swallowing mechanism is immature. Direct

Breast feeding was started in such babies

after reaching corrected gestational age of

32 weeks, and is clinically stable and has

sucking and swallowing coordination. The

transition from tube to breast was gradual

and was managed by the nursing staffs.

Mothers will be encouraged to follow a

breast-feeding regimen i.e. an increase in

length and frequency of breast feeds and a

reduction in volume and frequency of tube

top ups. Feeds were stopped immediately,

if there is any clinical evidence of NEC

(modified Bell’s stage >/=1)17or features of

bowel obstruction like Increasing abdominal

distension, heavily bile-stained vomitus or

aspirates, having significant gastrointestinal

bleeding. Feed tolerance monitored by

abdominal girth and abdominal distention

and growth by daily Weighing.

Results

There were 250 LBW babies admitted to

NICU, out of these 20 were excluded from

the study as 11 babies required ventilator

support for Respiratory Distress Syndrome

and 9 babies had sepsis.Among 230


308

babies,119 were males and 111 were

females. Table 2 showing demographic

details and basal data of patients including

the weeks of gestation, hours of life at the

time of admission and birth weight.

In group I, there were 35 babies of which 28

were enrolled. Weeks of gestation was

ranging from 28 to 30 weeks, hours of life at

the time of admission was ranging from 1 to

5 Hrs and Birth weight was ranging from

860 to 980 grams. In group II, there were 40

babies of which 32 were enrolled. Weeks of

gestation was ranging from 28 to 32 weeks,

hours of life at the time of admission was

ranging from 2 to 7 Hrs and Birth weight

was ranging from 1100 to1240 grams. In

group III, there were 60 babies of which 58

were enrolled. Weeks of gestation was

ranging from 30 to 35 weeks, hours of life at

the time of admission was ranging from 2 to

10 Hrs and Birth weight was ranging from

1260 to 1480 grams. In group IV, there were

60 babies of which 58 were enrolled. Weeks

of gestation was ranging from 34 to 36

weeks, hours of life at the time of admission

was ranging from 2 to 18 Hrs and Birth

weight was ranging from 1560 to 1800

grams. In group V, there were 55 babies of

which 54 were enrolled. Weeks of gestation

was ranging from 34 to 36 weeks, hours of

life at the time of admission was ranging

from 2 to 10 Hrs and Birth weight was

ranging from 1820 to 1880 grams.

Table 3 showing the Mean and SD of full

feeding reached, weight gain started days,

discharge weight and hospital stay in days

in each group and incidence and % of

incidence of NEC. In group I, full feed was

reached by 15-19days, weight gain started

from 21-26 days, discharge weight was

ranging from 1200 to 1320grams, and total

duration of hospital stay was ranging from

34-48 days. Two patients out of 35

developed NEC (7.1%) in this group. In

group II, full feed reached by 8-14 days,

weight gain started from 11-19 days,

discharge weight was ranging from 1200 to

1400grams, and total duration of hospital

stay was ranging from 18-40 days. One

patient out of 40 developed NEC (3.1%).In

group III, full feed reached by 6-10 days,



1500 grams, and total duration of hospital

stay was ranging from 11-27 days. None

had NEC in this group. In group IV, full feed

reached by 5-9 days, weight gain started

from 7-14 days, discharge weight was

ranging from1480 to 1800grams, and total

duration of hospital stay was ranging from

9-18 days. None had NEC in this group. In

group V, full feed reached by 4-5 days,


309



1820 grams, and total duration of hospital

stay was ranging from 8-14 days. None had

NEC in this group.

Discussion

Currently no single specific strategy exists

for preventing NEC.Prematurity is one of

the most important risk factor for NEC18,

which is most difficult to control. With

improvement in care of preterm babies, the

survival of preterm babies has improved

further. Besides prematurity, only enteral

feeding has a firm association with

NEC.There are limited number of studies to

compare the incidence of NEC and

implementation of the standardized feeding

regime.

Our study showed a prevalence of NEC is

about1.3% which is comparable with 5% of

prevalence of NEC of total NICU admissions,

i.e., implementation of standardized

feeding regime has reduced the incidence

of NEC in high risk group. The benefit of

feeding regimen could be related to

decreasing variations in enteral feeding

practices as well as increased awareness

leading to early detection and management

of feed intolerance. Variations in enteral

feeding strategies in clinical practice has

been proposed to be iatrogenic component

of NEC.19, 20

Variations in enteral feeding strategies for

preterm neonates have also been reported

by parole et al.21Given such evidence and

the consistent reports of significant and

prolonged decline in the incidence of NEC

after implementation of SFR,it is almost

certain that variations in clinical practice

contribute to the incidence of

NEC.Kamitsuka et al,22 developed a SFR to

reduce variability in feeding practice for

neonates weighing >1250 gm. The risk of

NEC was reduced by 84% after the

introduction of feeding schedules. Before

the feeding schedules, those who

developed NEC were more likely (73.3% v

52.1%) to have been started on formula and

receive it as the first feed(83% v 20%) than

those who developed NEC after

implementation of the feeding

schedules.Brown et al,23reported that NEC

was virtually eliminated from their nursery

after they implemented a cautious and

conservative feeding schedule.Spritzer et

al,24 introduced a cautious a SFR based on

the recommendations of Brown et al,and

reported their experience as dramatic

decrease in the incidence of NEC.

