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Journal of Evolution of Medical and Dental Sciences/ Volume 1/ Issue 3/ July- Sept 2012

Page 69

USE OF TRADITIONAL MEDICINE IN FEVER

Purabi Phukan

1. Associate Professor, Department of Community Medicine, Srinivasa Institute of Medical Sciences and Research

Centre, Mangalore- 574146

CORRESPONDING AUTHOR:

Dr Purabi Phukan,

Associate Professor,

Department of Community Medicine,

Srinivasa Institute of Medical Sciences and Research Centre,

Mangalore- 574146,

Karnataka, India.

Email ID- [email protected]

INTRODUCTION:

Malaria is the most common cause of fever in India and is an age old problem in India

claiming thousands of life over the years 1,2. WHO launched its first ever comprehensive traditional

Medicine strategy in 2002 strategy to assist countries to gather and preserve knowledge on such

practices with the hope to develop a good database for finding antimalarial properties in future in

wake of drug resistance. Majority of the rural and tribal in rural areas have vast store of knowledge

and practice of traditional medicines as it is cheaper and easily accessible to them 3 4 5. Traditional

Medicine often becomes the first source of treatment for these communities. The WHO estimated

that 80% of the world’s population use botanical medicines for their primary health care needs,

malaria treatment inclusive6. The current study was therefore undertaken with an objective to find

out the knowledge and practices of traditional medicines among rural and tribal communities for

fever and the factors influencing such practices.

KEY WORDS: Malaria, Traditional Medicine, Fever, Ethnopharmacology

MATERIAL & METHODS:

A community based cross-sectional study was undertaken from June 2009 to May 2010 in

Rani Community Development Block which is the Rural Field practice area of Gauhati Medical

College, Assam. The Block has 96 villages with total population of 86,539 and literacy rate is 66.8%

(2001 Census). The block has 18% tribal population residing in 36 villages.

Considering expected frequency as 50%, by using Epi Info Version 7 sample size was

calculated to be 300 (95% confidence level, confidence limits of 5.65%). To get a representative

population, the households were selected by Proportionate Probability Stratified Random Sampling

technique from 16 villages. The 16 villages together formed a uniform composition, firstly in terms

of tribal and non-tribal study subjects and secondly in terms of easier and more difficult access to

health services. Stratification was done based WHO Protocols and methods of malaria situation

analysis 6. Head of the household was interviewed and data was collected in a pre-tested and

predesigned proforma regarding socio-demographic characteristics, knowledge and practices of

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traditional medicines in fever and in known malaria, factors influencing their use. Also the herbs

and plants that are used was identified and recorded. However the pharmacological property of

these plants and herbs are out of the scope of this study and review of Botanical Plants literature

was done to find out available data on its use and medicinal properties. Statistical Analysis of the

data was subjected to descriptive analysis and Epi Info Version7.

RESULTS:

The Socio demographic profile of the study population is shown in Table 1. Among the 150

tribal and 150 non-tribal households visited it was found that literacy level of head of the

household was 82.7% and 92.6% respectively, with total literacy rate of 87.7%. According to

occupation of the head of the families it was found that majority are cultivators (51.2%) among the

tribal and businessman (40.7%) among the non-tribal communities and 24 % and 12.6% of the

tribal and non-tribal families are living below poverty line (income less than Rs 228.9 per capita per

month at 1993-94 prices). The respondents belonged to the age group of 19 -59 years, of which,

among the tribal 61.4% are males and 38.6% are females while among the non-tribal respondents,

72% are males and 28% are females. Majority of the tribal respondents belonged to Hindu (82.4%)

and rest were Christian (21.3%) whereas among the non-tribal respondents majority were Hindu

(86%) and the rest Muslim (14%).

Table 2 shows that knowledge and practice of traditional medicine. Out of the 300

households visited only 49 (16.3%) households knew of traditional medicines used in fever. Out of

these 49 households, majority, 38 (25.3%) belonged to the tribal community while 11 (7.3%)

belonged to non-tribal community. However, out of the 49 households, only 8 (5.3%) of the tribal

households and 3 (2%) of the non-tribal households are currently involved in collection and

preparation and distribution of the medicine prepared from the herbs. The names of the herbs and

plants used and the mode of preparation and administration was demonstrated and explained by

them.

The remaining 251 (83.7%) of the respondents did not have any faith in traditional

medicines for treatment of malaria and they neither had any knowledge of these remedies. Further,

it must be mentioned that although use of traditional medicines was reported by 49 households, it

is usually used as an initial management; if fever does not improve in next 2-3 days then they opt

for allopathic medicines.

Table 3 shows the common factors influencing the practice of traditional medicines for

fever. However, 40 (81.6%) respondents, 32 (84.2%) tribal and 8 (72.7%) non-tribal respondents

said they would also prefer to use traditional medicines as an adjunct to antimalarials if diagnosed

as malaria fever.

In this study 6 botanical plants that are practiced in the study area were identified and

recorded. Table 4 shows the different plants and herbs that were identified. These are Murraya

koenijii, Vitex negundo, Centella asiatica, Azadiracta indica, Ocimum sanctum/Ocimum basilicum

and a plant known as Tupurilata or Panipanta locally (scientific name unknown) are identified to be

used for treatment of fever and malaria as home remedy.

It was found that in case of the plant Tupurilata (local name), it was made into a thin paste

mixed with coconut oil and is applied over the scalp of infants and young children with high fever

when parents fear to giving allopathic medicines because they believe them to be having adverse

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side effects. The other plants and herbs like Narasingha, Pasotia are grinded together applied on

scalp or body to get relief from headache and bodyache associated with fever. Whereas Manikmoni,

Neem and Tulsi taken orally in the treatment of persistent fever for young children as well as adults

by grinding and mixing them together and making a decoction and taken orally to get relief from

fever.

DISCUSSION:

The results of this study revealed that knowledge of traditional medicines was present only

in 49 (16.3%) of the respondents while only 11 (3.6%) practiced it in their homes recently. Similar

result was found in another study where 2.1% of the tribal community used local herbs for

treatment of malaria7. This value is comparatively less than the findings in other studies in Assam

where initial treatment through traditional healer (Vaidya) was found in 39.2% 8. The remaining

97% of the respondents did not have any knowledge about these traditional medicines used nor

believed that they can be helpful in malaria treatment.

The decreasing knowledge and practice of traditional medicines may be due to increased

malaria awareness campaigns in recent years and also due to high literacy rate of the study

population.

However in this study none of the respondents said that they will depend solely on TM if

fever is known to be due to malaria which is a positive finding in this study. After initial home

management if fever does not improve in 2-3 days than they opt for allopathic treatment from

doctor. This shows that access to early diagnostic facility would prevent the morbidity and

mortality that occurs due to delay in diagnosis. The factors like severity of fever, associated

symptoms of jaundice, infants and young children with persistent fever and fever in elderly people

and fear of side effects of the antipyretics and anti-malarials influenced the use of traditional

medicine. They are of the opinion that these medicines are safer to give to infants rather than

antimalarials as they seen side effects after using these. Similar finding was observed in Nigeria9.

Affordability of medicines was not a factor as they were aware of the free antimalarials available at

the health center.

Regarding the medicinal value of the plants used it was found that some of them indeed

were found to be having some benefit in treatment of fever and even in malaria.

Ocimum sanctum, locally known as “Tulosi” was found to be having many properties

including antipyretic and anti-malarial activity against P. falciparum and P vivax 10, 11, 12.

Similar use for fever and cough was also found in Arunachal Pradesh among Khamti tribes

in Lohit District13 and in rural area of Tamil Nadu14. In another study insecticidal property of tulsi

was also found15.

Azadirachta indica, locally known as “neem” was also found to exhibit antimalarial activity

by inhibiting the growth of P. falciparum 16and even against drug resistant strains of P. falciparum 17, 18.

Vitex negundo, locally known a “pasotia” meaning five leaved plant, Ayurveda it is called

nirgundi and in the west known as Chastetree, has proved to be useful in fever, spleen enlargement

and convulsion14 and in malaria19. Besides this it was also found to have insecticidal and pesticidal

properties by other studies 20, 21, 22.

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Centella asciatica, locally known as “manikmoni”, was also found to be useful malarial fever 23, 24, 25.

Murraya koenigii, locally known as “Narasingha” in this study area was also found to be

having anti-inflammatory property and hepatoprotective26.

A study in Africa has shown that traditional medicine can reduce 1 million malaria deaths.

In rural Tanzania a study about traditional Masai medicine showed 48% children already had

knowledge about these plants which have been preserved in the UN database for future reference27.

“Tupurilata” was not found in any database and it is a new plant found in this study which needs to

be studied. B N Prakash, a researcher with the foundation for the revitalization of Local Health

Tradition, based in Bangalore found Guduchi (Tinospore coeditdia) to have shown to reduce

malaria related deaths by 5 to 10 times.

CONCLUSION:

The study indicates that knowledge and practices regarding traditional medicines for

malaria or fever has significantly declined in the study population. The study indicates that delay in

malaria diagnosis may be one of the causes of depending on traditional medicine which can be

improved by making easier access to early diagnosis. That the use of traditional medicines does

more damage than good does not hold good in the current scenario when many studies did reveal

their usefulness. But certain remedies which have not been tested for efficacy is not encouraged so

vigorous research on the efficacy of traditional plants on malaria treatment should be carried out to

ascertain their usefulness. Ethno-pharmacological studies are encouraged to determine the

usefulness these traditional remedies, as few of these were found to be having some anti-malarial

property. The commonly used plants are brought out in this study along with their use. For this

purpose a book called “Traditional medicines and plants and malaria” by Merlin Wilcox, Gerard

Bodeker and Phillipe Rasanova provides guidelines on how to conduct such studies.

TM practice is an established health care system in India and is fast growing importance in

the western world. India can therefore contribute immensely for development and research for

alternative malaria treatment.

ACKNOWLEDGEMENT:

I thank, Dr R Sarma, Professor, Department of Community Medicine, Gauhati Medical

College, for her guidance pertaining to this work. I also would like to thank Ms. M Baruah, Lecturer

Botany, Arya Vidyapeeth College and Dr N D Bendegeri, Professor and Head, Department of

Community Medicine, KBNIMS for providing their valuable suggestions in preparation of this paper

for publication.

REFERENCES:

1. (Dhiman RC, Pillai CR, Subbaroa SK. Investigation of malaria outbreak in Bahraich district,

Uttar Pradesh. Malaria Research Center (ICMR), Delhi, India. Indian J of Med. Res. May 2001;

113:186-91.

2. C D Alert. Some important outbreaks of malaria in India during 2000. Jan 2001; 5:1.

3. WHO. Traditional Medicine Strategy 2003-2005. Geneva. Document: WHO/EDM/TRM/

2002.1.

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4. Pulok K. Mukherjee and Atul Wahile. Integrated approaches towards drug development

from Ayurveda and other Indian system of medicines. Journal of Ethnopharmacology; 2006;

103: 25–35.

5. Merlin Willcox. Traditional herbal medicines for malaria. BMJ. 2004; 329 (7475):1156

6. Protocols and methods for malaria situation analysis. WHO, HIV/AIDS, Tuberculosis,

Malaria. Roll Back Malaria. July 2003. Trial Edition. Pg.1-88. (WHO/HTM/RBM/ 2003.47)

7. V Soan, Gyan Chand. Proceedings of National Symposium on Tribal Health. Knowledge,

Attitude and Practices towards Malaria in Tribal Community of Baigachak Area, Dindori

District (MP), Pg-75-78 (http://www.rmrct.org/files_rmrc_web/centre's_publications/

NSTH_06/NSTH06_9.V.Soan.pdf)

8. Chaturvedi HK, Mahanta J and Pandey A. Treatment-seeking for febrile illness in north-east

India: an epidemiological study in the malaria endemic zone. Malaria Journal.

17 December 2009; 8:301 (doi:10.1186/1475-2875-8-301)

9. Erhun W O, Agbani E.O and Adesanya S.O. Malaria Prevention: Knowledge, Attitude and

Practice in a Southwestern Nigerian Community. African Journal of Biomedical Research;

2005; 8: 25 - 29.

10. Pandey BP, Anita. In: Economic Botany; 1990. p. 294 (Published by Chand and Company

Ltd., Ramnagar, New Delhi.

11. P. Prakash and Neelu Gupta. Therapeutic uses of Ocimum sanctum Linn. (TULSI) with a note

on Eugenol and its pharmacological action: A Short Review. Indian J Physiol Pharmacol

2005; 49 (2): 125–131

12. Savitri Godhwani, J.L. Godhwani and D.S. Vyas. Ocimum sanctum: An experimental study

evaluating its anti-inflammatory, analgesic and antipyretic activity in animals. Journal of

Ethnopharmacology. November 1987; 21(2): 153-163

13. Hui Tag, AK Das, Hari Loyi. Anti-inflammatory palnts used by Khamti tribes in Lohit District

of Auranachal Pradesh, India. Natural Product Radiance. 2007; 6(4):334-340.

14. Chellaiah Muthu, Muniappan Ayyanar, Nagappan Raja and Savarimuthu Ignacimuthu.

Medicinal plants used by traditional healers in Kancheepuram District of Tamil Nadu, India.

Journal of Ethnobiology and Ethnomedicine; 2006, 2:43 doi:10.1186/1746-4269-2-43).

(available online at: http://www.ethnobiomed.com/content/2/1/43)

15. Ocimum sanctum. The Indian home remedy. In: Current Medical Scene, March-April 1992;

(Edited and published by S. Rajeshwari, Cipla Ltd., Bombay Central, Bombay.

16. Rochanakij, S., Thebtaranonth, Y., Yenjal, C. H. and Yuthavong, Y. Nimbolide, a constituent of

Azadirachta indica inhibits Plasmodium falciparum in culture. Southeast Asian J. Trop. Med.

Public Health; 1985; 16: 66–72.

17. Kausik Biswas, Ishita Chattopadhyay, Ranajit K Banerjee and Uday Bandopadhyay.

Biological activities and medicinal properties of neem (Azadirachta indica). Curent Science;

82(11):1336-1345.

18. Badani, L., Deolankar, R. P., Kulkarni, M. M., Nagsampgi, B. A. and Wagh, U. V. Biological

activities and medicinal properties of neem. Indian J. Malariol.; 1987; 24: 111–117.

19. agnus-castus.co.uk. [homepage]. Agnus castus (Vitex negundo). (available from

http://www.herb-agnus-castus.co.uk)

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20. Vishal R Tandon. Review article: Medicinal Uses and biological properties of Vitex negundo.

NISCAIR Online Periodicals Repositories (NOPR). 2005; 4 (3): 162-165.

21. Hebbalkar DS, Hebbalkar GD, Sharma RN, Joshi VS, Bhat VS. Mosquito repellent activity of

oils from Vitex negundo Linn. leaves. Indian J Med Research; 1992; 95:200–203.

22. Krishnan Kannathasan & Annadurai Senthilkumar & Manivachagam Chandrasekaran &

Venugopalan Venkatesalu. Differential larvicidal efficacy of four species of Vitex against

Culex quinquefasciatus larvae. Parasitol Res; 2007; 101:1721–1723.

23. Nima D. Namsaa, M. Mandal and S. Tangjang. Anti-malarial herbal remedies of northeast

India, Assam: An ethnobotanical survey. Journal of Ethnopharmacology. Article. In Press-

Corrected Proof. 2010).

24. Sakshi Singh, Asmita Gautam, Abhimanyu Sharma and Amla Batra. Centella asiatica (L.): A

plant with immense medical potential but threatened. International Journal of

Pharmaceutical Sciences Review and Research. 2010; 4(2). Article 003 (Available online at

www.globalresearchonline.net).

25. Rahmatullah Mohammad, Ferdausi Dilara, Mollik Haque Ariful Md., Jahan Rownak,

Chowdhury H. Majeedul, Haque Mozammel Wahid, A survey of medicinal plants used by

Kavirajes of Chalna Area, Khulna District, Bangladesh. Afr. J. Trad. 2010; 7(2): 91-97

26. Bitterroot restoration [homepage]. Herbal Medicine> Medicinal Plants-Murraya koenijii.

27. IRIN: AFRICA: Turning to traditional medicines in fight against malaria. [Homepage]. IRIN:

The humanitarian news and analysis. A service of the UN Office for the co-ordination of

Humanitarian Affairs). (available at: http://www.irinnews.org)

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* fisherman, silkworm rearing, selling household produce like betel nuts and vegetables,

agricultural labourer, income from house rent and income from pension.

Table 1. Socio-demographic profile of the study population

Socio demographic Tribal (150) Non-tribal (150) Total (300)

profile No. (%) No. (%) No. (%)

Religion

Hindu 118 (78.7%) 129 (86%) 247 (82.4%)

Muslim - - 21 (14%) 21 (14%)

Christian 32 (21.3%) - - 32 (21.3%)

Sex

Male 92 (61.4%) 108 (72%) 200 (66.7%)

Female 58 (38.6%) 42 (28%) 100 (33.3%)

Age range (years)

19-28 15 (10.0%) 9 (6.0%) 24 (8.0%)

29-38 44 (29.2%) 49 (32.7%) 93 (31.0%)

39-48 52 (34.8%) 52 (34.8%) 104 (34.7%)

49-58 28 (18.8%) 26 (17.3%) 54 (18.0%)

>59+ 11 (7.2%) 14 (9.2%) 25 (8.4%)

Education Level

Illiterate 26 (17.3%) 11 (7.4%) 37 (12.4%)

Primary School 56 (37.3%) 35 (23.3%) 91 (30.4%)

High School 44 (29.3%) 57 (38.0%) 101 (33.7%)

HSCL passed 16 (10.7%) 21 (14.0%) 37 (12.4%)

HS passed & above 8 (5.4%) 26 (17.3%) 34 (11.4%)

Occupation

Cultivator 77 (51.2%) 47 (31.3%) 124 (41.3%)

Daily wage earner 62 (41.3%) 19 (12.7%) 81 (27%)

Skilled labour 5 (3.3%) 2 (1.3%) 7 (2.3)

Service 26 (17.3%) 37 (24.7%) 63 (21%)

Business 10 (6.6%) 61 (40.7%) 71 (23.7%)

Others* 17 (11.3%) 8 (5.3%) 25 (8.4%)

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Table 2. Head of household having knowledge and practice of traditional medicine in fever

Traditional

Medicine

Tribal

(n=150)

Non-tribal

(n=150)

Total

(N=300)

No. % No. % No. %

Current knowledge Yes 38 25.3 11 7.3 49 16.3

No 112 74.7 139 92.7 251 83.7

Practicing within household Yes 8 5.3 3 2 11 3.6

No 142 94.7 147 98 289 96.3

Table 3: Reason for use of traditional medicines in fever

Variables Tribal

(n=38)

Nontribal

(n=11)

Total

(N=49)

Very high fever in young children 29 76.3 2 18.1 31 63.3

Fever associated with jaundice 10 26.3 2 18.1 12 24.5

Fear of side effects of allopathic drugs 20 52.6 10 90.9 30 61.2

Use side by side with allopathic treatment 32 84.2 8 72.7 40 81.6

Side effects of Antimalarials drugs 20 52.6 10 90.9 30 61.2

Fever in Elderly with poor physical status 10 26.3 4 36.4 14 28.6

*Multiple responses

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Table 4- Showing information collected about the botanical plants used.

Local name Scientific name Parts of plants

used.

Mode of use

Panipanta/

Tupurilata

Unknown leaf is the useful

part.

Leaf is made to a thin paste, after

mixing with oil and applied to the

scalp

Narasingha Murraya koenijia leaf and stem Leaves are eaten directly or by

boiling in water and making a paste

Pasotia Vitex negundo leaf

Leaves are eaten directly as

vegetable or boiled and thin paste

made

Manikmoni Centella asiatica leaf A paste of the leaves are made and

given empty stomach.

Mahaneem Azadiracta indica leaves, stem and

roots

Boiled in water and the water is

given to drink

Tulsi Ocimum sanctum/

Ocimum basilicum

leaves Leaves are eaten directly.

CASE REPORT

Journal of Evolution of Medical and Dental sciences/ Volume 1/ Issue 3/ July- Sept 2012 Page 79

UNUSUAL LOCATION OF CYSTICERCOSIS LESION PRESENTATION

Dr. V. Geeta, Dr. Parimla Devi, Dr. A. Sirisha, Dr. Rama Devi, Dr. Jijiya Bai, Dr. Shravan Kumar

1. Assistant Professor, Department of Pathology, Gandhi Medical College, Secunderabad-6

2. Associate Professor, Department of Pathology, Gandhi Medical College, Secunderabad-6



5. Professor and HOD, Department of Pathology, Gandhi Medical College, Secunderabad-6

6. Professor, Department of Pathology, Gandhi Medical College, Secunderabad-6


Dr. V. Geeta,

Assistant Professor,

Department of Pathology,

Gandhi Medical College,

Secunderabad-6


INTRODUCTION:

Cysticercosis in humans is exclusively caused by larvae of T.solium which have predilection

for skeletal muscle, eyes, and central nervous system. In literature head and neck manifestations of

Cysticercosis is reported as soft tissue swellings at sub mental area, cheek as well as tongue1-4.

Cysticercosis presenting as a nodule or mass on neck is a very rare occurance5. The diagnosis was

usually made on Histo pathologic examination. The ensuing clinical disorder is named after the

organism at this larval stage, cysticercosis cellulose Larva of pork tapeworm Taenia solium.

KEY WORDS: Cysticercosis, T.solium

CASE HISTORY:

A 21 years male presented with a painless solitary nodular swelling on right side of the

upper neck of 2 years duration. The nodule was gradually increasing in size, associated with

anxiety, easy fatigability, palpitations, decreased appetite and weight loss.

Local examination revealed 2 x 2 cm round, smooth swelling present on right side of neck at the

level of Thyroid cartilage and anterior to the upper 1/3rd of sternocleido mastoid muscle and on

palpation the swelling is cystic, non tender, firm in consistency, not moving with deglutition and on

protrusion of tongue.

Skin over the swelling was non pinchable. No local rise in temperature. Swelling was mobile

both horizontally and vertically, not attached to the underlying muscle. General and systematic

examination within normal limits.

Clinical Diagnosis made was

1) Benign cystic swelling of right neck.

CASE REPORT


2) Sebaceous cyst

3) Lipoma

4) TB lymph node

5) Aberrant thyroid

6) Salivary gland

FNAC: S/o ‘?’ necrotic lymph node, complex cyst or parasitic cyst.

U/S: S/o ‘?’ necrotic lymph node

Excision of the cyst was done and sent for HPE

The Histopathologic examination revealed ‘Cysticercosis Cellulose’ characterized by a scolex

and epithelium lined by tortuous body and continuous with outer cystic layer. Cyst enclosed by a

fibrous capsule infiltrated with lymphocytes, plasma cells and eosinophils. Figure.1

The post operative period was uneventful.

DISCUSSION:

Taenia solium passes its life cycle in two hosts. The definitive host is human who harbors

the adult worm and intermediate host in pig which harbors the larval stage. The adult worm lives in

the small intestine of man. Usually one adult worm is present which lives for years. It is about 3

meters long with proglotids, the gravid segments with about 50000 eggs in each gravid segment.

The worm sheds gravid segments laden with eggs in the stools which infect pigs on reaching the

alimentary canal of the intermediate host penetrate the gut wall and reach systemic circulation and

are lodged in different organs and muscles. They develop in to larvae referred as cysticercosis

Human being are infected through eating under cooked contaminated pork or infected vegetables.

Adult worms shed gravid segment laden with eggs in the stool, which re infect pigs. Thus

completing the cycle. Autoinfection of man may occur by contaminated fingers or by reversal of

peristaltic movements of intestine, the gravid segments are thrown back to the stomach and larvae

disseminate throughout the body via Arterio Venous Channels and lymphatics encysting in

subcutaneous tissue, striated muscle, brain and ocular tissue6.

Cysticercosis manifestations are different and depend on the location in the body and also

number of cysticercosis of a particular site and associated inflammatory response. 87%

cysticercosis cases – presents as solitary or multiple subcutaneous nodules on the trunk, upper

arm, neck, tongue, face and breast has been reported in this order of frequency.

In many patients involvement of central nervous system in the form of neuro Cysticercosis is

diagnosed when multiple cystic ring enhancing parenchymal lesions has been detected on CT Scan7.

We are not reporting this case because of its unusual site of presentation, but also the importance of

histopathologic examination is emphasized since neither the clinical examination nor history

suggested the diagnosis other than a benign lesion.

CASE REPORT


Photo micrographs showing cystic lesion containing parts of parasite and the cystic wall containing

granulation tissue with inflammatory reaction.

REFERENCES:

1. Kinnman J, Chi CH, Park JH. Cysticercosis in Otolaryngology. Arch Otolaryngol 1976;

102:144-7

2. Beaver PC, Jung RC, Cupp EW. Clinical Parasitology, 9 th edition. Philadelphia: Lea & Febiger,

1984.

3. Jain RK, Gupta OP, Aryya NC. Cysticercosis of the tongue. J Laryngol Otol 1989; 103:1227-8

4. Gupta SC and Gupta SC. Cysticercosis of the tongue. Ear Nose Throat J 1995;74:174-8

CASE REPORT


5. Cysticercosis of the neck-a report of unusual case. Danai Tanechpongfamb, dept.of oto rhino

laryngeology; Pathum thani Hospital, Journal of Medicine and health sciences, faculty of

medicine, srinakharin wirat university, Vol. 12, No.2, Aug-2005.

6. Park K. Epidemiology of Communicable diseases. In: Park K. Park's Textbook of Preventive

and Social Medicine. 16 th ed. New Delhi: M/s Banarsidas Bhanot Publishers, 2000; 229.

7. Smiti S, Sripathi H and Naik L. Unusual location of cysticercosis lesions in soft tissue –

Report of three cases. Ind J Radiol Imag 2003;13:157-8

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences / Volume 1 / Issue 3 / July- Sept 2012 Page 83

CLINICO– EPIDEMIOLOGICAL PROFILE OF ROAD TRAFFIC INCIDENTS

ADMITTED AT A TERTIARY CARE HOSPITAL IN GARHWAL-

UTTARAKHAND

Sumeet Dixit, Praveen K. Tyagi, Amit K. Singh, Sudhir K. Gupta, Nidhi Malik

1. Dr. Sumeet Dixit, Assistant professor, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

2. Dr. Praveen K. Tyagi, Assistant professor, Department of General Surgery, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

3. Dr. Amit K. Singh, Associate professor, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

4. Dr. Sudhir K. Gupta, Associate professor, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

5. Miss Nidhi Malik, Demonstrator, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)


Dr. Amit K. Singh,


(Community Medicine),

VCSG Govt. Medical College,

Srinagar – Garhwal, Uttarakhand,

India– 246174.


ABSTRACT:

BACKGROUND: The magnitude of Road traffic incidents and fatalities in India is alarming. In 2009,

4.22 lakh road traffic incidents and 1.27 lakh road traffic fatalities were reported. These numbers

translate into one road accident every minute and one road accident death every four minutes

METHODS: The study (based on Jorgensen and Abane model, 1999) was conducted over a period

of one year during April 2011 to March 2012, among 136 victims (including 33 drivers) of road

traffic incidents coming to Veer Chandra Singh Garhwali government medical college, Srinagar,

Garhwal. RESULTS: 136 victims including 33 drivers were interviewed who were brought to the

causality in the aforesaid period. 23 people were brought dead. There is clustering of cases from the

month of August to October when compared to other months of year. 40% of drivers were

drunk/or using some other substance at the time of accident. Only 12.1% of drivers were using seat

belts at the time of accident. 57.6% were having driving license and 54.5% were either refractive

error or hearing impairment or both. Human error, High speed, Lack of sleep, effect of Alcohol and

mechanical fault of vehicle were reasons of accident as told by the drivers CONCLUSIONS: During

August to October there is clustering of cases. This period coincides with “Char Dham Yatra” and

rainy season both. Special efforts should be done during this period. Strong vigilance of drivers for

ORIGINAL ARTICLE


alcohol use, presence of driving license, compulsory use of seat belts, and premedical checkup for

refractive errors may prove valuable and morbidity and mortality can be minimized.

KEY WORDS: Road Traffic Incident, Determinants, Hilly region

INTRODUCTION:

Road traffic incidents which are generally unintended and preventable are a common risk

every day to life that can happen to almost every one, anywhere. The problem of road traffic

incident is increasingly becoming a threat to public health and national development in many

developing countries. Road traffic incidents contribute to poverty by causing deaths, injuries,

disabilities, grief, lost of productivity and material damages. Road traffic incidents are the most

frequent causes of injury-related deaths world wide1. According to the World Report on Road

Traffic Injury Prevention2 traffic accidents account for about 3000 daily fatalities worldwide.

Statistical projections show that during the period between 2000 and 2020, fatalities related to

traffic incidents will decrease with about 30% in high income countries. The opposite pattern is

expected in developing countries, where traffic accidents are expected to increase at a fast rate in

the years to come. In developing countries the trend has reached an alarming state, but very little

attention is paid to the problem3. There is evidence that using minimum safety standards, crash

worthiness improvement in vehicles, seatbelts use laws and reduced alcohol use can substantially

reduce deaths on the road4. The magnitude of Road traffic incidents and fatalities in India is

alarming. In 2009, 4.22 lakh road traffic incidents and 1.27 lakh road traffic fatalities were

reported5.These numbers translate into one road incident every minute and one road incident

death every four minutes. However, this is an underestimate, as not all injuries are reported to the

police5. Hilly regions are prone for RTA and there are very few number of studies in such areas.

Therefore this study is under taken to identify the clinic – epidemiological profile of Road traffic

incidents amongst patients admitted at Base hospital, Srinagar - Garhwal and to assess the factors

associated with the causation of the same.

METHODOLOGY:

A model for traffic incident as inspired by the ecological model of a disease was developed

by Jorgensen and Abane (1999)6 who made a heuristic adjustment of this basic model to suit road

traffic accident analysis. The model is characterized by three main components:

1. The vehicle (corresponding to the vector in disease ecology) which describes vehicles into

its composition, age, technical conditions and safety equipments like seat belts in a car.

2. The environment, comprising the road system and the wider physical and built up

environment. The physical environment splits further into different aspects such as;

Daylight and climate (weather conditions and road conditions), Spatial conditions

(arrangements and Macro structures), Settlement pattern (Urban or rural / sparse or

populated area), situation of areas of residence and working areas, Principle of traffic

separation, topography and road constructions qualities.

3. The behavior of the population; including its characteristics such as age and sex ratio as

well as attitudes and general traffic behavior. And it goes further into driving behavior,

driving experience, driving style, risk compensation and risk driving (influence of alcohol

and drugs).

ORIGINAL ARTICLE


Superimposed on this model is a system of traffic laws, regulations and mode of enforcement

designed to ensure that the population adheres to the controls and regulations so as to maintain

some level of road safety i.e. traffic rules (speed restrictions, road signs), speed controls and

convictions for various road traffic offences6. Based on this model this cross sectional study was

done with the help a pretested questionnaire, in a tertiary care hospital in Garhwal. All cases of RTA

coming to the tertiary care hospital during March 2011 to February 2012 were included in the

study. Questions were asked for assessing various risk factors as per the above said model and data

entry was done on excel and analyzed thereafter.

ETHICAL CONSIDERATIONS:

Ethical clearance from institutional review board/ institutional ethical committee was taken

for the study. Written consent was sought from the all respondents. They were informed about the

nature and the purpose of the survey.

RESULTS:

During the study period a total of 136 individuals came for the medical assistance (Figure-

1).117 were males 19 were females. Out of them 33 were drivers of the vehicle, which got the

accident. The number of brought dead persons because of Road Traffic Incidents, in the aforesaid

period was 23. Out of the brought dead individuals 5 were drivers of the vehicle. Maximum number

of morbidity because of RTI is evident in the month of December. There is clustering of cases from

the month of August to October when compared to other months of year (Figure-1).

Most of the drivers were literate. Out of 33 drivers interviewed only 3 (9%) were illiterate.

Nearly 40% of drivers were drunk/or using some other substance at the time of accident.50% of

drivers were >40 years of age. 15.8% of drivers were less than 20 years of age. Most of the drivers

(51.5%) who met the accident were having driving experience of >5 years. 12.1% of drivers were

having driving experience of less than 1 year. Only 12.1% of drivers were using seat belts at the

time of incident. 57.6% were having driving license and 54.5% were either refractive error or

hearing impairment or both. Most of the respondents told that it was mistake of other drivers

which led to the accident. High speed, Lack of sleep, effect of Alcohol and mechanical fault of vehicle

were other reasons of accident as told by the drivers (Table-2). 78% of victims were brought to the

hospital with help of 108 helpline service. Rest 22 % were came either by themselves or by other

people (Figure-1).

ORIGINAL ARTICLE


Figure -1: Monthly distribution of RTI cases

Figure-2: Mode of transfer to the hospital

310

27

15 12 92

41

4 7 5

117

1 0 0 1 2 0 2 29

0 0 2

19

410

28

1712 11

4

50

4 7 7

136

0

20

40

60

80

100

120

140

160

No

of

case

s

Year- Month

Distribution of cases monthwise

Male

Female

Total

78%

15%

6%

1%

Mode of transfer to the hospital

108 helpline

Other people

self

other

ORIGINAL ARTICLE


Table-1: Clinico-epidemiological profile of RTI cases

*Human error: wrongful U-turn by other vehicle , Wrongful overtaking by un-coming vehicle

**Mechanical fault: break failure, burst tyre, and locked steering mechanism

Maximum number (47.8%) of RTI morbidity was because of polytrauma associated. And

upper limb injury was least responsible for the mortality.50% of accidents took place in the evening

Drivers interviewed Yes % age

Education(n=33)

Illiterate 03 9.1

Up to 5th std 13 39.4

5-12 th std 16 48.4

Graduate/Post graduate 01 3.1

Age(n=38,

Including the

brought dead

drivers)

<20 years 6 15.8

20-40 years 13 34.2

>40 years 19 50

Alcohol /other substance use at the time of accident( n=33) 13 39.4

Driving experience

( n=33)

<1 year 4 12.1

1-5 years 12 36.4

>5 years 17 51.5

Seat belt use( n=33) 4 12.1

Driving license( n=33) 19 57.6

Refractive error /Hearing impairment / both( n=33) 18 54.5

Cause as told by

driver( Multiple

answers could

be given)

Mistake of others/Human error*( n=33) 23 69.7

More speed 14 42.4

Lack of sleep 11 33.3

Alcohol use 09 27.3

Mechanical fault of the vehicle** 09 27.3

Others including environmental

conditions

04 12.1

ORIGINAL ARTICLE


hours. 72.7% of vehicles were older than 5 years of age. Fall from hill was the mode of accident in

most of the cases and the mortality and severe injuries were also more in fall from hillside, followed

by accident from the sides and head on collision.

Table -2: Epidemiological profile of RTI cases

DISCUSSION:

Maximum number of Morbidity because of RTI is evident in the month of December. It was

fall of a bus, from the hill side leading to higher toll in mortality and morbidity in month of

December. There is clustering of cases from the month of August to October when compared to

other months of year. “Char dham yatra” which lead to sudden increase in number of vehicles on

hillside and heavy rainy season both coincides with this period. These can be contributing factor for

such clustering of cases. Most of the drivers were literate. Out of 33 drivers interviewed only 3 (9%)

were illiterate. Substance use including drinking behavior was noticed in 39% of the drivers at the

Variable Number % age

Injury( n=136) Involved head 20 14.7

Upper limb 14 10.3

Lower limb 21 15.5

Abdomen 16 11.7

Multiple / polytrauma 65 47.8

Time of accident(N=38) 12pm -6 pm 14 36.8

6pm-9pm 19 50.0

9pm-6am 02 5.3

6am- 12 pm 03 7.9

Age of the vehicle(N=33) <5 years 09 27.3

>5 years 24 72.7

Type of

collision/accident(N=38)

Head on 04 10.5

From behind 02 5.3

From sides 07 18.4

Fall from hill 18 47.4

Other 07 18.4

ORIGINAL ARTICLE


time of accident. Experienced drivers (>5 years) met the accident in maximum number.

Overconfidence leading to recklessness can be the reasons for such happening. 77.9% drivers were

not using seat belt at the time of accident and when asked for the driving license only 42.4% could

not produce the same. 50% of drivers who met the accident were >40 years of age. In the elderly

visual impairment prevents adequate visual function, which may be responsible for the accident.

When examined, 54.5% were having either refractive error or hearing impairment or both. A study,

which examined the association between visual impairment and RTI among 1,428 drivers seen at

the accident and emergency department of a hospital in the United Arab Emirates, also identified

visual impairment to be significant risk factors7. Likewise Davidson in his examination of the

interrelationship between British drivers’ visual abilities, age and RTI histories found strongest

positive association between RTI variables and visual disabilities, among older drivers8. Most of the

respondents told that it was mistake of other drivers which led to the accident. High speed, Lack of

sleep, effect of Alcohol and mechanical fault of vehicle were other reasons of accident as told by the

drivers. Study by Asogwa et al9 showed that commercial drivers drive for hours without sleep and

food, until fatigue inevitably sets in and a crash may be the end result. Effect of alcohol or other

substances was also substantiated by Lemoineet al10. Maximum number (47.8%) of RTI morbidity

was because of polytrauma associated. And upper limb injury was least responsible for the

mortality. This is in contrast to the study by Biswas G11 who cited that the maximum (56.4%)

injuries were found on head and neck, followed by thorax (54.5%) and abdomen (44.5%). Other

studies12,13 also showed a high incidence of head injuries in their studies. 50% of accidents took

place in the evening hours. Fall from hill was the mode of accident in most of the cases and the

mortality and severe injuries were also maximum in such mode of accident followed by accident

from the sides and head on collision.

CONCLUSION:

During “Char Dham Yatra” period and rainy seasons there is clustering of cases. Special

efforts should be done during this period. Strong vigilance of drivers for alcohol use, presence of

driving license, compulsory use of seat belts, premedical checkup for refractive errors, must be

ensured. The role of 108 helpline14 cannot be ruled out and strengthening of this service can be of

paramount importance. All These measures may prove valuable and morbidity and mortality can be

minimized.

ACKNOWLEDGEMENT:

The author acknowledges medical social workers of department of community medicine,

Veer Chandra singh Garhwali govt. medical college, Srinagar, Garhwal for their work and support in

the study. The author also acknowledges the respondents who formed the building blocks for the

study.

REFERENCES:

1. Astrom, J. S, Kent, M.P. and Jovin, R. D. (2006) Signatures of Four Generations of Road Safety

Planning in Nairobi City, Kenya In: Journal of Eastern African Research and Development.

Vo. l20, pp. 186-201.

ORIGINAL ARTICLE


2. Peden, M. (Ed), (2004), World Report on Road Traffic Injury Prevention. World Health

Organisation, Geneva.

3. Odero, W., Garner, P. and Zwi, A. (1997). Road traffic injuries in the developing countries: a

comprehensive review of epidemiological studies. Journal of Tropical Medicine and

International Health. 2(5), 445-460.

4. Leon, S.R. (1996).Reducing death on the Road.The effects of minimum safety standards,

Unpublicised crash test, seat belts and alcohol. Am J Public Health; 86(1):31-3.

5. Road Accidents in India, 2009. Transport Research Wing, Ministry of Road Transport &

Highways, Government Of India, New Delhi.

6. Jorgensen, S. H., and Abane, A. M. (1999). A comparative study of urban traffic accidents in

developing and developed countries: Empirical observations and problems from Trondheim

(Norway) and Accra (Ghana). Bulletin of Ghana Geographical Association. No. 21, 113-128.

7. Bener A, Ahmad MF, El-Tawil MS, Al- Bakre S. Visual impairment and motor vehicle

accident. Middle East Journal of Emergency Medicine. 2004; 4: 1-9

8. Davidson PA. Inter-relationships between British drivers’ visual abilities, age and road

accident histories. Opthalmic and Physiological Optics. 1985; 5:195-204.

9. Asogwa SE. Kola nut and road traffic accidents in Nigeria. American Journal of Public Health.

1978; 68:1228.

10. Lemoine P, Ohayon M. Abuse of psychotropic drugs during driving. Encephale. 1996; 22:1-6.

11. Biswas G, Verma SK, Sharma JJ, Aggarwal NK. Pattern of Road Traffic Accidents in North

East Delhi. Journal of Forensic Medicine & Toxicology.2003; 20(1):27-32.

12. Sahdev P, Laeque MD, Singh B and Dogra TD. Road Traffic Accidents in Delhi, causes, injury

pattern and incidence of preventable deaths. Accid Anal Prev 1994; 26:12-18.

13. Salgado MSL, Colombage SM. Analysis of fatalities in road accidents. For Sci Int .1998;

36:91-96.

14. In Uttarakhand, Emergency helpline Number “108″ to tackle disaster calls, complaints.

Available at http://www.indiahillstoday.com/2010/10/12/in-uttarakhand-emergency-

helpline-number-108-to-tackle-disaster-calls-complaints/

ORIGINAL ARTICLE


A STUDY ON EVALUATION OF APPROPRIATE USAGE OF FRESH FROZEN

PLASMA (FFP)

Dr. V. Geeta, Dr. I. Srilakshmi, Dr. A. Krishnayya, Dr. Lakshmi, Dr. Poornima, Dr. O. Shravan Kumar,

Dr. P. Jijiya Bai

1. Assistant Professor, Department of Pathology, Gandhi Medical College, Secunderabad, AP.



4. Blood bank Medical Officer, Gandhi Medical College, Secunderabad, AP.

5. Post Graduate Student, Department of Pathology, Gandhi Medical College, Secunderabad, AP.

6. Professor & HOD, Department of Pathology, Gandhi Medical College, Secunderabad, AP.

CORRESPONDING AUTHOR-

Dr. V. Geeta,




Secunderabad, AP.

Email id- [email protected]

ABSTRACT:

The term FFP refers to the fluid portion of 1 unit of human blood that has been centrifuged,

separated & frozen solid at -18°C or colder within 8hrs of collection. The indications for transfusing

FFP are very limited, as it can cause unpredictable adverse reactions. A retrospective study of FFP

transfusion was carried out at the blood bank-Gandhi Medical College for a period of 6 months; i.e

January 2011–July 2011 for various indications. We evaluated 840 patients who received 1534

units of FFP and classified them as appropriate, clinically appropriate and inappropriate. In our

study appropriate and clinically appropriate transfusions of FFP were about 61%- a good

proportion of FFP transfusions were justified but 39% were of without any appropriate indication.

KEY WORDS: Fresh Frozen Plasma, Centrifugation, Adverse Reactions

INTRODUCTION:

The use of FFP has increased due to multiple factors, possibly increased acceptance of the

concept of component therapy.FFP contains the labile as well as stable components of the

coagulation , fibrinolytic & complement system; the proteins(that maintain oncotic pressure &

modulate immunity) and fats, carbohydrates & minerals are present in concentrations similar to

those in circulation. The most labile coagulation factors are preserved for 1 yr if FFP is kept at -30°

C or below. The FFP should be administered as soon as possible after thawing & in any event within

12 hrs if kept at 2-6°C.

ORIGINAL ARTICLE


Contents of 1 unit of FFP prepared from 450ml of whole blood

Plasma : 175-230ml

All Coagulation Factors : 1 i.u/ml of each factor including factors V

& VIII)

Fibrinogen : 200-400 mgm

INDICATIONS OF FFP:

� Active bleeding,

� Liver diseases

� Disseminated intravascular coagulation (DIC)

� Thrombotic Thrombocytopenic Purpura (TTP)

� Coagulopathy in massive transfusion

� Familial Factor V deficiency

� Deficiency of Factors II, VII, IX, X

� Antithrombin III deficiency

� Congenital or Acquired coagulation factor deficiency1

DOSAGE OF FFP:

About 10ml/Kg body wt. Post transfusion assessment of levels of APTT, PT & fibrinogen is

done for monitoring the effect of FFP2. Plasma should be ABO compatible with the recipient blood.

AIMS & OBJECTIVES:

Evaluation of appropriate usage of FFP in a period of 6 months (January 2011- June 2011)

in Gandhi Hospital.

MATERIALS & METHOD:

A Retrospective study was conducted at Gandhi Hospital Blood bank for a period of

6months (January 2011-june 2011). We evaluated 840 patients, who received 1534 units of FFP &

classified them as 1.Appropriate; 2.Inappropriate; 3. Clinically appropriate.

Table: 1- SEX RATIO (M: F ratio- 1:1.5)

SEX MALE FEMALE TOTAL

No. of patients 382 458 840

% 45.5% 54.5% 100%

Table: 2- AGE GROUP

AGE

GROUP

JAN FEB MARCH APRIL MAY JUNE TOTAL JAN

0-20 33 35 36 34 28 56 222 26.7%

21-40 71 44 49 68 74 91 397 21-40

41-60&

ABOVE

31 39 30 25 24 62 211 31

ORIGINAL ARTICLE


Table: 3- Guidelines-British Committee for Standard Hematology3

SNO CLINICAL

CONDITIONS

TOTAL

REQUIREMENT

APPROPRI

ATE

CLINICALY

APPROPRIATE

INAPPROP

RIATE

%

1. Liver Diseases 152 ---- 152 ---- 18%

2. DIC 84 ---- 84 ---- 10%

3. Hemophilia 168 168 ---- ---- 20%

4. Sepsis + Burns 168 60 ---- 108 20%

5. Cardiac

surgeries

168 ---- ---- 168 20%

6. Snakebite 80 50 ---- 30 9.5%

7. Others 20 ---- ---- ---- 2.5%

8. Total 840 278 236 306

Table: 4- Total patients-840 ; Total units-1534

BLOOD

GROUP

O+ve B+ve AB+ve A+ve O-ve A-ve B-ve AB-ve

No. of

Patients

338 227 48 168 13 6 20 2

Percentage 40.9

%

27.3

%

5.9% 20% 1.7% 0.9% 2.8% 0.5%

RESULTS:

• Total patients who received FFP are 840, out of which males were 382 and females we 558

(table:1)

• Age group ranging from 0-20 years constitute 26.4%; 21-40 years 47.2%; 41-60 years

26.2% (table:2)

• Depending upon the conditions patients received FFP have been divided into 8 groups

according to the guidelines provided by British Committee for Standard Hematology3

(table:3)

• Out of 840 patients, conditions like liver diseases, disseminated intravascular coagulation

are clinically appropriate (where there is active bleeding leading to coagulopathy) and

hemophilia, sepsis, burns, rheumatic heart diseases, snake bite and shock are considered to

be appropriate (the term appropriate is limited to the treatment of coagulation protein

deficiency, for which specific factor concentrates are un available or undesirable)-(table:3)

• No.of units of FFP transfused are 1534 in six months period. Of this 40.9% are transfused to

O positive blood group (table: 4).

DISCUSSION:

� FFP is efficacious for treatment of Deficiencies of factors II, V, VII, IX, X & XI.

� Reversal of warfarin effects: Patients who are anticoagulated with warfarin are deficient in

functional vitamin K dependent coagulation factors II, VII, IX, X as well as protein C & S. FFP

can be used to achieve immediate hemostasis.