The process per se developing and

implementing aSFR is associated with an


310

increased awareness of the existing

evidence and with early detection and

management of NEC.The benefits of SFR

may be related to the process of developing

and implementing the SFR as well as to the

constituents of the SFR itself. The

differences in the population

characteristics, clinical practices and

constituents of SFR in the various studies,

however indicate that the benefits are most

probably related to the process of

developing and implementing the SFR

rather than its specific constituents.

Our study was a hospital based study the

prevalence of the NEC and outcome may be

different from a community setting. In our

study the feeding was started and

categorization was on the basis of birth

weight and gestational age was not

considered which has direct correlation

with gut prematurity and high incidence of

NEC. We didnot make different feeding

regime for IUGR babies and AGA babies

which might also have some influence on

outcome.

CONCLUSION:

Our study showed that

implementation of SFR can reduce the

incidence of NEC in high risk group.The

benefit of feeding regimen could be related

to decreasing variations in enteral feeding

practices as well as increased awareness

leading to early detection and management

of ‘’feeding intolerance” and early NEC.

ACKNOWLEDGEMENTS:

The authors would like to thank all the

babies and their parents, their

colleagues for their participation and

cooperation in this study.

CONFLICT OF INTEREST: None

ETHICAL CLEARENCE: Institutional ethical

clearance obtained

SOURCE OF FUNDING: Self


311

REFERENCES:

1)Klingman,Stanton,St.Geme,Schor, Behrman, Prematurity and intrauterine growth restriction, Nelson text book of pediatric,19th edition, 555 2)Aizenman E, White WF, Loring RH, Rosenberg PA (August 1990). "A 3,4-dihydroxyphenylalanine oxidation product is a non-N-methyl-D-aspartate glutamatergic agonist in rat cortical neurons". Neuroscience Letters116 (1-2): 168–71. PMID1979663. 3) Frye RE, Landry SH, Swank PR, Smith KE (2009). "Executive dysfunction in poor readers born prematurely at high risk".Developmental Neuropsychology34 (3): 254-71.doi10.1080/87565640902805727. PMC2692028.PMID 19437202.: 4)Koloske AM. Pathogenesis and prevention of necrotizing enterocolities. Pediatrics 2010; 125; 777-785. 5)Reber KM. Neonatal intestinal circulation: physiology and pathophysiology. ClinPerinatol 2002; 29:23-39. 6) Wynn JL,Wong H R. pathophysiology and treatment of septic shock in neonate: clinPerinatol 2010; 30:50-54. 7)Kosloske AM. Pathogenesis and prevention of necrotizingenterocolities.Pediatric 1984; 74:1086-1092. 8) Singh, singh,&shikha,2007.a prospective analysis of etiology and outcome of preterm labour. The journal of obstrics and Gyneclogy OG india.57 (1), 48-52. 9) Samantha S. et al. Feeding the low birth weight infants. Indian J PractPediatr 2005;7 (4):304.

10) NNF. Neonatal morbidity and mortality - Report of National Neonatal, Perinatal data base.Indian Pediatr 1997; 34. 11)Kliegman, Behrman,Jenson, Stanton, The high risk infant, Nelson edition18, pg no 702 12)GuilletR,StollBJ,CottonCM,et al. Association of h2 blocker therapy and higher incidence of necrotizing enterocolities in very low birth weight infants. Pediatrics 2006;117: e 137-142. 13) Korszun P, Dubiel M, Breborowicz G, et al. Fetal superior mesenteric arteryblood flow velocimetry in normal and high-risk pregnancy. J Perinat Med 2002; 30:235. 14) Blott M, Greenough A, Gamsu HR, et al. Antenatal factors associated with obstruction of the gastrointestinal tract by meconium. BMJ 1988; 296:250. 15)Robel-TilligE,Vogtmann C, Bennek J. Prenatal hemodynamic disturbance pathophysiological background of intesnal motility disturbances in small for gestational age infants. Eur J PediatrSurg 2002; 12:175–9. 16)Mihatsch, WA, von Schenaich P, Fahnenstich H et al. The significance of gastric residual in the early enteral feeding advancement of extremely low birth weight infants.Pediatrics 2002; 109:457-459. 17) Srinivas PS, Brandler MD. Necrotizing enterocolities: Clin in perinatal 2008; 35; 251-272. 18)Bell EF,Acarregui MJ. Restricted versus liberal water intake for preventing mortality in preterm infants, Cochrane. Database Syst Rev 3 (2001): CD000503.