ORIGINAL ARTICLE


� Massive Blood Transfusion: In patients with documented blood clotting abnormalities,

prolonged APTT, INR after huge blood loss requiring 4 or more units of packed red cells-

FFP is commonly recommended.

� FFP can be used as a source of Antithrombin III in patients who are deficient of this

inhibitor & undergoing surgery or who require heparin for the treatment of thrombosis.

� FFP useful in infants with secondary immunodeficiency associated with severe protein

losing enteropathy, FFP can be used as a source of immunoglobulin for children & adults

with human immunodeficiency.

� FFP is used in treatment of Thrombotic thrombocytopenic purpura.

ASSOSIATED RISKS:

• Anaphylactoid reactions

• Alloimmunisation

• Transfusion related acute lung injury (TRALI): antibodies against the patients granulocytes

may cause leucocyte aggregation in pulmonary vessels leading to TRALI4

• Increase in infections

• Excess usage-Hypervolemia & cardiac failure (The guidelines set by British Committee for

Standard Hematology was followed in our study). 3

Approximately 60% FFP used are inappropriate according to Kakkar et al 5, but clinically

apparent cases like liver diseases, coronary bypass surgeries reduced the inappropriate usage to

28%. Severe liver disease6, 7, 8 is one of the most common clinical indications for transfusion of FFP.

Patients with liver diseases have several abnormalities that can lead to bleeding like coagulopathy,

Disseminated Intravascular Coagulation (DIC), Thrombosis. According to Consten et al9 & LA

Harker et al10 in cardiac surgery 11 post operative bleeding due to residual effects of heparin may be

corrected with transfusion of FFP.

CONCLUSION:

In our study appropriate & clinically appropriate transfusions of FFP were about 61%. It is

desirable that educational programmes be arranged for doctors regarding appropriate usage of

FFP.

Blood bank associations & Hematologists should more firmly adhere to the guidelines.

In our institution 61%, a good proportion of FFP transfusions were justified and 39% were

used without any appropriate indications.

ACKNOWLEDGEMENT:

I extend my special thanks to all the technical staff off blood bank and the personnel of

record room of Gandhi Hospital for helping me in collecting the necessary data.

REFERENCES:

1. NIH consensus conference: Fresh frozen plasma: indications and risk JAMA1985; 253:551-

3.

2. Snyder AJ, Gotschall JL and Menitove JE. Why is fresh frozen plasma transfused?

Transfusion1986; 26:107-12.

ORIGINAL ARTICLE


3. British Committee for standards in Hematology, blood transfusion Task force. Guidelines for

the use of Fresh frozen plasma, cryoprecipitate and cryo supernatant.TransfusionMed1992;

2:57-63.

4. Nordhagen R, Conradi M, Dromtort SM. Pulmonary reaction associated with transfusion of

plasma containing anti-Vb. VOXSANG. 1986; 5:`102-8 (Pubmed)

5. Kakkar N, Kaur R and Dhanoa J. Improvement in fresh frozen plasma transfusion practice:

results of an outcome audit. Transfus Med 2004; 14231-5.

6. Schofield WN, Rubin GL and Dean MG. Appropriateness of platelet, fresh frozen plasma and

cryoprecipitate transfusion in New South Wales public hospital. Med J Aust 2003; 178:117-

21.

7. Spector I, Corn M and Ticktin HE. Effect of plasma transfusion on the prothrombin time and

clotting factors in liver disease. Eng J Med 1966; 275: 1032-7.

8. Mannucci PM, Franchi F, Dioguardi N. Correction of abnormal coagulation in chronic liver

disease by combined use of fresh frozen plasma and prothrombin complex concentrates.

Lancet 1976; 2: 542-5.

9. Consten E, Henny CP, Eijsman L, Donglemant DA, Van Oers MH. The routine use of fresh

frozen plasma in operations with coronary bypass surgery is not justified. J thorac

Cardiovasc Surg 1996; 112:162-7.

10. LA Harker, TW Malpass, HE Branson, EA 2d Hessel and SJ Slichter. Mechanism of abnormal

bleeding in patients undergoing coronary bypass surgeries. Acquired transient platelet

dysfunction associated with selective Alpha granule release. Blood 1980; 56: 824-34.

11. Wilhelmi M, Franke U, Cohmert T, Weber P, Kaukemuller J, Fisher S, et al. Coronary artery

by pass grafting surgery with out the routine application of blood products: Is it feasible?

Eur J Cardiothorac Surg 2001; 19: 657-61

CASE REPORT

Journal of Evolution of Medical and Dental Sciences / Volume 1 / Issue 3 / July- Sept 2012

Page 96

PALATAL PLEOMORPHIC ADENOMA WITH FLORID SQUAMOUS METAPLASIA: A

POTENTIAL DIAGNOSTIC PITFALL

Abdul Hakeem Attar, Mandakini B. T, Azhar Fatima

1. Assistant Professor, Department of Pathology, KBN Institute of Medical Sciences, Gulbarga, Karnataka


3. Lecturer, Unanai College


Dr Abdul Hakeem Attar,

C/o Abdul Azeem Attar,

Shameem Masala,

Attar Gazar, Gulbarga.


ABSTRACT:

Pleomorphic adenoma is the most common benign tumor occurring in the major

and minor salivary glands. We report a case of pleomorphic adenoma with extensive

squamous metaplasia in the palate of a 20 year old man. The dimensions of the tumor were

3x2x2cm. More than 75% 0f the epithelial element in the tumor was composed of sheets of

squamous cells, with multiple keratin filled cysts. This case illustrates that pleomorphic

adenoma with squamous metaplasia presents a potential for misinterpretation as

mucoepidermoid carcinoma and squamous cell carcinoma. We discuss the various pitfalls

and the features that are helpful in distinguishing between these lesions.

KEY WORDS: Pleomorphic adenoma, Squamous metaplasia

INTRODUCTION:

Pleomorphic adenoma is the most common benign tumor occurring in the major or

minor salivary glands. [1] The tumor is characterized by epithelial and modified

myoepithelial elements intermingled with tissue of mucoid, myxoid or chondroid

appearance. It has a wide spectrum of morphological patterns, [2] squamous cells, oncocytes,

sebaceous cells, bone, adipose tissue and crystalline materials can be found in the tumor.

We report a benign salivary gland tumor with a predominant and extensive squamous

component. The features are those of a pleomorphic adenoma with florid squamous

metaplasia. This case illustrates the difficulty of making a correct diagnosis in the initial

tissue specimen and we discuss the diagnostic pitfalls of this pathological entity.

CASE PRESENTATION (CLINICAL DETAILS):

A 20 year old patient presented with complaint of swelling in the oral cavity since

two years. The swelling was painless and progressively increasing in size .Physical

examination showed a firm nodule of 4x4cm in diameter on the left side of the hard palate

and anterior part of soft palate.

CASE REPORT


Page 97

CYTOLOGICAL FINDINGS:

Fine needle aspiration was done and demonstrated some clusters of squamous cells,

with some of the cells showing keratinizing cytoplasm .Also seen some clusters of cells with

features suggestive of glandular differentiation .Differential diagnosis of well differentiated

squamous cell carcinoma & pleomorphic adenoma was made .

GROSS / HISTOPATHOLOGICAL FINDINGS:

Surgical resection was done. Gross specimen comprised of well circumscribed, well

encapsulated mass, grey white in color and measured 3x3x2cm .No cystic area, hemorrhage

or necrosis was seen .Histological examination showed a well encapsulated tumor more

than 75% of epithelial element in the tumor was composed of squamous cells with multiple

keratin filled cysts. The rest of areas showed features of conventional pleomorphic

adenoma.

DISCUSSION:

Histological diversity is the hallmark of pleomorphic adenoma. [3] Histological

patterns vary considerably between different parts of same tumor. [3] Focal squamous

metaplasia is found in about 25% of pleomorphic adenoma. Rarely focal squamous

metaplasia is reported. [4] Squamous metaplasia is commonly associated with repair

following infarction and necrosis of the salivary gland. In the present case necrosis was not

seen and squamous cells were detected in FNA biopsy as well as in the resection specimen.

squamous metaplasia has been noted in non-neoplastic entities like chronic sialadenitis,

necrotizing sialometaplasia, lymphothelial cysts occurring in the vicinity of salivary gland .

Potential for misdiagnosis of pleomorphic adenoma as mucoepidermoid carcinoma and

squamous cell carcinoma have been reported. In our case also the features misinterpreted

as mucoepidermoid & squamous cell carcinoma. To avoid misinterpretation of pleomorphic

adenoma with squamous metaplasia as mucoepidermoid carcinoma on cytology, a close

scrutiny for fragments of chondromyxoid stroma – a characteristic feature for pleomorphic

adenoma. In our case also on reviewing the slides again after histological diagnosis we could

find occasional tiny fragments of stroma . Also keratinization especially of the extracellular

type is rare in mucoepidermoid carcinoma. How ever even if the features diagnostic of

pleomorphic adenoma are identified, the differential diagnosis may still includes a

mucoepidermoid carcinoma arising in a preexisting pleomorphic adenoma.

CONCLUSION:

We have reported a case of palatal pleomorphic adenoma with florid squamous

metaplasia and with potential pitfalls in the diagnosis.

ACKNOWLEDGEMENT:

The work was indeed a mammoth task to accomplish and would not have been

possible without active co-operation, constant strategic support and encouragement by our

CASE REPORT


Page 98

beloved – PRESIDENT- (Khaja Bandanawaz Institute of Medical Sciences)—DR.SYED SHAH

KHUSRO HUSSAINI.

REFERENCES:

1. Spiro RH. Salivary neoplasms : overview . Head Neck Surg 1986; 8 :177-84

2. Waldron CA. Mixed Tumor ( pleomorphic adenoma ) and myoepithelioma. In : Ellis

GL, Auclair PL, Gnepp PR. Eds . Surgical pathology of salivary glands. Philadelphia :

Saunders , 1999; 165-86

3. Das DK. Anim JT. Pleomorphic adenoma of salivary glands. Cytopathology 2005 : 16:

65-70

4. Lam KY, Ng IOL, Chan GSW. Palatal pleomorphic adenoma with florid squamous

metalasia . J Oral Pathol Med. 1998; 27: 407-10.

CASE REPORT


Page 99

Fig 1- Photograph showing swelling in the palate

Fig 2- Gross photograph showing well circumscribed tumor

CASE REPORT


Page 100

Fig 3- Photomicrograph showing squamous cells with keratin pearls. (H&E, 400X)

CASE REPORT


Page 101

Fig 4- Photomicrograph showing conventional pleomorphic adenoma (H&E, 400X)

CASE REPORT

Journal of Evolution of Medical and Dental Sciences/Volume 1/Issue 3/July- Sept 2012 Page 102

CUTANEOUS NECROTISING VASCULITIS – THERAPEUTIC FACT-A CASE

REPORT

Dr Kiran. D. R, Dr Palaniswamy

1. Associate Professor, Department of General Medicine, Karuna Medical College, Vilayodi, Chittur, Palghat,

Kerala.

2. Professor, Department of General Medicine, Karuna Medical College, Vilayodi, Chittur, Palghat, Kerala.


Dr. Kiran D R.,


Department of Medicine,

Karuna Medical College, Vilayodi,

Chittur, Palghat, Kerala.


ABSTRACT: INTRODUCTION: Mixed connective tissue disorder, unlike other connective tissue

disorders have a milder course. MTCD with only necrotizing cutaneous vasculitis without organ

damage respond well to Immunosuppresents and Steroids. CASE REPORT: Middle aged Young

lady presented with multiple non healing large pressure sores and multiple nonblanchable

purpuric lesions. She was bedridden, anaemic and with significant weight loss. All her major

organ functions were normal. Her U1 RNP Antibody is positive and Skin Biopsy showed

positive direct fluorescent test for IgG. She responded well to immunosuppresants and steroids.

CONCLUSION: This patient who presented with MTCD, with predominant necrotizing

cutaneous vasculitis and without major organ involvement showed good recovery and

responded well to cyclophosphamide pulse therapy, daily azathioprine and good wound care.

KEY WORDS: Necrotising Vasculitis, MCTD, U1 RNP Antibody, Immunosuppresants

INTRODUCTION:

Vasculitis is not a disease but rather a disease process (from Merck manual).Here we

came across a MCTD with predominant necrotizing vasculitis involving only skin .This is been

reported so as to stress the fact that MTCD , unlike other connective tissue disorders has milder

course and necrotizing vasculitis confined to skin do well with immunosuppresives, steroids

and good wound care 5.

CASE REPORT:

Female patient aged 34 year old, presented with weight loss( more than 10%), lethargy

and multiple non healing open ulcers associated with necrotic base over pressure bearing areas

predominantly confined to extensor areas of limbs of one year duration. She had intermittent,

moderate grade fever without cough and rashes. She was bed ridden due to sever nonhealing

disabling ulcers over the pressure bearing areas and joint contractures.

On examination, Patient is thin built and poorly nourished.

Multiple non blanchable purpuric lesions, multiple depigmented lesions on face and loss of scalp

hair.

Pallor present, Febrile, Tachycardia present.

Systemic examination– Normal.

CASE REPORT


Investigations: Hb 6gm/dl, WBC -8200, Eosinophils increased, Platelet count- 80,000, ESR-110,

CRP elevated,

LFT and RENAL FUNCTION: Normal

Urine Routine: Normal, No albumin or microscopic Haematuria

ECG: WNL

Echo: No pericardial fluid, EF – 60%, Normal Function.

PFT: Normal curve, No features of interstitial pattern.

Chest X Ray: CP angles free and normal, lung parenchyma normal, No Infiltrates.

USG Abdomen: NO Organomegaly, pelvis normal.

Stool examination: No occult blood.

CT brain: Normal study.

NCS: Normal.

Ophthalmological Examination: Visual Aquity-6/6, Fundus –Normal.

ANA positive, RA Factor negative

ANCA negative, U1 RNP Antibody positive,

Skin Biopsy – direct fluorescent test positive for IgG, Complements were normal ,

HIV 1&2 negative, Hepatitis B & C Negative.

Diagnosis of MCTD was made with above findings.

TREATMENT GIVEN:

Patient was started with steroids, monthly pulse therapy of Cyclophosphamide and daily

2mg of Azathioprine. Other general conditions maintained with blood transfusion and

supportive care. Wounds were been taken care of by debridement and allowed them to go for

healing by secondary intention. Some of the wounds healed in one setting, but others required

2-3 attempts. Finally in six months duration all wounds healed well and now patient is

ambulatory, self dependant with only Azathioprine daily.

ACKNOWLEDGEMENT:

I take this opportunity to extend my sincere thanks and indebtedness to all those

persons and dignitaries who helped me to complete this work.

It gives pleasure to express my sense of gratitude to my professor Dr Palaniswamy for

his guidance, encouragement and constant source of inspiration during case management.

Above all I thank the Almighty for the successful completion of this work.

DISCUSSION:

MCTD also known as Sharp’s syndrome an undifferentiated connective tissue disease.

MCTD a combined feature of scleroderma, myositis, SLE and Rheumatoid Arthritis (with some

source adding polymyositis, dermatomyositis and inclusion body myositis) and is thus

considered as overlap syndrome. MCTD commonly causes joint swelling, malaise, Raynaud’s

phenomenon, Sjogren’s syndrome, muscle inflammation and sclerodactyly. Distinguishing lab

characteristics are positive speckled ANA and an anti U1RNP antibody. It is associated with HLA

DR-41.

Vasculitis induced injury to blood vessel may lead to increased vascular permeability,

vessel weakening that cause aneurysm formation, haemorrhage and intimal proliferation,

thrombosis that result in obstruction and local ischemia2. It is critical to distinguish vasculitis

occurring as a primary autoimmune disorder from vasculitis secondary to infection, drugs,

malignancy or connective tissue disease such as SLE/ RA. Much of the diagnostic work up in a

CASE REPORT


patient with suspected vasculitis is directed at excluding secondary causes that can mimic

vasculitis3.

Immunoglobulin finding may be helpful in diagnosing MTCD. Indirect Immuno

fluroscent test – Presence high titre of IgG against U1RNP as the only autoantibody support

MTCD. The fluroscent auto nuclear antibody test typically reveals a speckled pattern of staining

on HEP-2 substrate. Recent studies revealed that antibody directed to an appropriate specific

epitop on 70 kd are specifically associated with MTCD than other anti 70 k antibody. Direct

Immuno fluroscent test- Performed on lesional skin of patients with MTCD, this may reveal

epidermal nuclear IgG staining. The staining is thought to be related to high titres U1RNP

antibody in the patient seen. In some cases Lupus Band test may be positive (linear deposition

of Ig, Fibrin and/or compliment components present at the basement membrane) 4.

Treatment option includes corticosteroids, Immunosuppressive drugs to reduce the

inflammation. Cyclophosphamide may be in severe vasculitis. Dramatic remission seen in

patient with alternate day corticosteroid treatment with continuation of cyclophosphamide.

Later corticosteroid was discontinued. Mean duration of remission was 22 months. No patient

showed recurrence of disease during treatment with cytotoxic agents5. IV cyclophosphamide is

better than oral and recommended at least six months. Substitution of Azathioprine after

remission with cyclophosphamide did not increase the rate of relapse.

Newer treatment approach includes deoxysperagualin, achieved a high rate of disease

remission and permitted prednisolone reduction. Other newer Immunosuppresives are

Leflunamide, TNF antagonists – Infliximab and ENBREL. Colchicine not that much effective in

skin va sculitis, but some showed improvement. Development of plasma exchange including

semi specific immunoabsorption with L-tryptophan or Protein A columns to remove ANCA

without depletion of non Ig plasma proteins and appear of comparable efficacy to plasma

exchange6.

CONCLUSION:

MCTD, although called as overlap syndrome, here we came across MCTD without major

organ involvement, without associated other connective tissue diseases. Predominant

presentation was confined to skin as necrotizing cutaneous vasculitis. The disease here showed

a chronic disabling course which provided enough time to treat with Pulse cyclophosphamide

therapy, daily Azathioprine and good wound care. MCTD without predominant organ

dysfunction and confined to skin manifestation as a good prognosis with regular treatment than

the systemic vasculitis or MCTD with other connective diseases, which has mixed results to the

regular treatment.

REFERENCES:

1 Aringer M, Steiner G, Smolen JS (Aug-03). “Does MCTD exist? Yes.” Rheumatic disease clinical

North America. 31(3): 411-29.

2 Mandell BF, Hoffman G.S. Differrentiating the Vasculitis. Rheumatic disease clinical North

America (1994); 20:409-42.

3 Hunder G. Vasculitis Diagnosis and therapy. Am. J Med: 1996; 100(22):375-455

4 H Ihn, K Yamane, N Yazawa, M Kuba, M Fujimoto, S Sato, K Kikuchi and K Tamaki; Distribution

of antigen specificity of Anti U1RNP antibody in patient with systemic sclerosis. Clinical

Experimental Immunology(1999)117(2);383-387.

5 FauciAS,Katz P,Haynes BF, Wolf SM:Cyclophosphamide therapy for sever necrotizing

vasculitis(1979) vol 301:235- 238.

CASE REPORT


6 Jayne D (2000)Evidence based treatment of systemic vasculitis. Rheumatology(Oxford)

39:585-595.

ABBREVIATIONS:

MCTD: Mixed Connective Tissue Disease

HLA: Human Leucocyte Antigen

SLE: Systemic Lupus Erythematosis

RA: Rheumatoid Arthritis

RNP: Ribosomal Neucleo Protein

ANA: Anti Nuclear Antibody

ANCA: Anti Nuclear Cytoplasmic Antibody

Post Treatment- Healed cutaneous Vasculitis on face, Post Healed Hypopigmented Lesion

CASE REPORT


PLASMA CELL LEUKEMIA- LIGHT CHAIN SECRETORY TYPE, WITH

PRIMARY AMYLOIDOSIS



Kerala.



Dr. Kiran D R.,






ABSTRACT:

INTRODUCTION: Secondary PCL (Plasma Cell Leukemia), arising from multiple myeloma is

aggressive and rare variant of multiple myeloma. It is known that AL (Amyloid Light Chain)

type of Amyloidosis is primary amyloidosis occurring in multiple myeloma. Attempt to report

this case of secondary PCL of light chain secretory type with primary amyloidosis. Emphasis

given to this report is so as to highlight the helpful prognostic tools in this rare variety.

CASE REPORT: 60 year old female presenting with Hepatosplenomegaly, severe anemia,

bleeding manifestations and fever. She had pancytopenia with ESR of 170. Peripheral smear

showed plenty of plasma cells >20% and bone marrow biopsy showed mature to immature

plasma cells, plenty in number. Skull X ray showing multiple punched out lesions.

Electrophoresis was normal, abdominal wall fat stained positive for Congo Red and Serum Free

Light Chain Assay was positive. Diagnosed as PCL of light chain secretory type. CONCLUSION:

PCL itself, high plasma cell labeling index, increased LDH, increased serum

β2microglobulin,renal indices like increased serum creatinine, organomegaly, non secretory

variety-all carry bad prognostic signs.

KEY WORDS: PCL, Primary Amyloidosis, Light chain, Punched out bone lesions

INTRODUCTION:

It is known that incidence of PCL is <1 / million cases and 2% of multiple myeloma1. It is

an aggressive and rare presentation of multiple myeloma2. It has features of acute leukemia and

multiple myeloma.PCL usually arises from myeloma having IgD or IgE as M component. PCL,

arising from pre existing multiple myeloma of light chain secretory type associated with AL

(Amyloid Light chain) type of Amyloidosis is very rare. Since there are no large trials on

treatment of patients with PCL, we here make an attempt report this case.

CASE REPORT:

A 60 years old female patient presented with history of fever and epistaxis of one month

duration. On examination she was Febrile, having tachycardia and pallor. She had no

generalized lymphadenopathy but had moderate Hepatosplenomegaly. She had sternal

tenderness.

CASE REPORT


INVESTIGATIONS:

WBC count – 1, 22,000

Hb-2.8mg/dl

Platelet count – 80,000

ESR- 170

Renal and Liver function tests are normal

Serum calcium: 12 mg/dl

Serum uric acid: normal

Serum LDH: 310u/L

Serum β2 microglobulin: 3.1mg/L

Serum Electrophoresis showed no M band

Serum Free Light Chain Assay: detected

Urine Bence Jones protein: Negative

Peripheral Smear Report: RBC showed hypochromia and anisocytosis. Neutrophils were

decreased in number. A large number of plasma cells were seen .Immature and abnormal

plasma cells were seen in plenty. A good number of binucleated plasma cells also seen.

Immature cells exceeded 20%. Platelets grossly decreased in number.

Bone Marrow Aspiration Report: Hypercellularmarrow.RBC precursors were reduced in

number and were normopoietic. Granulocytic precursors were also reduced in number. Each

field showed sheets of plasma cells. Many of the plasma cells were atypical. Some of them were

rounded, some had nuclear abnormalities and some were binucleated. A large number of

plasma blasts were also seen. Megakaryocytes were reduced in number.

Flow Cytometry of Bone Marrow Aspirate: Showed intense positivity for CD 38 and the

presence of cytoplasmic kappa light chains.

Abdominal fat stained positive for Congo Red.

Skull X-ray showed multiple punched out lesions.

Our patient was diagnosed to have primary PCL – light chain type with Primary Amyloidosis,

based on peripheral smear, bone marrow and flow cytometric analysis.

Treatment: Patient was given supportive treatment. Prednisolone and Melphelan were started.

Patient expired in two months after diagnosis.

DISCUSSION:

Plasma cell leukemia is a lymphoproliferative disorder. It is a rare monoclonal

neoplasm having B lymphocyte lineage. It is one of the aggressive human neoplasms accounting

for 2-4% of all cases of plasma cell diseases3. Rarity of PCL can be accessed from the fact that at

M.D. Anderson cancer centre, 27 patients with PCL were seen in 20 year period whereas at

Policlinico-Sanmateo in Italy, 15 cases were seen in 15 years, both representing 2-5% of total

cases of multiple myeloma seen at these centers. Incidence of PCL is less than 1 case per million

population1. Presentation may be primary, secondary – evolving from an existing case of

multiple myeloma as part of the terminal phase of the disease or denova. Sixty to seventy

percent cases are primary. PCL is of two types, Secretory and non-secretory. No M protein is

detected in the non secretory type of PCL4.

WHO criteria to diagnose PCL are - Plasma cells constitute more than 20% of cells in the

peripheral blood with an absolute plasma cell count of more than 2 X 109 / litre.

Lab findings: There is overlap between cells of multiple myeloma and Primary PCL. PCL plasma

cells more frequently express the CD 20 antigen than those of multiple myeloma and they often

CASE REPORT


lack CD 56 antigen which is present on the majority of myeloma cells. CD 56 is important in

anchoring plasma cells to bone marrow stroma and its expression is associated with poor

prognosis. CD 28 is more frequently expressed on malignant plasma cells in secondary than in

primary PCL. Acquisition of CD 28 is associated with increased proliferative rate and disease

progression. PCL is derived from terminally differentiated B cells and the malignant cells stain

positive for mature B cell markers (CD38 and PCA1, Prostate Cancer Antigen 1)5.

In 80% of PCL patients, using FISH (Flourescent In Situ Hybridisation) technique- losses in long

arm of chromosome 13 (13 Q) and deletion of one of the homologous chromosome 13

(Monosomy 13). In 80% of cases, loses on chromosome 16 also occur. Overexpression of

PRAD1/cyclinD1 (Parathyroid associated Neoplasia gene) also present (help in controlling cell

cycle). PCL is more frequent in light chain (Bence Jones’s protein) or IgD myeloma and less in

IgA or IgG myeloma. Hypercalcaemia and increased LDH are known bad prognostic signs of

disease 6. PCL is an extremely aggressive disease with no standard treatment regimen so far

due to the rarity of the disease. Median survival is 2-8 months, prognosis is very poor.

Regimens includes MP, (Melphelan, Prednisolone) VAD (Vincristine, Doxorubicin,

Dexamethasone) TD (Thalidomide, Dexamethasone) VBAP (Vincristine, Carmustine,

Adriamycin, Prednisolone) 7. Case reports regarding long time survival after autologous bone

marrow transplantation or stem cell transplantation also exists but again there is no long term

prospective data on a large number of patients. We presented this case for its rarity.

CONCLUSION:

PCL itself has aggressive course, short survival time, high plasma cell labeling index,

expression of CD 28, Cyclin, PRAD 1 indicate high proliferation. Lytic bone lesion is more

common in multiple myeloma than PCL. Biochemical parameters like increased serum

creatinine, LDH, Serum β2microglobulin and calcium have poor prognosis. Amyloidosis

associated multiple myeloma indicate tumor burden. Non secretory variety has got bad

prognosis. So above mentioned prognostic tools may help to judge the severity of the tumour

burden in a PCL case and act accordingly

ABBREVIATIONS:

PCL: Plasma Cell Leukemia

LDH: Lactate Dehydrogenase

CD: Cluster Differentiating

AL: Amyloid Light

ACKNOWLEDGEMENT:



It gives me pleasure to express my sense of gratitude to my Professor Dr Palaniswamy,

for their guidance, encouragement and constant source of inspiration during case management.


CASE REPORT


Skull X Ray PA view- Showing punched out lesions

Skull X Ray Lateral view- Showing punched out lesions

REFERENCES:

1. Kosma MA, Gale RP. Plasma Cell Leukemia.SeminHaematology 1987.24; 202-8

2. DimopoulasMA,PalumboA,DelasalleKB,AlexanianR.Primary Plasma Cell leikamia.Br

Journal Hematol 1994;88;754-9.

3. Chan SM, George T, Cherry AM,Medeiras BC(2009) Complete remission of primary PCL

Bortezomito, Doxorubicin and Dexamethasone; a case report; cases 12: 1186/1757-

1626-2.

4. ShindoT,Yumoto Y, Yoshida M, Okuda T; Non Secretory Primary Plasma Cell Leukemia

successfully treated with VAD and MP therapy.RhinshoKetsueki; 2002;43; 107-11

5. Badhe BA, Basu D, Toe P Ch,Dutta TK, Ghotekar LH; Plasma Cell Leukemia; a case report.

Indian Journal Pathology Microbiology 2003; 46; 484-7.

6. Voutsadakis IA; Plasma Cell Leukemia. Hama 2000; 3:82-9.

7. Suzuki M, Kawauchi K, Sugiyama H, Yasuyama M, Watanabe H. Primary Plasma Cell

Leukemia; a case report of successful responder to a combination of Vincristine,

Doxorubicin and Dexamethasone. ActaHematol 1989; 82:95-7.

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/ Volume 1/ Issue 3/ July- Sept 2012 Page 110

ANTI-CONVULSANT ACTIVITY OF GANAXOLONE ALONE AND IN

COMPARISON WITH STANDARD ANTI-EPILEPTIC DRUGS IN

RODENT MODELS

Mr. S.K. Subhani Basha, Dr .B. L. Kudagi, Dr. R. Pravin Kumar

1. Tutor, Department of Pharmacology, Narayana Medical College, Nellore.

2. Professor & H.O.D., Department of Pharmacology, Narayana Medical College, Nellore.

3. PG Student, Department of Pharmacology, Narayana Medical College, Nellore.


Dr .B. L. Kudagi,

Professor & H.O.D.,

Department of Pharmacology,

Narayana Medical College,

Nellore.


ABSTRACT:

BACKGROUND: Presently, treatment of epilepsy with standard anti-epileptic drugs is

associated with a number of shortcomings inviting us to study newer agents that would

overcome these problems or search for the drugs or substances, which would enhance the

efficacy or reduce the dose or toxicity of these standard anti-epileptic drugs. Ganaxolone

(GNX) (3α-hydroxy-3β-methyl-5α-pregnan-20-one), a synthetic analog of the endogenous

neurosteroid allopregnanolone and a positive allosteric modulator of GABAA receptors, may

represent a new treatment approach for epilepsy. AIM: To evaluate the effect of Ganaxolone

on maximal electroshock (MES) induced and Pentylenetetrazol (PTZ) induced convulsions

and also their effect in combination with conventional antiepileptic drugs (CAEDs).

MATERIAL AND METHODS: Wister strain albino rats weighing 200-250 gm were used.

Effects of Ganaxolone (5 &10 mg/kg) alone and in combination with standard drugs were

studied in MES and PTZ induced seizure models. Abolition of tonic hind limb extension was

an index of anticonvulsant activity in MES, while for PTZ seizures; failure to observe clonus

for 5sec duration for 30min was the index. Following that, percentage inhibition was

calculated. STATISTICS: ANOVA followed by Newman-Keuls Multiple Comparison Test was

used for analysis of data between the groups. RESULTS: In MES seizures, significant anti-

epileptic activity was observed with 10mg of Ganaxolone compared to control group but

has less activity when compared to that of Phenobarbitone. In PTZ induced convulsions, the

anti-epileptic effect of Sodium Valproate was higher than Ganaxolone, but both were

statistically significant as compared to control. In PTZ-induced seizures, augmented effects

were obtained when Ganaxolone was combined with sodium valproate i.e. 55%.

CONCLUSIONS: The results provide a lead for potential benefit of adding Ganaxolone to

Sodium Valproate in the treatment of epilepsy, which needs to be explored further.

KEYWORDS: Seizures, Ganaxolone, Phenobarbitone, Sodium Valproate, Pentylenetetrazol,

Hydoxypropyl-β-Cyclodextrin, GABA.

ORIGINAL ARTICLE


INTRODUCTION:

Epilepsy is a common and chronic neurological disorder characterized by apparently

unprovoked recurrent paroxysmal events or seizures that are associated with a sudden

alteration in motor activity and behavior, with or without alteration in conscious

awareness. The alteration in state is the result of an abnormal and excessive hyper

synchronous firing within a group of epileptic neurons in the brain1. Epilepsy affects

around 50 million people worldwide and the majority of people with epilepsy (70%) have

a good prognosis if they receive appropriate treatment. The prevalence of active epilepsy is

roughly in the range of 5–10 per 1000 people2. Epilepsy's approximate annual incidence

rate is 40–70 per 100,000 in industrialized countries and 100–190 per 100,000 in

resource-poor countries; socioeconomically deprived people are at higher risk. In

industrialized countries the incidence rate decreased in children but increased among the

elderly during the three decades prior to 2003, for reasons not fully understood. Epilepsy's

lifetime prevalence is relatively high because most patients either stop having anti-epileptic

drugs or (less commonly) die3.

In about two-thirds of all patients affected with epilepsy, seizures are well

controlled with currently available anti-epileptic drugs, while in the remainder seizures are

refractory to treatment. Moreover, many of the existent anti-epileptic agents produce many

undesirable side-effects including drowsiness, mental dullness, nausea, ataxia, paresthesia,

hematologic changes, hirsutism, weight gain, hypertrophy of gums and congenital

malformations. For these reasons, new antiepileptic drugs are needed to improve seizure

control and decrease side-effect profile4.

At the neuronal level, seizure activity often occurs when glutamatergic excitatory

neurotransmission overrides GABA-mediated inhibition. Therefore, glutamatergic and

GABAergic systems are rational targets for antiepileptic drug development5. Pharmacological

manipulations leading to increased levels of GABA (by inhibition of GABA degradation or

reuptake) and/or positive allosteric modulation of the GABA receptor complex are among

the approaches that have been used to facilitate inhibitory GABAergic neurotransmission6.

Ganaxolone (3α-hydroxy-3β-methyl-5α-pregnan-20-one), the 3β-methyl analog of the

progesterone metabolite allopregnanolone, is the first synthetic neurosteroid related agent

to be evaluated in man for the drug treatment of epilepsy, which is now undergoing phase-

III clinical trials7. Ganaxolone, like Allopregnanolone, acts as a powerful positive

allosteric modulator of GABAA receptors, resulting in enhanced neural inhibition8.

Hence, the present study was undertaken to determine whether Ganaxolone alone or

along with standard antiepileptic drugs could provide superior seizure control in maximal

electroshock (MES) induced and Pentylenetetrazol (PTZ) induced convulsions as compared

to CAEDs.

MATERIALS & METHODS:

ANIMALS:

Wister strain albino rats weighing between 200-250gms were used, for this study.

The animals were obtained from the central animal house of Narayana Medical College,

ORIGINAL ARTICLE


Nellore. They were housed in standard polypropylene cages. The animals were excluded if the

weight of rats were below 200gms and if they had any visible diseases. The animals are

maintained under standard laboratory conditions (12:12 hr light: dark cycles and

temperature 250C ± 10C with free access to food and water ad libitum. All the experiments

were carried out around the same time each day. All the experimental procedures and

protocols were reviewed and approved by the Institutional Animal Ethics Committee (IAEC)

of the institute, with protocol number 12/2010/NMC.

CHEMICALS & DRUGS:

All standard chemicals used in this study were of analytical grade. Pure form of

Ganaxolone & Hydoxypropyl-β-Cyclodextrin were obtained from Sigma chemicals. Stock

solutions of Ganaxolone for injection were made in 40% Hydoxypropyl-β-Cyclodextrin in

water. By itself, β-cyclodextrin at concentrations as high as 50% failed to affect seizures.

ASSESSMENT OF ANTICONVULSANT ACTIVITY:

GROUPING:

To study the anti-epileptic activity of Ganaxolone, two models namely MES induced

convulsions and Pentylenetetrazol induced convulsions in rats were used. Each model

consists of five groups, each group containing 6 animals.

Groups were divided as follows,

Group I (Control group) was treated with 40% (w/v) Hydoxypropyl-β-Cyclodextrin 4ml/kg

body weight.

Group II received Ganaxolone at a dose of 5 mg/kg body weight.

Group III received Ganaxolone at a dose of 10 mg/kg body weight.

Group IV received standard drug (Phenobarbitone 20mg/kg – MES, Sodium Valproate

200mg/kg – PTZ seizures).

Group V received Ganaxolone at 5 mg/kg body weight and standard drug.

Separate groups of animals were used for different models and all the groups

received the drugs intraperitonially at different sites throughout the experiment.

Concentration of drugs were so adjusted that all the animals in the group received the

same volume of preparation throughout the study. All the drugs were given 30 min prior

to the induction of convulsions.

MES SEIZURE METHOD9:

Anticonvulsant activity of Ganaxolone was tested for MES seizure by inducing

convulsions with an electroconvulsiometer. In this method, electrical stimulation was

applied via clipped-ear electrodes (moistened with saline solution before each application)

which delivered a constant current of 150mA current for 0.2 seconds. Abolition of hind limb

tonic extension was taken as an index of anticonvulsant activity10. Parameters observed

were time for onset and duration of tonic hind limb extension (THE).

CHEMICALLY INDUCED SEIZURES9:

ORIGINAL ARTICLE


Pentylenetetrazol is a tetrazol derivative with consistent convulsive effect in a larger

number of animal species like mice, rats, cats, primates etc. It is believed to act by

antagonizing the inhibitory GABAergic neurotransmission10. This model was used to screen

the anti-epileptic efficacy of Ganaxolone against petit mal epilepsy as Ganaxolone also acts

through GABA-A receptor modulator mechanism.

Rats were injected with Pentylenetetrazol (70 mg/kg, i.p) 30 minutes after test drug

and standard drug (Sodium Valproate – 200mg/kg) and the occurrence of the first

generalized clonus (repeated clonic seizures of the fore and hind limb lasting over 5sec.

with an accompanying loss of righting reflex) or jerky movements were recorded during

individual observation for 30 min.

STATISTICAL ANALYSIS:

The data was collected in case record forms and then entered into excel

spreadsheet 2007. Statistical analysis was performed using Microsoft Excel – 2007 and

Sigma Graph pad prism version-5 USA. Data was described as Mean ± Standard deviation.

One way ANOVA followed by Newman-Keuls Multiple Comparison Test was used for

analysis of data between the five groups. For all inferential statistical tests a two tailed P

value of less than 0.05 was considered significant.

RESULTS:

EFFECT OF GANAXOLONE ON TONIC HIND LIMB EXTENSION IN MES:

Tonic hind limb extension was completely abolished in group IV (treated with

Phenobarbitone) and group V (combination of Ganaxolone and Phenobarbitone). Percentage

inhibition of duration of tonic hind limb extension increased with the use of Ganaxolone

10mg/kg up to 50% and were 100% for group IV and V. MES induced convulsions

blocking activity of Ganaxolone 10mg/kg was extremely significant (p<0.001) when

compared to that of control but it was less effective when compared to Phenobarbitone.

The combination of Ganaxolone + Phenobarbitone has a similar / superior MES induced

convulsions blocking activity compared to that of Phenobarbitone alone.

EFFECT OF GANAXOLONE ON PTZ INDUCED SEIZURES:

The onset of jerky movements in PTZ induced convulsions were significantly

delayed by Ganaxolone 10mg/kg (p<0.001) as compared to the control. Percentage

inhibition of duration of jerky movements with 10 mg of Ganaxolone was 37.5% and it was

45% for sodium valproate, whereas as the combination of Ganaxolone + Sodium Valproate

(group V) further decreased the duration of jerky movements up to 55%, implying that PTZ

induced convulsions blocking activity of Sodium Valproate was more than that of

Ganaxolone, but both were statistically significant. The combination of Ganaxolone and

Sodium Valproate has a superior PTZ induced convulsions blocking activity compared to

that of Sodium Valproate alone.

DISCUSSION:

ORIGINAL ARTICLE


The present study was aimed at evaluating the effect of Ganaxolone on maximal

electroshock (MES) induced and Pentylenetetrazol (PTZ) induced convulsions and also

their effect in combination with conventional antiepileptic drugs (CAEDs) using animal

models.

Ganaxolone (GNX) is the synthetic analog of allopregnanolone (3α, 5α-P ) it belongs

to a class of compounds referred to as neurosteroids that have been termed “epalons”

which has been presumed to possess sedative, anxiolytic, and anticonvulsant effects11.

Maximal electric shock induced convulsions is a suitable test for evaluating anti-

epileptic properties of drugs, because it is the best-validated preclinical test that predicts

drugs effective against generalized seizures of the tonic–clonic (grand mal) type.

In our study, we demonstrated significant anti-epileptic activity with 10mg of

Ganaxolone compared to control group but has less activity when compared to that of

Phenobarbitone but both were statistically significant. Using this model, Virinder Nohria et

al. (2007) reported that, although Ganaxolone effectively blocked tonic seizures induced by

maximal electroshock in mice (ED50 of 29.7 mg/kg, i.p.), it did so at doses that produced

ataxia on the rotorod ( mean toxic dose, TD50, of 33.4mg/kg, i.p.)12. Same results were

observed by Richard B. Carter et al (1997), who also reported that Ganaxolone was less

potent against MES (ED50 of 29.7 mg/kg i.p.) than sodium valproate, resulting in protective

indices of 1.1, as opposed to 1.9 for valproate9.

We also evaluated the anti-epileptic activity of Ganaxolone using Pentylenetetrazol

induced convulsions model, as this test is used for screening of drugs effective in petit mal

epilepsy or absence seizures. By analyzing our results we like to state that PTZ induced

convulsions blocking activity of Ganaxolone was slightly less than that of Sodium Valproate.

Our study was supported my Richard B. Carter et al (1997), who also reported that

Ganaxolone produced potent anticonvulsant effects with PTZ induced convulsions, with an

i.p. ED50 of 4.3 mg/kg in mice and 7.8 mg/kg in rats. Ganaxolone was also active after oral

administration in rats, with an ED50 of 21.0 mg/kg. The profile of anticonvulsant activity

obtained for Ganaxolone is similar in many respects to that of the clinically used reference

agent valproate. Ganaxolone is superior to valproate, however, in its ability to increase the

seizure threshold for i.v. PTZ infusion at nonataxic doses9.

Also, Marjolein Beekman et al (1998) concluded that the neuroactive steroid

Ganaxolone is superior to a host of standard antiepileptic agents (Diazepam, Clonazepam,

Valproic acid, Ethosuximide, Phenobarbitone) in controlling the behavioral disturbances that

result from both acute PTZ administration and a regimen of PTZ that induces seizure

kindling. Although much less potent than Ganaxolone, Phenobarbital was the drug that most

closely mirrored Ganaxolone in its anti-PTZ effects13 .

Furthermore, Virinder Nohria et al (2007) also reported that Ganaxolone was

effective against clonic convulsions induced by subcutaneous Pentylenetetrazol

administration in mice and rats (ED50 values of 4.3 and 7.8 mg/kg i.p., respectively). He

also stated that PTZ-induced seizures in rats did not develop tolerance to chronic treatment

with Ganaxolone12.

MES-induced tonic extension can be blocked by drugs that inhibit voltage dependent

Na + channels, such as phenytoin, carbamazepine, and valproate (Macdonald and Kelly,1995;

ORIGINAL ARTICLE


Rogawski and Porter, 1990; White, 1997), as well as by drugs that block glutamatergic

excitation mediated by the N-methyl-D-aspartate receptor, such as felbamate (McCabeet al.,

1993; Subramaniam et al., 1995; White et al., 1995). In contrast, clonic seizures induced by

PTZ can be blocked by drugs that reduce T-type Ca++ currents, such as ethosuximide

(Coulter et al., 1989), and drugs that enhance GABA-A receptor mediated inhibitory

neurotransmission, such as benzodiazepines, phenobarbital and perhaps valproate and

felbamate (Macdonald and Kelly, 1995; Rogawski and Porter, 1990; White, 1997)9.

Ganaxolone exhibits anticonvulsant activity to PTZ and to a lesser extent against

MES induced convulsions. Ganaxolone increased the seizure threshold before attaining a

dose sufficient to produce ataxia on the rota rod. The ability of Ganaxolone to both elevate

seizure threshold and block i.p. PTZ induced seizures can be attributed to its modulatory

effect on GABA-A neurotransmission. Whether this effect contributes to its ability to block

MES induced tonic extension is not known, but that is likely, because there is at present

no experimental evidence to suggest that Ganaxolone blocks voltage-dependent Na+ channels

or N-methyl-D-aspartate receptors.

Ganaxolone inhibits binding of the GABA-A chloride channel ligand and enhanced

binding of the benzodiazepine site ligand and the GABA site ligand. Electrophysiological

recordings showed that nanomolar concentrations of GNX potentiated GABA-evoked chloride

currents in Xenopus oocytes expressing human GABA-A receptor subunits α1, β2, γ2L, but

direct activation of chloride flux occurred only at micromolar concentrations14,15.

The unique potency and efficacy of Ganaxolone against PTZ induced convulsions have

several implications. First, these anti-epileptic effects of Ganaxolone in PTZ induced

convulsions appear to be predictive of the potency and efficacy of Ganaxolone against absence

seizures as it compares favorably with that of valproate. The results provide a lead for

potential benefit of adding Ganaxolone to Sodium Valproate in the treatment of epilepsy,

which needs to be explored further. Second, Ganaxolone may provide additional benefit in the

treatment of epilepsy by controlling anxiety, mood changes and other behavioral alterations

associated with preseizure activity. Finally, Ganaxolone may represent a novel treatment

approach to the clinical control of epilepsy.

CONCLUSION:

Overall, Ganaxolone is a high-affinity, stereo selective, positive allosteric modulator of

GABA-A receptors that exhibits potent, broad-spectrum anti-epileptic activity. The present

study supports clinical evaluation of Ganaxolone as an anti-epileptic medication with

potential therapeutic utility in the treatment of generalized, absence seizures as well as

simple and complex partial seizures, alone or as an add on drug with the conventional anti-

epileptic drugs to reduce their dose / adverse effects.

ACKNOWLEDGEMENTS:

The authors are thankful to the staffs and PGs of Narayana Medical College, Nellore

and Sigma Aldrich.

ORIGINAL ARTICLE


Table 1: Antiepileptic effect of Ganaxolone alone and in combination with Phenobarbitone

on Maximal Electric Shock (MES) induced seizures in rats

Table 2: Antiepileptic effect Ganaxolone alone and in combination with Sodium Valproate on

PTZ induced seizures in rats

S.No Group & Dose

(mg/kg i.p )

Mean time for

onset of THE

in secs

Mean time duration of

THE in secs.

Percentage

inhibition of

duration of THE

1. Control 2.7±0.52 7±0.63 ----

2. Phenobarbitone - 20 0** 0** 100

3. Ganaxolone - 5 3.5± 0.55* 6±0.89* 14.29

4. Ganaxolone - 10 6±0.63** 3.5±0.55** 50

5. Ganaxolone 5 +

Phenobarbitone - 10 0** 0** 100

** - p<0.001 compared to control , * - p<0.01compared to control ,

THE – Tonic Hind limb Extension

S.

N

o

Group & Dose

(mg/kg bw )

Onset of mean time

for jerky movements

in min.

Mean time

duration of jerky

movements in min.