312

19) Agwu JC, Narchi H. In a preterm infant, dose blood transfusion increases the risk of necrotizing enterocolities. Arch Dis Child 2005; 90(1):102-03. 20) RG Bury, Tudehope D. Enteral antibiotics for preventing necrotizing enterocolities in low birth weight or preterm infants. Cochrane Database Syst Rev 1(2001):CD000405. 21) DB McElhinney, et al. “Necrotizing enterocolities in neonates with congenital heart disease: risk factors and outcomes.” Pediatrics 2005; 106(5):1080-7. 22) Berseth CL, Bisquera JA Paje VU, Prolonging small feeding volumes early in the life decreasing the incidence of necrotizing enterocolities in very low birth weight infants. Pediatrc 2003; 111(3):529-34. 23) Soto TT, Oldham K.T. Abdominal drain placement versus laproscopy for NEC with perforation: Clin in perinatol2004; 24:577-589. 24) McGuire W. Slow advancement of feedvolume to prevent necrotizing enterocolities in very low birth weight infants. Cochrane Database syst Rev-01 JAN 2008 (2):CD001241.


313

Tables

Table 1: categorization of babies in to groups

Group Birth

weight

(gm)

Initial rate

(ml/kg/day)16

Volume

increase

(ml/kg/day)16

Frequency

(Hrly)

Timing of starting feeding

(NNF guidelines)

I

<1000

10

10-20

Initially

hourly

then 3rd

hourly

As early as clinically

appropriate in stable babies

II

1001-1250

20

20-30

3rd

As early as clinically

appropriate in stable babies

III 1251-1500 30 30 3rd With in 24 hrs

IV 1501-1800 30-40 30-40 3rd With in 24 hrs

V 1801-2000 40 40-50 3rd With in 24 hrs


314

Table 2 : Demographic details and basal data of the babies

Group Total admission during July 2009 to June 2011

Total babies included in study

Week of gestation

Hrs of life at time of admission

Birth Weight (kg)

Gender Total Gender Total

Male Female Male Female Mean SD P*Value sign

Mean SD P*Value sign

Mean SD P*Value Sign

I 18(51) 17(49) 35 15(54) 13(46) 28 28.1 0.4

p<0.001 HS

2.4 1.1

p<0.001 HS

0.94 0.04

p<0.001 HS

II 22(55) 18(45) 40 18(56) 14(44) 32 29.93 0.6 3.7 1.2 1.16 0.05

III 34(57) 26(43) 60 33(57) 25(43) 58 32.6 1.5 4.6 1.9 1.35 0.06

IV 28(47) 32(53) 60 27(47) 31(53) 58 34.29 0.7 5.0 2.9 1.59 0.07

V 27(49) 28(51) 55 26(48) 28(52) 54 35.75 0.7 5.9 2.0 1.83 0.01

Total 129(52) 121(48) 250 119(51) 111(48) 230 32.6 2.7 4.5 2.3 1.43 0.3

SD: Standard Deviation, HS : Highly Significant , *one way ANOVA test


315

Table 3: Mean and SD of full feeding reached, weight gain started days, discharge weight and hospital stay in days in each group and incidence and % of incidence of NEC

Group

Full Feeding reached(Days)

Weight gain started(Days)

Discharge weight(kg)

Hospital stay(days)

NEC





Incidence % Incidence

I 18.14 1.35

p<0.001 HS

24.4 2.1

p<0.001 HS

1.26 0.04

p<0.001 HS

39.60 4.87

p<0.001 HS

2 7.1

II 10.33 2.12 16.25 2.34 1.31 0.04 29.03 6.40 1 3.1

III 7.63 0.92 12.12 1.88 1.36 0.06 18.13 3.54 0 0

IV 6.33 0.86 10.43 1.94 1.57 0.07 14.40 2.39 0 0

V 4.27 0.65 7.45 1.05 1.76 0.02 10.58 1.65 0 0

Total 8.48 4.50 13.07 1.65 1.48 0.2 20.31 10.48 3 1.3

SD: Standard Deviation, HS : Highly Significant , *one way ANOVA test


316

Characteristics of some studies

Reference Author and year Weight NEC incidence before study

NEC incidence After study

23 Brown et al 1978 LBW 14/1745 1/932

24 Spritzer et al 1988 <2 kg 51/529 0/604 - 3/937

22 Kamitsuka et al 2000 LBW 23/477 5/467

21 Patole et al 2000 VLBW 3/68 3/77


317

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