Percentage

inhibition of

duration of jerky

movements

1. Control 1.8±0.34 40±4.1 ------

2. Sodium Valproate – 200 8.9±1.3** 22±1.8** 45

3. Ganaxolone - 5 4.4±0.86** 33±1.2** 17.5

4. Ganaxolone - 10 7.8±0.88** 25±1.5** 37.5

5. Ganaxolone 5 +

Sodium Valproate – 200 9.5±0.7** 18±1.2** 55

** - p<0.001 compared to control

ORIGINAL ARTICLE


ANTICONVULSANT ACTIVITY OF GANAXOLONE ON PTZ SEIZURES

ORIGINAL ARTICLE


REFERENCES:

1. Fisher RS, Van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy:

definitions proposed by the International League Against Epilepsy (ILAE) and the

International Bureau for Epilepsy (IBE). Epilepsia 2005;46(4):470-2.

2. "Epilepsy". World Health Organization. January 2009. Retrieved January 5, 2012.

3. Sander JW. The epidemiology of epilepsy revisited. Curr Opin Neurol 2003; 16: 165-70.

4. Maciej Gasior, Richard B Carter, Steven R Goldberg, Jeffrey M Witkin. Anticonvulsant

and behavioral effects of neuroactive steroids alone and in conjunction with Diazepam.

J Pharmacol Exp Ther 1997; 282: 543-553.

5. Bradford H F. Glutamate, GABA and epilepsy. Progress in Neurobiol 1995; 47:477–511.

6. Macdonald R L, Olsen RW. GABAA receptor channels. Annu. Rev. Neurosci. 1994; 17:

569–602.

7. Nohria V, Giller E. Ganaxolone. Neurotherapeutics 2007;4:102–105.

8. Rogawski MA, Reddy DS. Neurosteroids: endogenous modulators of seizure

susceptibility. In: Rho JM, Sankar R, Cavazos JE, editors. Epilepsy: scientific

foundations of clinical practice. New York: Marcel Dekker; 2004. P.319–355.

9. Carter RB, Wood PL, Wieland S, Hawkinson JE, Belelli D, Lambert JJ, et al.

Characterization of the anticonvulsant properties of Ganaxolone (CCD 1042; 3-alpha-

hydroxy-3-beta-methyl-5-alpha-pregnan-20-one), a selective, high-affinity, steroid

modulator of the gamma-aminobutyric acid (A) receptor. J Pharmacol Exp Ther

1997;280:1284-95.

10. Mittal R. Antiepileptics. In: Gupta SK, editor. Drug Screening Methods. 1st ed. New

Delhi: Jaypee Brothers Medical Publishers; 2009. P. 408-9.

11. Gee K.W. Epalons as anticonvulsants: actions mediated by the GABA-A receptor

complex. Proc West Pharmacol Soc 1996; 39: 55-60.

12. Virinder Nohria, Earl Griller. Ganaxolone. Neurotherpeutics: The Journal of the

American society for Experimental Neurotherpeutics 2007; 4(1): 102-5.

13. Marjolein Beekman, Jesse T Ungard, Maciej Gasior, Richard B Carter, Durk Dijkstra,

Steven R Goldberg, et al. Reversal of behavioral effects of Pentylenetetrazol by the

Neuroactive Steroid Ganaxolone. JPET 1998; 284(3): 868-77.

14. Liptakova S, Velisek L, Veliskova J, Moshe SL. Effect of Ganaxolone on flurothyl seizures

in developing rats. Epilepsia 2000; 41:788–93.

15. Kaminski RM, Livingood MR, Rogawski MA. Allopregnanolone analogs that positively

modulate GABA receptors protect against partial seizures induced by 6-Hz electrical

stimulation in mice. Epilepsia 2004; 45: 864–67.

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/ Volume 1/ Issue 3/ July-Sept 2012 Page 119

SERUM MAGNESIUM AS A MARKER OF DIABETIC COMPLICATIONS Dr Mirza Sharif Ahmed Baig1, Dr Mohd Shamshuddin2 Dr K L Mahadevappa 3, Dr Abdul Hakeem

Attar1 Dr Abdul Kayyum Shaikh1

1. Department of Biochemistry, KBN Institute of Medical Sciences, Gulbarga.

2. Department of Biochemistry, Al Ameen Institute of medical Sciences, Bijapur.

3. Department of Biochemistry, KempeGowda Institute of Medical Sciences, Bangalore.


Dr Mirza Sharif Ahmed Baig,

Plot No. 109,

Macca Colony, Ring Road,

Gulbarga- 04,

Karnataka.


Ph- 0091 9916039995

ABSTRACT:

Type 2 diabetes has become a leading cause of morbidity and mortality world over.

Magnesium homeostasis has been hypothesized to be a link between insulin resistance type 2

diabetes mellitus, hypertension and CAD. This study was under taken to evaluate the relationship

between serum magnesium and diabetes mellitus without and with complications. We found

significantly low levels of serum magnesium in patients with DM when compared to control.

Further significantly low levels of serum magnesium were found in patients with diabetic

complications when compared with diabetic patients without complications. Hence it is concluded

that the lower levels of serum magnesium may have a bearing on the complication and morbidity in

patients of DM, and estimation of serum levels of magnesium may be helpful to monitor the severity

of complications in diabetic patients.

KEY WORDS: Coronary Artery Disease, Diabetes Mellitus, Diabetic Retinopathy, Hypomagnesemia.

INTRODUCTION:

Magnesium, the fourth most common cation in the body, has been the recent focus of much

clinical and scholarly interest. Previously underappreciated, this ion is now established as a central

electrolyte in a large number of cellular metabolic reactions, including DNA and protein synthesis,

neurotransmission, and hormone receptor binding. It is a component of GTPase and a cofactor for

Na+/ K +-ATPase, adenylate cyclase, and phosphofructokinase.

Magnesium is a cofactor in more than 300 cellular enzymatic systems and has a key role in

cellular metabolism, the recognition that Mg deficiency or excess may be associated with significant

clinical consequences has resulted in an increased interest in the utility of serum Mg

measurement(1). Magnesium is an important intracellular cation that is distributed into three

major compartments: mineral phase of bones (65%), intracellular space (34%) and extracellular

fluid (1%) (2).

ORIGINAL ARTICLE


In several studies reduced magnesium concentrations have been observed in diabetic adults

(3-7).

The interrelationships between magnesium and carbohydrate metabolism have regained

considerable interest over the last few years. The association between diabetes mellitus and

hypomagnesaemia is compelling for its wide ranging impact on diabetic control and complications.

Magnesium depletion has been linked to the development of retinopathy (8). The etiology of

hypomagnesiamea cannt be clearly explained and serum magnesium levels have been shown to be

inversely related to the severity of diabetes (9). Hypomagnesaemia has been linked to poor

glycemic control, coronary artery diseases, hypertension, and diabetic neuropathy and foot

ulcerations (10).

Hence this work was undertaken to evaluate the relationship between serum magnesium

and diabetes mellitus without and with complications.

MATERIAL AND METHODS:

The present study was carried out in the Department of Biochemistry KBN Institute of

Medical Sciences and KBNTGH Gulbarga, and KempeGowda Institute of Medical Sciences,

Bangalore. Clearance was obtained from the institutional ethical committee.

The study was carried out on 30 age and sex matched healthy controls and 60 type 2

diabetic patients who attended the outpatient and inpatient department of KempeGowda Institute

of Medical Sciences, Bangalore during the year 2007-2008.A total 60 patients of type 2 diabetes

mellitus between 40 – 70 years, which were divided into following groups.

Control group: Included 30 healthy, age and sex matched individuals.

Group I: Included 30 patients of type 2 diabetes without complications.

Group II: Included 30 patients of type 2 diabetes with proven complications, like CAD,

retinopathy and neuropathy.

The diagnosis of type 2 diabetes mellitus was established with the recommended criteria’s

of American diabetes Association.

Inclusion Criteria: Patients in the age group of 40–70 years with type 2 diabetes without

and with proven complications, like CAD, neuropathy and retinopathy were selected.

Exclusion Criteria: Patients with recent infectious disease, immunological disorders, taking

diuretics and magnesium containing antacids, malabsorption syndrome, chronic diarrhea, renal

failure, pancreatitis, alcoholism, liver diseases, tuberculosis and thyrotoxicosis were excluded from

the study.

Informed consent was taken from patient and control subjects. A pre-structured and pre-

tested proforma was used to collect the data. Baseline data including age and sex, detailed medical

history including conventional risk factors, clinical examinations and relevant investigations

including ECG, echocardiogram, nerve conduction test, fundoscopy etc were included as part of the

methodology.

Fasting venous blood samples were collected from cases and controls and the samples were

centrifuged, serum was separated and stored at 40C. Serum magnesium was estimated by Calmagite

dye method (11) by using auto-analyzer (A25Biosystem). Magnesium reacts with the blue dye,

calmagite, in alkaline medium to form red colored complex which is measured at 530-550nm. The

intensity of the color formed is directly proportional to the amount of magnesium in the sample.

ORIGINAL ARTICLE


Protein interference and dye precipitation are avoided including the 9-ethylene oxide adduct of p-

nonylphenol (Bion NE9) and Polyvinyl pyrrolidone (Bion pup). Calcium interference is avoided by

preferential combination with EDTA and heavy metal interference is prevented by Potassium

cyanide. The reference range for serum magnesium concentration does not vary significantly for

age or sex and is closely maintained within a range of 1.7-2.4mg/dl.

PPBS were estimated 2 hours after breakfast. Urine sample was analyzed for protein and

sugar.

STATISTICAL METHODS:

Student `t’ test /Chi-square test has been used to find the significance of homogeneity of

study characteristics between three groups of patients. Analysis of variance has been used to find

the significance of study parameters between three groups. Results were expressed as mean + SD.

Probability values of P< 0.05 were considered to indicate statistical significance.

STATISTICAL SOFTWARE:

SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used for the analysis of the data and

Microsoft word and Excel have been used to generate graphs, tables etc.

RESULTS:

Results of the present study showed significant low values of serum magnesium (P<0.001)

in patients of DM without complications when compared with controls. Further significant low

values of serum mg (P<0.001) were found in patients of DM (Table 1 & Fig 1) with complications

when compared with control.

DISCUSSION:

The magnesium ion has been shown to play an important role in the metabolism of

carbohydrates by activating various enzyme systems and helping insulin for its action. In this study

it was observed that the mean serum magnesium level was statistically significantly low (P<0.001)

in Diabetic patients without and with complications when compared with controls. This indicates

the association of hypomagnesaemia with diabetes mellitus. These results are in accordance with

the observation of Tosiello L (12), Kao WH (13), and Chamber E C (14). In our study, serum

magnesium level in cases with diabetic complications (1.29 + 0.31) was much lower than those

without complications (1.61 + 0.41).

We also noted that in subjects with diabetic complications serum magnesium levels were

much lower when compared to diabetics without complications. Hatwal A et al, Andrea Corsenello

et al and Rodriguez Moran M et al have found similar results in patients with diabetic

complications. Ishrath Kareem et al found that serum magnesium levels in patients with diabetic

retinopathy were significantly lowered compared to patients without retinopathy (15). Aradhana

Sharma et al also found that serum magnesium levels were significantly lowered in patients with

diabetic complications when compared to diabetic patients without complications (16).

In our opinion the release of insulin caused by a glucose challenge is partly dependent on

adequate magnesium. Insulin, via its interaction with ligand activated tyrosine protein kinase

associated receptors, initiates a cascade of biochemical interactions that result in several

ORIGINAL ARTICLE


physiological, biochemical and molecular events that are involved in carbohydrate, lipid and

protein metabolism (17). Although the binding of insulin to its receptor does not appear to be

altered by magnesium status, the ability of insulin once bound to receptor to activate tyrosine

kinase is reduced in hypomagnesaemia states (18). As a result reduced peripheral glucose uptake

and oxidation are often noted in subjects with hypomagnesaemia. Decrements in the enzymatic

activities of several metabolic pathways are seen in DM patients as a result of the relative

magnesium deficiency (19).

The exact cause of diabetic hypomagnesaemia is still unknown but an increased urinary loss

of magnesium may contribute to it. Hypomagnesaemia has been reported to occur at an increased

frequency among patients with type 2 diabetes compared with their counter parts without

diabetes. Despite numerous reports linking hypomagnesaemia to chronic diabetic complications,

attention to this issue is poor among clinicians. The precise mechanism for development of

microvascular changes is not fully understood, it is possible that hypomagnesaemia inhibits

prostacyclin receptor function producing an imbalance between prostacyclin and thromboxane

effect which has marked atherogenic potential which is responsible for microvascular

complications.

Thus we conclude that the estimation of serum magnesium levels is helpful to monitor the

severity of complications in type 2 diabetes and also be useful for proper medical intervention.

Hence further studies on serum magnesium levels and on oral supplementation to prevent

late complications of diabetes will be interesting and helpful.

Table 1: Serum Magnesium in the three study groups

Study

parameters Controls

DM without

complications

DM with

Complications

Sr.Mg /dl 2.17±0.35 1.61±0.41** 1.29±0.31**

Results are presented in Mean ± SD P < 0.001 highly significant

Fig 1: Serum Magnesium in the three study groups

0

0.5

1

1.5

2

2.5

3

Controls DM without complications

DM with complications

Sr. M

g (m

g/dl

)

ORIGINAL ARTICLE


REFERENCES:

1. Elin R. J.Assement of magnesium status. Clin Chem 1987; 33:1965 – 1970.

2. Gums J G. Clinical significance of magnesium: A review. Drug Intell Clin Pharm 1987; 21:

240 – 246.

3. Maltezos E,Papazoglou D, Exiara T, Kambouromiti G, Antonoglou C. Serum magnesium

levels in non diabetic offspring of patients with type 2 diabetes mellitus. Diabetes Nutr

Metab 2004; 17:12 – 16.

4. Mc Nair P, Christiansen C, Madshad S. Hypomagnesaemia a risk factor in diabetic

retinopathy. Diabetes 1978; 27:961 – 965.

5. Mather H M, Nisbet J A, Bruton G H. Hypomagnesaemia in diabetes. Clin Chem Acta

1979; 95:235 – 242.

6. Fuji S, Tekemura T, Wada M, Akai T, Okurr k m. Magnesium levels in plasma ,

erythrocyte and urine in patients with diabetes mellitus. Horn Metab Res 1982; 14: 161

– 162.

7. Johansson G, Danielsson B G, Ljunghalls, Wibell L. Evidence for a disturbed magnesium

metabolism in diabetes mellitus. Magnesium 1982; 3:178 – 180.

8. Ceriella A, Giugliano D, Dellorurso P, Passariello. Hypomagnesaemia in relation to

diabetic retinopathy. Diabetic Care. 1982; 5:558 – 559.

9. Hamid Nasri, Hamid Raza Baradaran. Lipids in association with serum magnesium in

diabetes mellitus patients. Bratisl Lek Listy.2008;109(7):302-306

10. Pham PC, Pham PM, Pham SV et al .Hypomagnesaemia in patients with type 2 diabetes

.Clin Am Soc Nephrol 2007;2:366-73.

11. Gindler EM, Heth DA. Colorimeter determination with bound “Calmagite” of magnesium

in human blood serum. Clin Chem 1971; 17:662.

12. Tosiello L. Hypomagnesaemia and diabetes mellitus. A review of clinical implications.

Arch Intern Med 1996; 156(1):1143 – 1148.

13. Kao W H. Serum and dietary magnesium and the risk for type 2 diabetes mellitus. The

Atherosclerosis risk in communities study. Arch Intern Med 1999; 159(8):2151 – 2159.

14. Chambers EC, Heshkas, Gallagherd.Serum magnesium and type 2 diabetes in African

Americans and Hispanics a Newyork Cohort. J Am Coll Nutr. 2006; 25:509 – 513.

15. Ishrat Kareem, Jaweed SA. Bardapurkar JS et al. Study of magnesium, glycosylated

hemoglobin and lipid profile in diabetic retinopathy. Indian Journal of Clinical

Biochemistry, 2004; 19(2);124-127.

16. Aradhana Sharma, Surekha Dabla, RP Agarwal et al. Serum magnesium; An early

predictor of course and complications of diabetes mellitus. J Indian Med Assoc

2007;105:16-20.

17. Lefebvre P J, Scheen A J. Improving the action of insulin. Clin Invest Med 1995; 18:342 –

347.

18. Suarez A. Decreased insulin sensitivity in skeletal muscle of hypomagnesaemia rats.

Diabetologia 1993; 36:A82.

19. Laughlin M R, Thompson D. The regulatory rule for magnesium in glycolytic flux of the

human erythrocyte. J Biol Chem 1996; 271: 28977 – 83.

CASE REPORT


LUPUS VULGARIS: - AN UNUSUAL FACIAL INVOLVMENT

Mandakini. B. T, Hakeem. A, Zennath. B

1. Assistant Professor, Department of Pathology, KBN Institute of Medical Sciences, Gulbarga.


3. Associate Professor, Department of Pathology, KBN Institute of Medical Sciences, Gulbarga.


Dr Mandakini. B. Tenglr,

C/O Dr. Srinivas,

H. No. 1-888/1, Shastri Nagar,

Gulbarga- 04, Karnataka,

Email id- [email protected],

Ph- 0091 9844586236.

ABSTRACT:

BACKGROUND: Primary infection with tuberculosis occurs only rarely on the skin. The lesions of

Lupus vulgaris are usually found on the head or neck. The skin of and around the nose is

frequently involved. But, we report a rare case, where a 36 years’ old male patient presented with

a Lupus vulgaris lesion over the upper part of the cheek, near the outer canthus of the right eye, of

9 years’ duration. Histopathological examination showed granulomatous infiltration, with caseous

necrosis. Mantoux test was positive. The lesion showed marked improvement on antituberculous

treatment. We want to emphasize that histopathological examination has diagnostic value in

Lupus vulgaris.

KEYWORDS: Lupus vulgaris, facial skin, granuloma, caseation necrosis.

INTRODUCTION:

There is a resurgence of tuberculosis everywhere because of a combination of factors

including immigration from endemic countries, HIV pandemic, poverty, etc. as a result,

tuberculosis remains a clinical and diagnostic problem[1].

Lupus vulgaris is the most common morphological variant of cutaneous tuberculosis

accounting for approximately 59% of cases of cutaneous tuberculosis in India. [4, 6, 10].

Cutaneous tuberculosis forms a small proportion of extrapulmonary tuberculosis [3, 7].It has

been shown that Lupus vulgaris is the most common form in adults. [3, 8].

In India, the sites of predilection are the buttocks and trunk [3, 9].

We report a rare case of Lupus vulgaris affecting facial skin.

CASE REPORT:

A 36 year’s old male patient presented with history of a chronic progressive nonhealing

lesion on the upper part of the right cheek, near the outer canthus of the eye, of 9 year’s

duration. Clinical examination revealed a well-demarcated, irregularly bordered, reddish-brown

patch, containing deep-seated nodules, each about 1mm. in diameter, with central area of

atrophy and scarring (fig-1).

CASE REPORT


Topical antibacterial, antifungal and steroid ointments were tried earlier, but there was

no response.

Clinical diagnosis of Granuloma annulare was made, and Lupus vulgaris was the

differential diagnosis. There was no pervious history of tuberculosis, either pulmonary or extra-

pulmonary. There was no regional lymphadenopathy, and systemic examination showed no

abnormalities. There was no similar family history Routine hematological examination revealed

lymphocytosis and raised ESR-80mm. Mantoux test was positive. Biochemical investigations like

random blood sugar, TB-IgG/IgM (slide method), VDRL, HIV, serum creatinine, and serum urea

levels were within normal limits. Chest X-ray was done which showed bronchitis with no

evidence suggestive of tuberculosis.

Histopathological study of the punch biopsy from the edge of the lesion revealed normal

epidermis, and the dermis showed tuberculoid granulomas consisting of epithelioid histiocytes,

Langhans giant cells surrounded by lymphocytes, with slight central caseation necrosis. Tissue

sections were negative for Acid fast bacilli.

DISCUSSION:

Infection of the skin and subcutis by Mycobacterium tuberculosis occurs by three routes;

1) By direct inoculation into the skin.

2) By hematogenous spread from an internal lesion.

3) From an underlying tuberculous lymph node by direct extension (causing

scrofuloderma).[1]

Mycobacterium bovis, atypical Mycobacteria and the BCG Vaccine can cause tuberculosis

involving the skin [5]. The diagnosis of cutaneous tuberculosis is challenging and requires the

correlation of clinical finding with diagnostic testing. [5] The determinants of what happens in

tuberculosis infection, includes, the virulence of the organism, the size of the inoculum, the

route of infection, and the immune status of the patient. The lesions of Lupus vulgaris are

usually found on the head and neck. The lesion in our case was a well-demarcated, reddish-

brown patch, containing deep-seated nodules, each about 1mm in diameter, with central area

of atrophy and scarring. The diagnosis in this case was based on histopathological study of the

biopsy of the lesion, which showed typical granulomatous tubercles with epithelioid cells,

Langhans giant cells and a mono-nuclear inflammatory infiltrate (fig-3&4). Caseation necrosis

was seen (fig-5) and AFB Negative

The patient was administered antitubercular therapy and the lesion resolved completely

in 6 months and 2 year follow-up shows no recurrence. (Fig-2).

Lupus vulgaris is completely curable as has been seen in the present case. The

consequences of failing to make an early diagnosis can be disastrous for the patients, as the

progression of the disease can lead to necrosis, destruction of bones and cartilage leading to

permanent deformity [4, 6, 9, and 10].

The special test like polymerase chain reaction (PCR) for TB can be done to substantiate

the diagnosis or wherever the histopathology is inconclusive [4, 6, 9, and 10].

CASE REPORT


Fig 01 Fig 02

Fig 03 Fig 04

CASE REPORT


Fig 05

REFERENCES:

1). Sebastian L. Bacterial Diseases. In: Lever’s Histopathology Skin. David E Elder.

Lippincott Williams & Wilkins 9th edition 2005.

2). Afsar SF., et al. Lupus vulgaris in a pediatric patient: a clinicohistopathological

diagnosis. Braz J Infect Dis vol. 12 no. 2 Salvador Apr. 2008.

3). Jain, V. K.,et al. Hypertrophic Lupus vulgaris an unusual presentation. Indian J

Dermatol 2009: 54(3): 287-9.

4). Chakravarti: A., et al. Lupus vulgaris of external nose. Indian J Tuberc 2006; 53: 220-

222.

5). Wg Cdr P Kinra, Col S Srinivasan, Col SPV Turlapti, Lt Col A Kumar. Lupus vulgaris

with abscess. MJAFI 2009; 65: 84-85.

6). Ramesh V, Misra RS, Jain RK. Secondary tuberculosis of skin: clinical features and

problems in laboratory diagnosis. Int J Dermatol 1987; 26: 578-581.

7). Yates VM, Rook GA. Mycobacterial infections In: Burns T, Breathnach S, Cox N,

Griffiths C, editors. Rook’s Textbook of Dermatology. 7th ed. Oxford. Blackwell Scientific

Publications; 2004. p. 28.1-39.

8). Sehgal VN, Wagh SA. Cutaneous tuberculosis Int J Dermatol; 1990: 237-52.

9). Khadim Ullah Kakakhel. Cutaneous Tuberculosis. International Journal of

Dermatology 1989; 28: 355-362.

10). S Khandpur, BSN Reddy. Lupus vulgaris: Unusual presentations over the face.

Journal of European Academy of Dermatology and Venereology 2003; 17: 706-710.

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/July-Sept 2012 Page 128

Epidemiology of Needle-Stick Injuries in Mangalore Dr. Prakash. K. P

1. Assistant Professor, Department of Community Medicine, Kasturba Medical College. Mangalore.


Dr. Prakash K.P, Kurubarahalli Patel,

PES Medical College,

Kuppam– 517425, AP, India,


Ph- 0091 9686448868.

ABSTRACT:

BACKGROUND: Health care workers (HCWs) are always at greater risk of infection by needle-

stick injuries (NSIs) owing to their greater handling of sharps in various situations. OBJECTIVE:

The main objective was to review the epidemiology of NSIs among HCWs, and describe the

circumstances under which these injuries occurred. METHODS: A questionnaire based, cross

sectional study was done during the month of January 2008 at 3 Kasturba Medical College

(KMC) institutions, Mangalore. The data was computed and analyzed using SPSS statistical

package. RESULTS: During the study period 272 HCWs were self administered

questionnaire/interviewed and 102 HCWs reported (37.5%) incidents of injuries with needles

during the past 12 months. Doctors were the most frequent victims (64.7%), followed by waste

disposal staff (25.5%) and Nurses (7.8%). More than 50% of the victims had more than 3 pricks

in the last 12 months. Hospital wards and operation theatre were the major locations of needle-

stick incidents (31.4% each). Most commonly, injuries occurred during suturing (41.1%) and

when using solid bore or suturing needle (47.1%). Majority of them neither reported the injury

(60.8%) nor received post-exposure prophylaxis (70.6%). Patient tested sero-negative was the

major reason for not reporting the injury. Government hospital staff and waste disposal staff

had significantly higher chance of NSI when compared to their counterparts. Conclusions: The

study re-emphasized the importance of continued educational and prevention programmes for

HCWs in the prevention of needle-stick injuries.

KEYWORDS: Epidemiology, Needle-stick injuries, Health care workers, Mangalore.

INTRODUCTION:

Many infections including blood-borne viruses such as Human Immuno-deficiency Virus

(HIV), hepatitis B and C can be transmitted by exposure to infected blood or other body fluid via

an accidental inoculation injury (1). Health care workers (HCWs) who are exposed to needles

during clinical and non-clinical activities are at increased risk of acquiring needle-stick injuries

(NSIs) (2).

Accidental NSIs are an occupational hazard for HCWs. According to a global estimation,

16,000 Hepatitis C (HCV), 66,000 Hepatitis B (HBV) and 1000 cases of HIV may have occurred

worldwide in the year 2000 among HCWs through their exposure to NSI’s (3). In Germany,

about 500,000 needle-stick injuries occur annually among HCWs (4). More than 100,000 and

600,000 to 800,000 injuries annually have been reported in UK hospitals and in USA

respectively (5, 6). About half of these injuries go unreported (7-9,). Data from the EPINet

ORIGINAL ARTICLE


system suggest that approximately 28 needle-stick injuries/100 beds/year occur in US hospitals

(10).

Hollow-bore needles are most frequently implicated with the transmission of blood-

borne pathogens because the blood remaining inside the bore of the needle after use contains a

larger volume of organisms than the relatively small amount remaining on the outside of a solid

bore needle, such as the suturing needle (11). The activities associated with the majority of NSI

include withdrawing blood, recapping of needles, administering injections, inappropriate

disposal of needles, and missing the target while attempting to transfer blood or other body

fluids from syringes to specimen tubes or culture bottles (12).

Following a NSI with infected blood, transmission of the 3 principal viruses, HIV, HCV

and HBV occurs in 0.3, 3 and 30% of cases, respectively (13). Although the risk of infection

following a single NSI is very small, “universal precautions” and immunization against HBV may

reduce the risk of injury, infection and illness (14).

In general, only a few studies have been published on NSI from developing countries,

(15-17) although more than 90% of NSI occur in developing countries (18). Published data from

India (19-22) and in our institutions are limited, therefore, the present study was undertaken to

study the epidemiology of NSI in HCWs in the Kasturba Medical College (KMC) institutions, and

describe the circumstances under which these injuries occurred.

MATERIALS AND METHODS:

The study was conducted in the 3 KMC institutions (KMC Hospital (Attavar),

Government Wenlock and Lady Goschen Hospital) in Mangalore. Convenience non-random

samples of 372 HCW’s were self administered/interviewed using a pretested Performa. The

Performa was a self administered questionnaire that was completed by the HCW’s. The ancillary

staffs were interviewed and the questionnaire was filled by the trained medical students. The

assessment of data was done using modified methods established by World Health Organization

(WHO) (23).

The study was conducted during the month of January 2008. The target population was

HCWs in KMC institutions including doctors (staff, postgraduate students and Inters), nurses,

and waste disposal staff. The working definition of needle-stick injuries used was injuries

caused by hollow–bore needles such as hypodermic needles, blood collection needles,

intravenous (IV) stylets and needles used to connect parts of IV delivery systems (12). Data

collected from the Performa include: age, gender, details of the incident which included the type

of needlestick device and the circumstances under which the injury occurred. Additionally,

questions related to awareness as well as basic steps in management of injuries were also

included. The data also included was hepatitis B immune status, HIV and hepatitis B serologic

markers, the job category and place of work of the injured HCWs. Prevalence calculation was

according to, HCW who had at least 1 NSI during the last 12 months. The data was computed in

a Microsoft Excel 5.0 spreadsheet and statistically analyzed using the Statistical Package for the

Social Sciences (SPSS Inc, Chicago, IL, USA). Proportions were calculated and chi-square test was

used to test the significance and p value <0.05 was considered as significant at 95% confidence

interval.

RESULTS:

A total of 272 HCW’s were involved in the study. The basic characteristics of the study

population are shown in Table1. Of the 272, majority of them were in the age group of 25-34

ORIGINAL ARTICLE


years (51.5%), females (64%), doctors (57.4%) and from KMC, Attavar Hospital (42.6%). The

mean age and standard deviation of study subjects was 32.1±9.2 years. Almost 80% of HCW’s

had received hepatitis B vaccine, although only 75.3% had 3 complete doses. Fifty-four persons

(19.8%) received no immunization.

AWARENESS:

Nearly, 10% of the HCWs had no knowledge and 24% had partial knowledge about the

diseases transmitted through needle stick injuries. Approximately, 72% of them were aware of

the presence of written policy. Notably, 24% of the study subjects were not aware about the

correct disposal of sharps.

Approximately 37.5% (102/272) of the study subjects reported that they had at least

one NSI during the last 12 months. Needle-stick injuries and circumstances in which these

injuries occurred are depicted in table 2. Doctors were the most frequent victims (66/102 -

64.7%), followed by waste disposal staff (26/102 - 25.5%) and Nurses (8/102 - 7.8%).

Proportionately Waste disposal staff (26/42 - 61.9%), Doctors (66/156 - 42.3%) and Nurses

(8/62 – 7.8%) were the most common occupation among the NSI candidates. Alarmingly more

than 50% of the NSI’s had more than 3 pricks in the last 12 months. Nearly 63% of the injuries

occurred during suturing or during disposal of sharp objects. Solid bore or suturing needle was

the most common device causing the injury (47.1%). The most common cause of NSI was

accidental (45.1%) (Not preventable) followed by restless patient (17.6%) and rushed (11.8%)

or fatigued (11.8%). Surprisingly 60.8% of them who had NSI did not report to the authorities

even though majority (80%) of them said that they would report if they had a NSI and only

29.4% of the injured received post exposure prophylaxis. The common reason for not reporting

the injury was patient tested sero-negative. Only four (3 HBV and 1 HIV) of the patients on

whom the needle was used tested positive and in nearly 51% (52/102) of the patients disease

status was not know. Thirty two (31.4%) of NSI occurred in hospital wards, 32 (31.4%) in the

operation theatre, 18 (17.6%) in the waste disposal center (figure 1).

Government hospital staff had significantly higher chance of NSI (X2 = 8.05, p=0.01,

df=2) and waste disposal staff had significantly higher chance when compared to their

counterparts (X2 = 13.9, p=0.01, df=2) (Table 3)

DISCUSSION:

Needle-stick injuries are the most frequent occupational hazard affecting health care

workers, and the most life-threatening. This cross sectional study involved a total of 272 study

subjects among them 102 needle-stick injuries was reported. In this study the rate of NSIs being

0.42/doctor/year, 0.13/nurse/year, 0.62/waste-disposal staff/year was higher when compared

to a study in Saudi Arabia (0.06 /doctor/year and 0.11/nurse/year) (24) and lesser (0.57

/doctor/year and 0.83/nurse/year) when compared to a study in USA (25).

In our study, 37.5% (prevalence) of participant HCW’s had sustained at least one needle-

stick injury in the last 12 months, which is comparable to a study in Germany (31.4%) (4) and in

India (34.8%) (19). However, the reported prevalence was more than double in an Indian study

(80.1%) (26). Twelve months is a long period leading to bias which is a limitation in the study.

Nursing assistants are at high risk for NSIs because of their nature of work. Studies from Saudi

Arabia (65.8% and 19.2%) (24), Ireland (49.5% and 28.5%) (27) and in USA (40% and 28%)

(28) reported that the NSIs were more frequent among nurses than doctors, whereas doctors

reported frequent NSIs in Indian studies (19-22) including our study. This is probably because

ORIGINAL ARTICLE


in most of the Indian hospitals Junior/Senior resident doctors and Interns are more commonly

involved in clinical procedures. This wide variation in prevalence and proportions in various

studies could be due to underreporting (7-9), and/or different study methodologies (24). The

highest rate (26/42 - 61.9%) among waste disposal staff can be attributed to unsafe methods of

waste disposal and collection.

In this study, hospital wards and operation theatre were the common places of NSIs

(31.4% each). Similar observations were made in Saudi Arabia (45.1% - hospital wards, 16.9% -

OT) and Scotland (53% - hospital wards, 16% - OT) (24) (29).

The proportion of medical staff who reported to the authorities after a NSI was 20.0% in

our study. The main reason for not reporting in our study was patient tested sero-negative.

Other possible explanation may be that some doctors are inclined to self-assess and not report

such injuries, thus contributing to the apparent lower reporting of NSIs (29). Historically,

suboptimal (under-reporting) reporting of incidents can introduce bias in studies on self-

reported injuries. (30). Some researchers have shown that the rate of under-reporting among

doctors, especially among those frequently exposed to HIV-infected blood (31).

Some of the circumstances in which the injuries in various studies occurred are

compared in table 4 with the present study.

Continuing medical education (CME) programs for HCWs including health education

program for waste disposal staffs need to be conducted by the infection control department to

increase the awareness about the prevention and management of NSI’s because of proven

positive impact of intervention educational programmes (32). Hepatitis B vaccination of all at

risk HCWs in our institutions (23.4% never received). It is recommended by the CDC that all at-

risk HCWs be vaccinated against HBV infection (33). When the results of the study were

reported to the authorities, they were surprised and promised to take appropriate necessary

action.

In conclusion, Needle-stick injuries is a major concern in our institutions especially

government hospitals. The study re-emphasized the importance of continued medical

educational and prevention programmes for HCWs especially health education for waste

disposal staff in the prevention of needle-stick injuries. Mandatory reporting, laboratory testing,

post exposure prophylaxis (HBV) are some of the administrative measures (Accidental

Inoculation Policy) that needs to be taken to reduce the prevalence of NSIs in our institutions.

ACKNOWLEDGEMENT

The author is grateful for the assistance of the medical students in conducting the study.

All the HCWs who participated in the study and who supported in conducting this study are

acknowledged.

CONFLICT OF INTEREST:

None declared.

ORIGINAL ARTICLE


Table1. Socio-demographic characteristics of the study subjects at the KMC institutions,

Mangalore. (N=272)

Characteristics Numbers Percent (%)

Age:

<25 46 16.9

25-34 140 51.5

35-44 54 19.8

≥ 45 32 11.8

Gender:

Male 98 36

Female 174 64

Hospital:

KMC, Attavar 116 42.6

Govt. Wenlock 96 35.3

Lady Goschen 60 22.1

Occupation:

Doctors 156 57.4

Nurses 62 22.8

Lab Technicians 12 4.4

Waste disposal staff 42 15.4

Table2. Distributions of NSI’s according to the circumstances in which the injuries

occurred

Situation (N=102) Numbers Percent (%)

Injection related 18 17.6

Re-capping needles 8 7.8

Suturing 42 41.1

During disposal 22 21.6

IV-line related, canula 4 4.0

Accidental exposure 8 7.8

Device (N=102)

Hypodermic needles 12 11.8

Blood collection needles 12 11.8

IV stylets 6 5.9

Sharps related to IV delivery system 4 3.9

Solid bore/suturing needle 48 47.1

Don’t know 20 19.6

Cause of injury (N=102)

Rushed 12 11.8

ORIGINAL ARTICLE


Fatigued 12 11.8

Lack of skills 4 3.9

Restless patient 18 17.6

Lack of assistance 10 9.8

Not preventable 46 45.1

Reasons for not reporting (N=62)

It takes too much time 0 0

No benefit in reporting 10 16.1

Did not want to know the results 0 0

Stigma of having had a NSI 0 0

Not mandatory to report 18 29

Patient was tested sero-negative 34 54.8

Table3. Occurrence of needle-stick injuries in 3 different hospitals and among staff

Hospital (N=102): Yes No X2

KMC, Attavar 28 88 8.05,

p=0.01,

df=2

Govt. Wenlock 48 48

Lady Goschen 26 34

Occupation (N=100):

Doctors 66 90 13.9,

p=0.01,

df=2

Nurses 8 54

Waste disposal staff 26 16

Note: Laboratory technicians were excluded in the comparison because only 2of 12 reported

NSI

Table4. Comparison of NSI’s according to the circumstances in which the injuries

occurred

REFERENCES Present

Study 26 24 19 20 21

Situation

During Suturing 41.1 20.3 41.7 29.4* 62* 58.1*

Recapping

needles 7.8 39 29 30.4 6.3 14.8

Device Used

Solid bore/

suturing needle 47.1 33 15.1 30.5 19.2 20.9

Cause of injury

Restless patient 17.6 12 8 - - -

Not preventable 45.1 - - 10.9 - -

Fatigue 11.8 - - 50.4 - -

ORIGINAL ARTICLE


Note: All the numbers are percentage unless specified

* During clinical procedures including suturing

- Particular information not available

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ORIGINAL ARTICLE


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ORIGINAL ARTICLE


ROLE OF PLATELET TRANSFUSIONS IN DENGUE HEMORRHAGIC FEVER-

6 MONTHS REPORT

Dr. V. Geeta, Dr. Bheeshma, Dr. I. Srilakshmi, Dr.Ramya, Dr. Yashoda, Dr. Jijiya Bai.

1. Assistant Professor, Department of Pathology, Gandhi Medical College, Secunderabad.



4. Post Graduate, Department of Pathology, Gandhi Medical College, Secunderabad.

5. Medical Officer-Blood bank, Department of Pathology, Gandhi Medical College, Secunderabad.

6. Professor & Head, Evaluator, Department of Pathology, Gandhi Medical College, Secunderabad.


Dr. V. Geetha,

Assistant Professor of Pathology,


Secunderabad, Andhra Pradhesh,


Ph- 0091 09849450199.

ABSTRACT:

BACKGROUND: Allogenic platelet transfusion plays a major role in the management of

thrombocytopenia. The study includes details of platelet transfusion over a period of 6 months

from January-2011 to June-2011 at blood bank of Gandhi Hospital. Total number of patients who

received were 487 and proportionate use of total units of RDP (Random Donor Platelets) issued

from blood bank were as follows; dengue hemorrhagic fever (38%) and remaining for acute

leukemia (12%), Aplastic anemia (10%), sepsis (10%), DIC (Disseminated Intravascular

Coagulation) (10%), cardiac surgery (10%). In dengue hemorrhagic fever, correlation of platelet

count with platelet transfusion and platelet increment have been evaluated.

KEYWORDS: Thrombocytopenia, RDP, DIC, Aplastic anemia.

AIM: To evaluate the role of platelet transfusion in dengue hemorrhagic fever.

INTRODUCTION:

Dengue infection is usually a benign syndrome caused by an arthropod born virus. Dengue

fever and dengue hemorrhagic fever have emerged as a global public health problem in recent

decades. The South East Asian Countries such as India, Indonesia and Thailand are at the highest

risk of dengue accounting for nearly half of the global risk.

Dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) are life threatening

clinical manifestations1. The mechanisms of hemorrhagic manifestations of DHF/DSS are not well

understood. The suggested factors contributing to bleeding include thrombocytopenia,

coagulopathy and vasculopathy and Suggested mechanisms for thrombocytopenia include:

1) Maturational arrest of megakaryocyte production in the bone marrow

2) Platelet destruction by the virus it self

3) DIC

ORIGINAL ARTICLE


The world health organization manual and text books of pediatrics and infectious diseases

recommend infusion of fresh whole blood, fresh frozen plasma and/or platelet concentrates2.

Theoretically the risk of spontaneous bleeding becomes significant at a platelet count of <20 X

107/ml.


A retrospective study was conducted in the blood bank of Gandhi Hospital for a period of 6

months from 1st Jan to 31st June 2011. Total no. of patients received platelet transfusion is 487

and total units of RDPs given are 1116. Patients clinical data, platelet count and platelet

transfusion given to them were analyzed.

RESULTS:

Total no. of patients received platelet transfusion is 487 and total units of RDPs given are

1116 (Table.1), with males numbering 223 and females 264.

Age Group January February March April May June Total

0-10 16 17 10 21 27 38 129

11-20 10 25 30 17 07 22 111

21-30 16 7 28 15 19 25 110

31-40 4 11 6 18 07 13 59

> 41 12 10 9 9 13 15 68

Grand total 487

Blood group wise distribution of platelet transfusion is as follows

� B+ve: 180

� O+ve: 178

� A+ve: 161

� AB+ve: 37

� O-ve: 8

� B-ve: 14

Distribution of platelet transfusion by diseases wise are (Fig.1)

Dengue confirmed patients - 38% (186)

Acute leukemias (ALL + AML) - 12% (58)

A plastic anemia -10% (49)

Sepsis -10% (49)

DIC -10% (49)

Cardiac patients -10% (49)

Others -10% (49)

Total 489

ORIGINAL ARTICLE


Majority of Dengue patients belonged to B+ve and O+ve Blood groups, most common age

group is between 11 to 20 years (46%) and females outnumbered males at 101 Vs 85.

During the study period 186 patients had positive serology (IgM or IgG) to dengue fever

by ELISA method. Fever was the most common clinical presentation associated with headache,

myalgia, vomiting, and diarrhea. Platelet count less than 10,000 / cumm noted in 20 patients

(10.7%).

< 10,000 - 20 patients 10.7%

11-20,000 - 36 patients 19.35%

21-40,000 - 50 patients 26.88% - Moderate Risk

41-1 lakh - 80 patients 43% - Low Risk

Most of the patients received platelet transfusion recovered completely and were

discharged with 2-5 transfusions. The platelet count had picked up considerably. Guidelines for

platelet transfusions in dengue hemorrhagic fever as follows:

INDICATIONS:

Prophylactic transfusions (in a non bleeding patient) with Platelet count < 20 X 109/L

Therapeutic transfusions (in a bleeding patient)

1) Significant active clinical bleeding with platelet count < 50 X 109 / L.

2) DIC

DISCUSSION:

Dengue viruses belonging to the genus flavi virus of family flaviviridae has antigentically

four distinct serotype DEN-1, DEN-2, DEN-3 and DEN-4. The virus is transmitted to the human

being by the bite of infected Aedes Egypti Mosquito and few other members of Aedes species.

Dengue virus causes a broad spectrum of illness ranging from mild undifferentiated fever to

classical dengue fever, DHF, DSS.

Our study showed majority of dengue cases were children and adolescents in the age

group of 10-20. Chaunsumrit et al also noted high percentage of dengue cases in age group of 10-

14 years3. In contrast Ayyub et al and Lye et al noted adult preponderance in age group of 20-40

yrs4, 5.

Thrombocytopenia is a common problem in dengue. In our study thrombocytopenia was

found in all most all the confirmed cases of dengue which was equal when compared with findings

of Makroo et al and Chairulfatah et al (84.88% and 83% respectively)6, 7 .

In our study bleeding occurred significantly more often in patients with thrombocytopenia

most often in patients with platelet count less than 20,000 / cumm which is similar to Shivbalan et

al. but chairulfatah et al found significant bleeding with platelet count less than 15,000 / cumm8, 7.

In our study high risk patient: platelet count < 20,000-30%. Moderate risk: 27% (21,000-40,000)

and Low risk: 43% (40,000-1 lakh)

According to Makroo et al all Hospitalized patients with dengue with high risk should be

given platelet transfusion6.

High Risk

ORIGINAL ARTICLE


Dengue, 38%

Acute Leukemia, 12%

A Plastic Anemia, 10%

Sepsis, 10%

DIC, 10%

Cardiac, 10%

Others, 10%

Moderate risk patient can be given platelet transfusion if associated hemorrhagic

manifestations are present. Low risk patients can be managed with IV fluids and supportive

therapy. But in our study prophylactic transfusion of platelet given to 43% of low risk patients.

Most of the patients (99%) who received platelet transfusion recovered completely were

monitored for increment of platelet count after 2-3 transfusion at the time of discharge the

platelet count was above 1 lakh / cumm. Besides platelet transfusion FFP and PRP also

transfused.

Death occurred in 3% of patients due to complications like septicemia and severe bleeding

with multi organ failure belonged to age group of 31-40.

CONCLUSION:

All Hospitalized dengue patients can be categorized into high, moderate and low risk

patients based on platelet count at the time of Hospitalization. High risk patient should be given

priority and platelet transfusion accordingly. In our study the outcome is good with 97% recovery

of dengue patients with platelet transfusion and supportive therapy this clearly emphasizes the

role of platelet transfusion in the management of dengue patients.

Figure 1: Proportionate recipients of platelet transfusion

REFERENCES:

1. Directorate of health services, Management of Dengue Fever/DHF/DSS. Guidelines for

indoor patients, 2005:4

2. World Health Organization (2009) Dengue: guidelines for diagnosis, treatment, prevention

and control. World Health Organization, Geneva, pp 40–41.

3. Chuansumrit A, Phimolthares V, Tardtong P et al (2000) transfusion requirements in

patients with dengue hemorrhagic fever. Southeast Asian J Trop Med Public Health 31:10-

14

4. Ayyub M, Khazindar AM, Lubbad EH et al (2006) Characteristics of dengue in a large

public hospital, Jeddah, Saudi Arabia. J Ayub Medical coll Abbottabad 18:9-13

ORIGINAL ARTICLE


5. Lye DC, Lee VJ, Sun Y, Leo YS (2009) Lack of efficacy of prophylactic platelet transfusion

for severe thrombocytopenia in adults with acute uncomplicated dengue infection . Clin

Infecct Dis 48:1262-1265

6. Makroo RN Raina V, Kumar P, Kanth RK (2007) Role of platelet transfusion in the

management of dengue pts in a tertiary care hospital. Asian J Trans Sci 1:4-7

7. Chairulfatah A, Setibudi D, Agoes R, Colebunder R (2003) Thrombocytopenia and platelet

transfusion in dengue. Haemorrhagic fever and dengue shock syndrome.WHO Dengue Bull

27:141- 143

8. Shivabalan S, Anandanathan K, Balasubramaniyan S, Dutta N, Amalraj E; predictors of

spontaneous dengue, Indian J Ped. 2004; 71:33-6 (Pubmed)

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DRUG COMPLIANCE AND ADHERENCE TO TREATMENT Dr. T. Manmohan, Dr. G. Sreenivas, Dr. V.V. Sastry, Dr. E. Sudha Rani, Dr. K. Indira,

Dr. T. Ushasree.

1. Associate Professor, Department of Pharmacology. Gandhi Medical College, Secunderabad.

2. Assistant Professor, Department of Community Medicine. Gandhi Medical College, Secunderabad.

3. Professor, Department of Community Medicine. Gandhi Medical College, Secunderabad.

4. P.G. Student, Department of Pharmacology. Gandhi Medical College, Secunderabad.

5. Professor, Department of Pharmacology. Gandhi Medical College, Secunderabad.

6. Professor & Head, Evaluator, Department of Pharmacology. Gandhi Medical College, Secunderabad.


Dr. Tepoju Manmohan,


Secunderabad, AP,


Ph- 0091 09346935968.

ABSTRACT:

BACKGROUND: In spite of any number of medicines will not be of use unless patient takes’

them. After diagnosing the disease, the next most important step is to follow the instructions of

physician in terms of treatment. The doctor’s responsibility does not end with writing

prescription, assuming patient will adhere to it. He/she should cross check the behavior of

patient for drug compliance and see that patient follows it and get the benefit.

Non compliance is the main barrier for the effective delivery of the medical care. This

will have greater implications on the economic burden on the country in terms of frequent

hospitalization, use of expensive medicines in case of relapse due to non adherence.Though the

terms compliance and adherence are used synonymously, they differ in the delivery of quality of

the medicare as the former implicates the passive following of the physician instruction, while

in the later, patient actively participates in the development of the treatment plan, which will

improves outcome of the treatment. Adherence is the preferred term over compliance by WHO.

KEYWORDS: Adherence; compliance; concordance; non compliance; non adherence; treatment

INTRODUCTION: Significant advances have been made in understanding etiology of disease

states, and development of new therapeutic agents made it possible to cure or provide

symptomatic control. However, in many circumstances, drugs are not being used in the manner

conducive to optimal benefit and safety. Efforts to maintain or improve health, fall short of the

goals considered attainable, and has been attributed to patient’s noncompliance or partial

compliance.

Medication compliance (taking one’s medicine as prescribed) is a major concern as it

prevents hospitalization up to 5.5% and increase deaths by 8.48-fold to medication errors. Cost

and poor understanding of the directions for the treatment are major barriers in completing

treatment. WHO (World Health Organization) has estimates that only 50% of people complete

long-term therapy for chronic illnesses as prescribed1.

Half of all prescriptions for drugs to be taken on an ongoing basis are either not

completed or are never filled in the first place due to cognitive issues, depression or physical

problems 2-3. Medication for asymptomatic conditions is most likely not to be taken casually,

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else land up with devastating problems over a period of time, especially with conditions like

diabetes, high blood pressure or high cholesterol1. A report from the American heart association

reveals that nearly 60 percent of patients whenever taking five or more medicines gets confused

while taking them.

TYPES OF PATIENTS: Based on the acceptance of diagnosis and treatment initiation,

patients are categorized into four types

1.NON COMPLIERS: Those who do not accept diagnosis and need treatment.

2.PARTIAL COMPLIERS: Those who accept diagnosis and treatment but cannot fulfill

the recommended actions sufficiently to reach targeted improvements in their health.

3.OVER COMPLIERS: Those who take recommended actions in excess of targeted

improvements (These patients are rare).

4.ADEQUATE COMPLIERS: Those who follow health advice adequately to improve or

control their disorder.

TYPES OF MEDICATION-TAKING BEHAVIOR:

COMPLIANCE: It is the conscious effort to use drugs in the manner prescribed, it is the extent to

which all individuals’ behavior coincides with medical & health advice. Understanding how

medication should be used, with sufficient positive motivation, and intentions, looking at the

perceived self benefit and positive outcome. , it can also apply to other situations such as

medical device use, self care, self-directed exercises, or therapy sessions.

ADHERENCE: The extent to which a person takes medication as prescribed. WHO defines

adherence as “The extent to which a person’s behavior, corresponds with agreed

recommendations from a health care professional”. Concept of adherence is broadly viewed as

related to instructions concerning medicine intake, use of medical device, diet, exercise, life

style changes, rest and return for scheduled appointments4-7.

CONCORDANCE: Consultative and consensual course of therapy partnership between the

consumer and their doctor. Concordance is the process by which a patient and clinician make

decisions together about treatment8.

PERSISTENCE: A person’s ability to continue medical advice for the intended course, which

may range from few days to life long.

However the preferred terminology remains a matter of debate. In some cases,

concordance is used to refer specifically to patient adherence to a treatment regimen that is

designed collaboratively by the patient and physician, to differentiate it from adherence to a

physician only prescribed treatment regimen5-8, despite the ongoing debate, adherence is the

preferred term for the WHO1, the American pharmacists association9 and the US National

Institutes of Health Adherence Research Network8,10, and is important for optimum therapeutic

outcome which improves patient’s quality of life.

Concordance also refers to a current UKNHS (United Kingdom National Health

Services) initiative to involve the patient in the treatment process to improve compliance 11, 12.

Here patient is informed about their condition and treatment options, they are involved with

the treatment team in decision making process and partially responsible for monitoring and

reporting back to the team1.

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Non-compliance is a major obstacle to the effective delivery of health care. Estimates

from the WHO indicate that about 50% of patients with chronic diseases living in developed

countries do not follow treatment recommendations1, 13. Non-compliance means not following

the directions for treatment due to irrational behavior or willful ignoring of instructions leading

to increased morbidity, treatment failures, exacerbation of disease, more frequent physician

visits, increased hospitalizations and even death (Fig.1) 6, 14, 15.

(Fig.1: TYPES OF MEDICATION TAKING BEHAVIOR)

PRESCRIBED REGIME FOR ENTIRE PERIOD

FULLY COMPLIANT

FULLY PERSISTANT

PARTIALLY COMPLIANT

NON-PERSISTANT (STOPPED THERAPY BEFORE COURSE)

NON COMPLIANT & NON-PERSISTENT

NON PERSITENT, NON-ACCEPTANCE (NOT STARTED THERAPY)

The most common situations associated with non adherence are

� Failure to have the prescription dispensed or renewed, not refilling

prescriptions for chronic diseases states, not obtaining refills at appropriate

intervals, 25% don’t fill new prescriptions16-18 ,

� Omission of doses most common type of non compliance and more likely to

occur when a medication is to be administered at frequent intervals. Increased

frequency cause more interruption of normal routine, or work schedule,

especially in poly pharmacy or when treatment is needed with an extended

period of time. Few patients cannot identify their own medications 18,19.

� Errors of dosage, like giving instructions in measures of tea spoon (measure

range from 5ml. to 15ml.) and not following administration of medicines at night

time if patient falls into sleep etc., where dose of administration is incorrect20.

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� Incorrect administration of medication: includes not using proper technique like

using metered dose inhalers, wrong route of administration, such as taking

vaginal pessaries orally21.

� Errors in time of administration: in 8th hourly prescription, night dose is

adjusted in the day time.

� Premature discontinuation of treatment occur most commonly with antibiotics

and drugs used for chronic disorders like hypertension. American Association of

Retired persons (AARP) Survey of ambulatory elderly patients reported 33%

premature discontinuation of medications22. In a pediatric outpatient study on

acute otitis media therapy 37% discontinued early. Highly priced drugs are

prematurely discontinued 1, 23.

� Preference for self care other than medications, such as following other systems

of medicine or indigenous remedies etc., 24, 25.

� Not completing entire course of therapy, when symptoms subside with partial

usage of antibiotics or treatment regimen as seen in acute infections and

treatment of tuberculosis.

� Other patient factors such as, fear of dependency, social problem like usage of

diuretics causing polyuria, taking out dated or improperly stored medicines, or

friends and family members’ medications causes non adherence. Lowest

compliance of about 20-30% is seen with life style changes 26, 27. Addiction to

alcohol and smoking has decreased compliance in conditions like asthma,

hypertension and renal transplantations 28-38.

Main reasons for not filling prescriptions according to study in Americans with age 50

and above37, (Table No.1).

(Table No.1: prescription refill proportions in elderly patients)

Cost of the drug (40%)

side effect of drug (11%),

thought drug wouldn’t help much ( 11%)

Already taking many prescriptions (3%)

condition improved (4%)

don’t like taking prescription drugs (5%)

drug did not help (6%)

didn’t think i needed it (8%),

Other reasons (physical impairments etc,.) (12%)

NON PATIENT FACTORS ASSOCIATED WITH NON ADHERENCE ARE:

THE NATURE OF PATIENT’S ILLNESS: Patients suffering from schizophrenia has high

incidence of non compliance, due to distorted reality & lack of insight do not recognize their

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illness and need for treatment. Similarly in chronic disorders like hypertension, tuberculosis

etc., same pattern is observed 39.

THERAPEUTIC REGIME: Multiple drug therapy like 5-6 prescribed drugs13, 40-42 taking at

different timings ,taking tablets with same color, size and shape cause more confusion43 and

skip doses. Technical difficulty in using inhalers44-50.

DURATION OF TREATMENT: Compliance is inversely proportional to duration of treatment27,

51, 52. In a study of long term therapy, low compliance is observed as in bronchial asthma (50%)

and hypertension (50-70%) 53-60.

FREQUENCY: Increased frequency of drug administration causes more disruption of normal

routine or work schedule, hence many patients forget or inconvenienced or embarrassed. In one

of the study, compliance has improved from 59% on 8thhourly regimen to 84% with once a day

regimen 61-67

ADVERSE EVENTS: Events are like deterrents; in a study on elderly patients 40% experienced

side effects of this 20% stopped medications and in this only 18-19% informed their physicians

about discontinuation22. In one of the survey, over 60% are noncompliant due to adverse

events. Some drugs like Anti-Hypertensive agents, Anti depressants or Anti psychotics cause

sexual dysfunction which is frequently implicated for non compliance. 68-82

TASTE OF MEDICATION: Can be the cause for noncompliance especially in children.

Failure to comprehend the importance of therapy, as patient has limited knowledge

about the illness, become non compliant if beliefs and expectations are not met with. Poor

understanding of instructions also contributes to non compliance83, 84. Non compliance in elder

age group is due to2, 13, 33, 40, 41, 85 & 86

• Adverse effects,

• Increased, or decreased sensitivity to drugs,

• Frequent change of prescriptions( prescription cascade),

• Living alone,

• Lack of social support system,

• Difficulty in opening the medication container that has flip off type of lid

• Going to pharmacist/chemist due to physical problems like (osteoarthritis)

• Cognitive impairment,

• Impaired mobility or dexterity,

• Swallowing problems,

• Financial issues like, Low income and high cost of medications,

• Everyday inconvenience in carrying and taking of medicines.

CONSEQUENCES OF NON COMPLIANCE: Drugs do not work if people do not take them 87. Non-

compliance is a major obstacle to the effective delivery of health care. National Council on

Patient Information and Education designated it as America’s other drug problem88, 89. Under

use is very common, depriving the patient of anticipated therapeutic benefits and resulting in

progressive worsening of the condition or increased complications as in hypertension. overuse

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of medication is also common, where in patients increase dose or frequency of medications

anticipating extra benefit or quick action and remission of symptoms and some times it can be

an extra dose due to forgetfulness as in elderly age groups, causing increased adverse reactions,

leading to unnecessary use of medical resources such as

� Physician Consultations

� Emergency Department visits,90

� Unnecessary additional laboratory tests and

� Treatments which are preventable

(Table No. 2: Consequences of non adherence to treatment in elderly patients39, 91-93)

Cause Proportion of hospitalization

due to non compliance 10-33%9

inability to self-administer 23% of nursing home admissions

Studies on HIV/AIDS have revealed higher viral loads in patients with 10- days drug

holiday or 20% of missed doses of Anti retroviral agents, who are otherwise had nearly

undetectable viral loads94. Non compliance with anti psychotics in schizophrenia had relapses

with violent behavior. Similarly in Epileptics unexpected deaths are due to low the4rapeutic

concentrations of antiepileptic drugs95. Deaths in transplant patients who have waited for years

to get donor organ are because of organ rejection resulting from noncompliance in using

immunosuppressants96

Low rates of adherence to therapies for asthma, diabetes, and hypertension are thought

to contribute substantially to the human morbidity, mortality and economic burden of those

conditions1, 14. In asthma non-compliance incidence is 28-70% worldwide, increasing the risk of

acute severe asthmatic attacks requiring hospitalization. Non compliance to Anti Hypertensive

agents is very common even in developed countries, and it is the main cause for hypertension

related complications like heart diseases and strokes. In united States, it is estimated that drug

related morbidity & mortality expenditure exceeded $177.4 billions97

Compliance rates are often high or over estimated in a formal clinical trial but drops off

in a "real-world" setting. In a study, compliance rate for statins is 97% at the beginning, and

dropped to 50% after six months98.

ASSESSMENT TOOLS FOR MEDICATION ADHERENCE: Detection of non compliance is as

important as diagnosis of a medical condition Compliance or non compliance is not stable; it

may change over time, necessitating regular use of detection methods to measure the behavior

as part of assessment for therapeutic efficacy99.

Structured interviews using highly skilled and refined techniques, like Morisky scale which is

validated scale estimating the risk of medication non-adherence, is cited in numerous articles since

1986 used for many different disease such as, hypertension, hyperlipidemia, asthma and HIV.

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Compliance or non compliance is not stable; it may change over time, necessitating

regular use of detection methods to measure the behavior as part of assessment for therapeutic

efficacy99.

As such there are no gold standards for Assessment for medication adherence; the ideal

detection would measure compliance at the time and place of medication taking event. Direct

observation of the patient would come closest to providing this ideal measure of adherence.100.

Indirect methods of monitoring compliance other than Electronic event monitoring (EEM) are;

o Pill counts,

o Medication refill records,

o Patient self report,

o Structured interviews using highly skilled and refined techniques,

o Change in weight of meter dose inhaler canisters, ,

o Medication event monitoring using computer are most commonly

used.

o

Pill count is often used in clinical trials, it measures the difference between the dosage

units initially dispensed and number remaining on return visit or unscheduled home visit, but

pill dumping and medication discard misrepresents compliance101, 102

Structured interviews using highly skilled and refined techniques, like Morisky scale

which is validated scale estimating the risk of medication non-adherence, is cited in numerous

articles since 1986 used for many different disease such as, hypertension, hyperlipidemia,

asthma and HIV. It is a structured four item self reported adherence measure that addresses

barriers to compliance and permit health care provider to reinforce positive adherence

behavior 103

Sometimes achievement of treatment goals are used as a measure for compliance, like

normal blood pressure in hypertensive, normal blood glucose levels in diabetics, after

eliminating “ tooth brush effect” (like people brushing their teeth before seeing a dentist) where

patients load up medication just before their return visit to physician. Electronic event

monitoring is a recent and reliable computerized compliance monitoring, here medication

container cap is housed with microprocessor which records date and time of opening the cap

and data can be retrieved by connecting the micro processor to computer, the disadvantage

being no data is provided regarding actual amount of drug taken, It helps when supplemented

with other methods of measurements104.

Direct methods to measure adherence is by using biological markers and tracer

compounds like measurement of glycosylated hemoglobin which provides objective assessment

of metabolic control in preceding three months in Diabetics. Small amounts of tracer

compounds with long half- lives, like Phenobarbital or digoxin are added to the medications and

these tracers are measured in biological fluids.

Therapeutic drug levels monitoring in biological fluids is another direct method of

compliance assessment but draw backs are individual pharmacokinetic variations, and tooth

brush effect invalidate this type of measurement as data do not provide timing of doses10

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(Table: 3 Comparison of different methods for the measurement of adherence)

DIRECT METHODS INDIRECT METHODS

They are more sensitive and specific They are less sensitive and specific

They are direct pharmacologic indicators of

medication adherence

Tooth brush effect can not be ruled out

Limitations:

i) Legal and ethical issues

ii) Individual pharmaco-kinetic

variations of drugs

They are better measure of detection if two

different indirect methods are used and

correlated;

Eg: Pill count and electronic event monitoring

device.

HOW TO IMPROVE COMPLIANCE/ADHERENCE: Effective ways to help people follow

medication regimes could have far larger effects on health than any other treatment”-Haynes et

al. 2005106. Patient should be evaluated before changing therapeutic regimen as non adherence

is most common missed diagnosis.

Demographic factors such as age, marital status, sex, race, income, occupation, number

of dependents, intelligence, level of education, or personality type have been shown to be

marginally related to noncompliance107-111. Based on behavioral principles patient-centered

compliance models are described, taking into consideration of socio behavioral determinants112

which includes health belief models and health decision models , former is related to a

preventive health behavior and latter focusing more on health decisions which combines the

health belief model and patient preferences with comprehensive cognitive behavioral and

affective components for advocated behavior5, 113, 114.

Patient prerequisites for adherence:

� Understand diagnosis and potential impact

� Believe that treatment will be beneficial

� Treatment favors benefit over cost

� Confidence in health care practitioners

Patient factors for improved compliance include:

� Quick relief of symptoms � Becomes quickly ill without therapy � Treatment involving expensive procedure � Recurrence if treatment is stopped � Increased disability as a consequence with out treatment

HEALTH BELIEFS: To achieve compliance patient should believe that, he/she actually have

illness which is diagnosed, and with treatment, severity of condition is reduced. Patient

education & counseling should be designed to encourage health beliefs115-118.

Patient physician interaction also affects compliance or adherence. Patient who has

respect towards treating physician and is well known, giving information, assurance and

psychological support, showing empathy, improves compliance or adherence. The interaction

should be a negotiation between two active and equal participants with goal/strategy “to put ill

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at ease”.119-124. As recommended by NCPIE (National Council for Patient Information and

Education) physician should respond to patient’s queries regarding treatment and other related

topics.

IDENTIFICATION OF RISK FACTORS FOR NON COMPLIANCE: As it is difficult to identify a non

coplier, every patient is assumed a potential defaulter 125. By recognizing individuals who are at

risk, treatment is planned with simplest regimen compatible with patient’s normal activities,

such as avoiding expensive medicines, unnecessary medication, using long acting formulations

and combination medications, to decrease frequency of administration

Prescribing low cost medicines as high cost medicine prescription fill rates are low, even if

they buy reluctant to use entire prescribed quantity. Medication-flavoring formulary system

developed about three dozen flavors, to overcome taste problems in medications especially in

children

In cases with mental illness discuss with patients or family members regarding delayed onset

of therapeutic effects, and the need for prolonged treatment by prescribing medicines with

least side effects.

With physical disabilities such as visual impairment, communicate with patient verbally or

use tape record instructions, increase font size or color code medication bottles, advise pre-

measure and pre-cut medications. With hearing impaired patients the problem is solved by

using interpreter, or speaking to better ear using regular voice volume and lip movement with

eye contact maintained, repeat instructions when necessary, supplement with written

information, and turn up hearing aids2-3

In cases with reduced mobility and dexterity advise patients to store medications in easily

accessible location, using pre-cut, pre-measured medications or easy open tops that are easy to

administer. Foiled backed wrappers are avoided in patients with arthritis or tremors. Wherever

difficulty in swallowing is seen use alternative dosing formulations like liquids, trans-dermal

patches, crushable tablets or capsules that can be opened and mixed with soft foods.

DEVELOPMENT OF TREATMENT PLAN: Hippocrates: “decisions to deviate, un aware of

physician intentions keep watch also on the fault of patients which often makes them lie about

the taking of things prescribed”. Develop a simple plan on individual basis, involving patient in

deciding treatment with minimal inconvenience and overcome forgetfulness by timing doses

corresponding to regular activities in patient’s daily schedule. Do not write twice or thrice a day

instead of writing time in am/pm. in instructions44, 126

Health literacy is the degree to which individuals have the capacity to obtain, process

and understand basic health information and services needed to make appropriate health

decisions (world health organization, 2003)127. Patients with low health literacy were reported

to be less compliant with their therapy128. Written instructions and pictograms on medicine

labels has proven to be effective in improving patient’s compliance129.

PATIENT EDUCATION: Best way to improve compliance. Decide what information is necessary

for about illness and treatment130. Too much details/inappropriate presentation of adverse

events may alarm patient & decrease compliance. Involve patient in decision-making process.

Make patient understand benefits of treatment and importance of compliance without using

complex technical terms. Patient is asked to repeat the instructions. Encourage patients to ask

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questions. Patient education regarding asymptomatic hypertension, glaucoma, asthma, and

diabetes mellitus removes non adherence 64.

PHYSICIANS FACTORS: Asking few questions, occasional eye contact not understanding

language spend little time, giving large information in short time, lack of concern also effect

compliance131.

Physicians liability for non compliance is often over looked as they prefer pointing

deficiencies of the patients rather than themselves. Physician’s compliance is the extent to

which the behavior of doctor fulfills their professional duty like not being ignorant, adopting

new advances when they are sufficiently proved, writing prescription accurately and legibly,

warning patients about side effects or adverse effects, and counseling them to use medicines

effectively and safely.132-136

ORAL COMMUNICATIONS: Oral communication / counseling in a room with privacy137 and

free of distractions to give patient an opportunity to raise questions- supplemented by written

instructions. Studies indicate that counseling has improved adherence in hypertensive

patients138. Compliance clinics run by Pharmacists in western countries have improved

adherence by reducing hospitalizations when pre & post clinics are compared139, 140.

WRITTEN COMMUNICATION: Write timings and supplementary information regarding illness

& treatment, especially for acute conditions (e.g. antibiotics) compared to chronic conditions141.

One way communication is disadvantageous with illiterate. In a study 42% patients unable to

comprehend instructions142. So combine both oral and written and encourage patient to put

questions.

AUDIO VISUAL AIDS: help in visualizing the nature of illness, how a medicine has to be

administered eg; metered dose inhalers and how they act. Many health care professionals are

using very effectively by placing them in waiting room or consultation room and answering

questions patients may have.

CONTROLLED THERAPY: Hospitalized patients are entrusted to self medicate before

discharge, under direct supervision of health care professionals so that latter; can identify

situations that undermine compliance that are corrected by answering questions 143

Special programs and devices: In some situations highly structured programs are

developed to improve compliance eg; behaviorally oriented program for training medication

management skills in schizophrenia patients which increased compliance from 63% to

81%.Similar programs are needed for vision and hearing impairment subjects by producing

prescription labels in Braille, and hearing aids respectively.

PATIENT MOTIVATION: For achieving optimum benefit, information is provided to the patient

in a manner that is not coercive, threatening or demeaning, by counseling, providing written

materials, supplying cues for appropriate behavior. Cues may be verbal or non verbal in latter

case using special packaging or reminders, Negotiable physician- patient interaction 123 with

respect and positive attitude, and realistic appraisal of the circumstances ,or development of

contracts 144,145 or paying incentives in the form of monitory and non monitory like gifts,

vouchers etc., to achieve agreed upon treatment goals.146,147 Mass programs like sterilization

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and immunization, wherein patients are positively motivated by beneficiaries and neighbors

also improve compliance 3,148

TIME COMMITMENT: Patients may not be able to take time off work for treatment; as a

shorter traveling time between residence and healthcare facilities could enhance patient’s

compliance. Housewives more compliant to therapy they adapt well to clinic appointment times

and treatment 3, 149-151.

COMPLIANCE AIDS: The accuracy and specificity of information on the label of prescription

container and Auxiliary labels that provide additional information regarding the use,

precautions, and storage of medicines also help in improving adherence.

Medication Calendars and Drug Reminder Charts are designed and developed to assist

self administration of drugs by patients. Special medication container like 28- compartment

(MEDISET) container are designed to help patient organize their medications on weekly basis. fig

Specially designed caps for prescription container like The Prescript Time Cap; containing

digital time piece display time and date of last dose taken. They are effective in improving

adherence by patients who forgets doses or who are confused by the complexity of regimen.

Medication packaging also influence the patients adherence. Compliance Packs are

developed which are pre-packed units, which provides one treatment cycle of medication in a

ready to use package152. New dosage forms are developed to overcome non adherence due to

increased frequency, in the form of long acting and controlled release preparations. Similarly

Trans- dermal drug- delivery systems also permits less frequency of drug administration.

MONITORING THERAPY: 1. Self Monitoring-Patient should be appraised of the importance of

monitoring their own treatment and assume personal responsibility of adherence to treatment.

Pharmacist or physician monitoring. “.brown bag program was conducted by NCPIE

&The Administration on ageing in which patients are encouraged to put all their medicines in a

bag for personalized medicine review in geriatrics.

D.O.T (directly observed therapy.153-154 It is the ideal way to monitor therapy, especially

in cases of prolonged drug intake.

“French saying- 5 centuries back about patient care “To care sometimes, to restore often,

and to comfort always”

Summary: Valuable resources like time, effort and expenses put on diagnosis of illness

with the aim of developing treatment plan for cure, control or increased survival are not

achieved, unless patient complies to treatment. Non adherence is responsible for missed

diagnosis, treatment failures and changing prescriptions with more potent, expensive and toxic

drugs.

Adherence to medication is not routinely measured in clinical practice, for reasons as

busy practice and depriving patients on close attention and monitoring therapy are not

acceptable155. The highest priority should be given for patients adherence problems.

Improved adherence benefits every body (patient, physician, pharmaceuticals,

pharmacist & community). For patient there will be increased efficacy and safety of treatment

and decreased physician and hospital visits. For pharmacist increased recognition and respect

for advise and services. Pharmaceuticals by manufacturing drugs suitable to the patients need,

like blister pack, increase sales of drugs. Finally society at large and health care system gets

benefit as a result of few problems with non compliance.

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ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/July-Sept 2012. Page 160

INTERESTING LESIONS OF BONE MARROW WITH SPECIAL REFERENCE

TO METASTASIS.

Dr. I. Sreelakshmi, Dr. P. Sunethri, Dr. B. Bheeshma, Dr. V. Geetha, Dr. P. Jijiya bai, Dr. O. Shravan

Kumar, Dr. M. Anjani Devi, Dr. K. Ramakrishna Reddy.

1. Assistant Professor, Department of Pathology. Gandhi Medical College, Hyderabad.


3. Associate Professor, Department of Pathology. Gandhi Medical College, Hyderabad.


5. Professor & Head of Department, Department of Pathology. Gandhi Medical College, Hyderabad.

6. Professor, Department of Pathology. Gandhi Medical College, Hyderabad.

7. Post Graduate, Department of Pathology. Gandhi Medical College, Hyderabad.



Dr. I. Sreelakshmi,


Musheerabad, Secunderabad, AP,


Ph- 0091 09346371707.

ABSTRACT:

BACKGROUND: Bone marrow examination is a commonly used diagnostic modality in the

evaluation of hemato-oncological disorders and in patients with malignancies of visceral organs

to detect metastasis. This study reviews clinical, hematological and pathological data of

interesting cases with bone marrow involvement. Out of 490 bone marrow aspirations

performed during a period of 4 years, 5 cases show metastatic carcinomatous deposits which

included adenocarcinomas(3), squamous cell carcinoma(1) and neuroendocrine tumour(1),

Non-Hodgkins lymphomas(2), storage disorder(2), granulomatous lesions(1), gelatinous

transformation(1). Fever, generalized weakness, loss of appetite and loss of weight were the

main symptoms. Anemia and pancytopenia were the main hematological findings. Dry tap was a

significant finding in bone marrow aspiration in cases of metastatic cancers.

KEYWORDS : Bone Marrow Biopsy, Dry tap, Metastasis Cancer.

INTRODUCTION: Bone marrow examination is used commonly in evaluation of myeloid or

lymphoid haematological malignancies, suspected storage disorders, plasma cell neoplasms, to

detect infections & reactive changes, metastasis in patients with cancer of visceral organs &

staging of tumors. Most common tumors that metastasize to bone in adults are prostrate, breast

& lung cancer and in children neuroblastoma, rhabdomyosarcoma, Ewing’s sarcoma &

Retinoblastoma.

Infiltration of marrow is suspected in unexplained haematological abnormalities, fever

of unknown origin, failure to thrive in infants, bone pains & pathologic fractures, hot spots in

PET CT and hypercalcemia, increased alkaline phosphatase.

We studied clinical, hematological, pathological data of interesting cases with bone

marrow involvement.

MATERIALS AND METHODS: A total of 490 bone marrow aspirations performed between

2008- 2011 were analyzed. A total of 19 bone marrow aspirations, followed by biopsy were

ORIGINAL ARTICLE


performed in patients with suspected bone marrow infiltration. Posterior iliac crest is common

site preferred. Patients clinic history, haematological, & pathological findings were reviewed

retrospectively. Clinical profile included information about patient’s age, sex, clinical history,

physical findings, and provisional diagnosis. Peripheral blood picture, bone marrow study were

reviewed. Leishman stain was done routinely. In addition special stains & IHC were done where

ever necessary.

RESULTS: Out of 19 cases with suspected bone marrow infiltration, 6 cases were

Lymphoma/Leukemia, 5 cases showed metastatic bone marrow involvement, 4 cases were

multiple myeloma, 2 cases of storage disorders, 1 case showed granulomatous lesion and 1 case

showed gelatinous transformation. Of the 5 cases which showed metastatic deposits, 2 cases

were from Carcinoma Breast, 1 case from Carcinoma Prostate, 1 case from Carcinoma Cervix

and 1 case from Neuroblastoma. Imprints were positive in 2 cases of adenocarcinoma. Dry tap

was seen in 3 cases. Primary site of the tumour was known in 4 cases. In one patient primary

site was detected subsequent to detection of the bone marrow metastasis -Carcinoma prostate

LESIONS FOUND IN THE BONE MARROW

AGE AND SEX DISTRIBUTION:

Lymphoma/Leukemia 3 yrs F

Lymphoma/Leukemia 5 yrs M





Metastatic involvement

Ca Breast 55 yrs F

Ca Breast 70 yrs F

Ca Prostate 70 yrs M

Ca lung 58 yrs M

Neuroblastoma 5 yrs M

LYMPHOMA/LEUKEMIA - 31%

METASTATIC BONE INVOLVEMENT -26%

ORIGINAL ARTICLE


Multiple Myeloma 62 yrs M




Storage disorders 3 yrs M

Storage disorders 9 m F

Granulamtous lesions 35 yrs M

Gelatinous transformation 40 yrs M

CLINICAL DETAILS

SYMPTOMS

Generalized weakness

NO. OF CASES

19

% OF CASES

100%

Loss of weight & loss of appetite 16 84%

Bone pain 10 52%

Fever 9 47%

Low back pain 8 42%

Organomegaly 7 36%

Lymphadenopathy 6 31%

HEMATOLOGICAL PROFILE

PERIPHERAL SMEAR FINDING

Anaemia

NO. OF CASES

19

% OF CASES

100%

Thrombocytopenia 12 63%

Pancytopenia 8 42%

Leucopenia 7 36%

Leucoerythroblastic picture 6 31%

Dry tap 3 15%

Rouleaux formation 3 15%

ORIGINAL ARTICLE


IMPRINT – LYMPHOMA ALCIAN-PAS POSITIVITY ON IMPRINTS

BMB: METASTATIC DEPOSITS FROM PROSTATE IHC-ER-POSITIVE IN BREAST METS TO BONE

MARROW

ROULEAUX FORMATION - MULTIPLE MYELOMA IMPRINTS OF BM- MULTIPLE MYLOMA

ORIGINAL ARTICLE


EPITHELOID CELLS – GRANULOMA GELATINOUS TRANSFORMATION OF BM

DISCUSSION : Bone marrow examination is very useful in the evaluation of hemato-oncological

disorders. Common findings in the peripheral blood - leucoerythroblastic blood picture,

Pancytopenia, rouleaux formation. Bone marrow aspirates and trephine biopsies are sensitive

techniques for detecting bone marrow pathology. Trephine biopsy is more sensitive than bone

marrow aspiration and sensitivity is increased by performing bilateral biopsies or by obtaining

a single large biopsy.

In adolescent individuals who were eventually diagnosed with Lymphoma/leukemia,

they initially showed pancytopenia with occasional atypical cells in the peripheral smear. Dry

tap was seen in both the cases. Imprint smears from bone marrow biopsy showed that the

marrow was packed with blasts.

Renal failure, low back pain and male predominance was common in all the cases of

multiple myeloma. All the four cases showed elevated levels of serum creatinine.

Marrow infiltration may be focal or diffuse. Reticulin and collagen fibrosis are commonly

present in bone marrow with metastasis. Fibrosis is more in case of greater degree of marrow

infiltration. Marked fibrosis is most common in carcinoma of breast, stomach, prostate, lung.

Marked fibrosis causes pancytopenia, chemotherapeutic drugs causes haemotoxicity, all these

carries bad prognosis. The two primary sites whose identification is most important because of

their sensitivity to hormonal therapy are breast and prostate. The presence of bone marrow

metastasis is helpful in detecting hormonal receptor status when it was not done on primary

tumour.

In children spleenic aspirate is supplementary to bone marrow aspiration in

identification of storage disorders. Neuroblastoma metastasis to bone marrow is very rare in

children less than one year age.

CONCLUSION: Bone marrow aspiration and trephine biopsy are effective and cheap methods of

evaluating various pathological lesions, more useful especially in visceral tumours

metastasizing to bone marrow. Bone marrow examination is indicated when there is significant

probability of identifying lesion which would affect the treatment of primary lesion. Bone

marrow examination itself sometimes gives clue to primary pathology. Imaging techniques like

radionucleide bone scan MRI, CT are usually less effective when compared to bone marrow

examination.

ORIGINAL ARTICLE


REFERENCES:

1. Singh G, Krause JR, Breit feld V (1977) Bone marrow examination for metastatic tumor,

Cancer 40:2317-2321.

2. Finkelstein JZ, Ekert H, ISSACSH, Higgins G (1970) Bone marrow metastases in children

with solid tumors. Amj Dis child 119:49-52.

3. Moid F, Depalma L (2005) comparison of relative value of bone marrow aspirater and

bone marrow trephine biopsies in the diagnosis of solid tumors metastasis and

Hodgkins Lymphoma. Institutional experience and literature review Arch Pathol Lab

Med 129:497-501.

4. Gangadeep Kaur, Metastatic bone marrow tumors: study of nine cases and review of the

literature J Blood Disorder Transfus 2011, 2:3.

5. Saadettin Kilickap, Bone marrow metastasis of solid tumors: Clinicopathological

evaluation of 73 cases: Turkish journal of cancer.

6. Atac B, Lawrence C, Goldberg SN, metastatic tumor: the complementary role of the

marrow aspinate and biopsy. Amj Med SCi, 1991; 302:211-213.

7. Nanda A, Basus, Marwaha N. Bone marrow trephine biopsy as an adjunct to

bonemarrow aspiration. J Assoc physicians India, 2002:50:893-895.

8. Bearden JD, Ratkin GA, Coltman CA Comparison of the diagnostic value of bone marrow

biopsy and bone marrow aspiration in neoplastic disease. J clin pathol. 1974:27:738-

740.

9. Bone marrow pathology, fourth edition B.J. Bain, D.M. Clark and B.S. Wilkins (c) 2010

Barbara.j. Bain, David M. Clark, Bridget S. Wilkins ISBN:978-1-405-16825-0.

10. Jonsson U, Rundles RW (1951) tumor metastases in bone marrow: Blood 6:16-25.

11. Papac RJ (1994) bone marrow metastases-A review cancer 74:2403-2413.

12. Savage RA. Hoffman GC, Shakar K (1978) Diagnostic problems involved in detection of

metastatic neoplasms by bone marrow aspinate compared with needle biopsy Amj Clin

Pathol 70:623-627.

ORIGINAL ARTICLE


CORRELATION BETWEEN BIOFILM FORMATION OF UROPATHOGENIC

ESCHERICHIA COLI AND ITS ANTIBIOTIC RESISTANCE PATTERN. Dr. SarojGolia, Dr. Vivek Hittinahalli, Dr. Sujatha K Karjigi, Dr. K. Mallika Reddy.

1. Professor & HOD, Department of Microbiology, Dr. B.R. Ambedkar Medical College. 2. Associate Professor, Department of Microbiology, Dr. B.R. Ambedkar Medical College.

3. Post Graduate, Department of Microbiology, Dr. B.R. Ambedkar Medical College. 4. Post Graduate, Department of Microbiology, Dr. B.R. Ambedkar Medical College.


Dr. Vivek Hittinahalli, Dr B R Ambedkar Medical College, Kadugondanhalli, Bangalore-45, Email id- [email protected], Ph- 0091 07760984581. ABSTRACT

BACKGROUND: Microorganisms growing in multilayered cell clusters embedded in a matrix of extracellular polysaccharide (slime) which facilitates the adherence of these microorganisms to biomedical surfaces and protect them from host immune system and antimicrobial therapy. There are various methods to detect biofilm production like Tissue Culture Plate (TCP) ,Tube method (TM) ,Modified Congo Red Agar Method (MCRA),bio luminescent assay ,piezoelectric sensors and fluorescent microscopic examination. OBJECTIVES : This study was conducted to compare three methods for the detection of biofilms and compare with antibiotic sensitivity pattern, in uropathogenic Escherichia coli. METHOD: This study was carried out at the Department of Microbiology Dr. B. R. Ambedkar Medical College from Dec 2011 to June 2012. Total number of 107 clinical Escherichia coli isolates were randomly selected from all age groups were subjected to biofilm detection methods and their antibiotic resistance pattern was compared. Isolates were identified by standard phenotypic methods. Biofilm detection was tested by TCP, TM and MCRA methods . Antibiotic susceptibility test of uropathogenic E coli was performed using Kirby –Bauer disc diffusion method according to CLSI guidelines.

RESULTS: From the total of 107 clinical isolate 74 (69.1 %) isolates showed biofilm formation by all the TCP, TM, CRP methods. Biofilm forming isolates from catheter associated UTI showed drug resistance to more than 6 drugs. Only 2(13.3%) isolates from Asymptomatic UTI showed biofilm by TM & MCRA methods & were sensitive all drugs. Biofilm forming isolates from symptomatic UTI showed mixed drug resistance pattern.

CONCLUSION: We conclude from our study that biofilm formation is more common in catheterized patients. TCP method is more quantitative and reliable method for the detection of biofilm forming micro-organisms as compared to TM and MCRA methods. So TCP method can be recommended for screening of biofilm as virulence marker in drug resistant E coli isolates. KEY WORDS: Escherichia coli, Biofilm, Drug Resistance, Congo Red Agar, Tissue Culture Plate

ORIGINAL ARTICLE


INTRODUCTION: E coli accounts for 70 to 95% of urinary tract infections1,13 Bacteria follow ascending route of infections in 90% of urinary tract infections. These are primarily derived from fecal flora of the host, but haematogenic infections do occur. Virulence factors like adhesins, toxins , lipo polysaccharides , iron acquisition , presence of capsule, or serum resistance , determine the uropathogenicity of E.coli strains. Adhesion to epithelial cells of urogenital bacteria is generally accepted as being essential for Uropathogenic bacteria because otherwise the bacteria would be washed out rapidly. In 100% E.coli isolates from pyelonephritis patients & 17% E.coli isolates from Asymptomatic bacteriuria, pap (pili associated pyelonephritis ) was a significant virulence factor. Uropathogenic E.coli (UPEC) can also express a fimbrial adhensins like AFA I , AFA III , which are encoded by gene clusters.

UPEC can invade and colonise the bladder epithelium establishing a urinary tract reservoir allowing an explanation of recurrent UTI that does not necessarily involve reinfection via the Gastrointestinal tract.1,10

Biofilm is an aggregate of micro-organism in which the cells are irreversibly attached to substratum or to each other. They are embedded in a matrix of extra cellular polymeric substances (EPS) in which they have produced and exhibit an altered phonotype with respect to growth rate and gene transcription2,3

Availability of key nutrients, chemotaxis towards surface, motility of bacteria, surface adhesins and presence of surface bacteria are some factors which influences biofilm formation.4 The bacteria enclosed within the biofilm are extremely resistant to treatment. This may be because the drug concentration obtained may be insufficient in certain areas of the film. The bacteria located at the base of the biofilm are metabolically inactive and are thus resistant to certain antibiotics and possess active antibiotic degradation mechanism that contribute to avoid the accumulation of an effective drug concentration.19

So in this study we screened 107 non Repetitive Clinical urinary Isolates of E.coli received in Department of Microbiology Dr. B.R. Ambedkar Medical college by conventional microbiological methods& were subjected to various methods of detections of biofilm production .These include Tissue Culture Plate (TCP)method,5 Tube method(TM) 6,Modified Congo Red Agar method(MCRA) 7.

The samples received by patients were also divided into three groups namely catheter associated infection, Asymptomatic bacteriuria and Symptomatic bacteriuria. The antibiotic susceptibility test was carried out by Kirby Bauer Disc diffusion Technique on Mueller Hinton agar. OBJECTIVE: Evaluation of different detection methods of biofilm formation of uropathogenic E.coli and their drug susceptibility pattern. MATERIALS AND METHODS:

PLACE AND DURATION OF THE STUDY: The prospective study was conducted at the Department of Microbiology, Dr. B.R. Ambedkar Medical College from Dec 2011 to June 2012 . INCLUSION CRITERIA: Pure growth of Escherichia coli isolates were randomly selected from all age groups.

ORIGINAL ARTICLE


E coli isolated from significant bacteriuria, in urine samples of catheterized patients, antenatal cases ,UTI complicated by urinary obstruction, antibiotic therapy, recurrent infections, chronic prostatitis were selected. EXCLUSION CRITERIA; Insignificant bacteriuria, mixed growth & any other organism showing significant growth .

SELECTION OF THE ISOLATES : Total number of 107 urine E coli isolates were subjected to biofilms detection methods. The urine samples of patients were divided into three groups namely – Catheter associated infections, Symptomatic bacteriuria, and Asymptomatic bacteriuria.

The organisms were identified by conventional microbiological methods. The antibiotic susceptibility test was carried out by Kirby Bauer Disc diffusion method

using reference strain of positive biofilm producer E.coli ATCC-25922. Statistical method used was linear correlation. TISSUE CULTURE PLATE METHOD5,8:

The organisms isolated from fresh agar plates were inoculated in Brain Heart Infusion(BHI) with 2% sucrose incubated for 24hrs at 37O c in stationary conditions. Broth was diluted 1:100 with fresh medium. Individual wells of sterile polystyrene 96 well flat bottom culture plate well were filled with 200ul aliquots of diluted cultures. Only medium served as control to check sterility and nonspecific binding of media.9

The TCP were incubated for 24hrs at 370 c. After incubation contents of each well was gently removed by taping the plates. The wells were washed four times with 0.2ml of phosphate buffer saline (PBS pH 7.2) to remove free floating planktonic bacteria. Biofilms formed by adherent ‘sessile’ organisms in plate were fixed with sodium acetate (2%) and stained with crystal violet (0.1%w/v) for one minute. Excess stain was rinsed off by thorough washing with deionized water and plates were kept for drying. Adherent E.coli cells usually formed biofilm on all side wells and were uniformly stained with crystal violet. Optical Density (OD) of stained adherent bacteria was determined with a micro ELISA auto reader (model 680, Bio rad) at wavelength of 570 nm (OD 570nm). These OD values were considered as index of bacteria adhering to surface and forming biofilms.8

Experiment was performed in triplicate and repeated three times, the data was then averaged and standard deviation was calculated. To compensate for background absorbance, OD readings from sterile medium, fixation and dye were averaged and subtracted from all test values. The mean OD value obtained from media control well was deducted from all test values. Classification of Bacteria Adherence:

We classified based on OD values obtained for individual strains of E.coli, but moderate biofilm forming isolates are taken as biofilm forming isolates.

Mean OD value Adherence Biofilm formation

< 0.120 Non Non/weak

0.120-0.240 Moderate Moderate

0.240 Strong High

ORIGINAL ARTICLE


Table no 1; Detection of biofilm formation by mean OD values

Negative OD <0.120

Strong positive OD > 0.240

Fig 1 Detection of biofilm formation by mean OD values.

TUBE METHOD : A quantitative assessment of biofilm formation was determined as previously described by Christensen et al BHI with2% sucrose was inoculated with loopful of microorganisms from overnight culture plates incubated for 24hrs at 37 c. Tubes were decanted and washed with PBS and dried tubes were stained with crystal violet 0.1%. Excess stain was removed and tubes were washed with deionized water Tubes were then dried inverted position and observed for biofilm formation.

Biofilm formation was considered positive when visible film lined the wall and bottom of the tube ring formation at the liquid interface was not indicative of biofilm formation, and interpreted as positive (tube 1) as negative(tube2) . Experiments were performed in triplicate and repeated three times.8 but moderate biofilm forming isolates are taken as biofilm forming isolates

Figure 2 . Tube 1 showing strong biofilm formation. Tube 2 negative for biofilm

production.

ORIGINAL ARTICLE


MODIFIED CONGO RED AGAR METHOD (CRA): Freeman et al15 had described an alternative method of screening biofilm formation by E coli isolates. In this study we use modified Congo red agar for biofilm formation. In vitro slime production ability on the published Congo red agar by Freeman et al (1989) in diffuse black pigment in the agar with growth of black pigmented colonies but pigmentation decreased with time. In the present study the modified Congo red agar (MCRA) was optimized to get strong black pigmentation at 48hrs incubation and then for 2-4 days room temperature. Black colored colonies with dry crystalline consistency interpreted- as positive biofilm producing strains. Red coloured colonies- interpreted as negative for biofilm production

Table 2; composition of Congo red agar.

fig 3 Congo red agar plate showing biofilm formation a) dry crystalline colonies-positive

for biofilm, b)red colored colonies-negative for biofilm

Antibiotic susceptibility test of biofilm producing bacteria was done on Mueller Hinton agar using the following antibiotic discs12:

Norfloxacin, Nitrofurantoin, Ceftizoxime,ceftazidime, Amoxyclavulanic acid, Cotrimoxazole, Ampicillin ,Amikacin Imipenem,Tetracycline.

All the antibiotic disc were obtained from the Himedia. E coli ATCC 25922 were used as positive control and susceptibility testing was performed by using the Kirby Bauer Disc Diffusion Technique according CLSI guidelines.

RESULTS: Among 107 patients 65 were males and 42 were females. From the total of 107 clinical isolates 74( 69.1 %) isolates showed biofilm formation by all the TCP,TM,CRP methods. Among 67 catheter associated UTI ,60 (89.5%)isolates produced biofilm by all the three methods .

Composition /Litter Congo Red Agar Modified Congo red agar

Congo red 0.8g 0.4g

Sucrose 36g -

Glucose - 10g

BHAI 52g -

BAB-2 - 40g

Water 100ml 1000ml

ORIGINAL

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/

Among Asymptomatic bacteriuria out of 15 isolates none produced biofilm by TCP method.

2(13.3%) produced biofilm&13(86.6%) were non biofilm producer by TM &MCRA meth

Among symptomatic UTI complicated from urinary obstructions, antibiotic therapy, recurrent infections, chronic site of infections(chronic prostatitis or stones) , 14(56%) were biofilm producers by TCPmethod,12(48%) by TM method,18(72%) by MCRA metin table3 & chart 3.

Table no 3 Above table shows percentage of

&its correlation with patient’s condition

CHART NO 1 : ABOVE CHART SHOWS PERCENTAGE OF BIOFILM & NON BIOFILM FORMING

E.COLI ISOLATES & ITS CORRELATION WITH PATIENT’S CONDITION.

0102030405060

bio

film

Bio

film

nonbiofilm

nonbiofilmbiofilmNonbiofm

TCP TM MCRA

E coli isolated from

TCP

biofilm

nonbiofilm

Catheter associated infection (n=67)

60(89.5%) 7(10.44%)

Asymptomatic bacteriuria (n=15)

0 15

Symptomatic bacteriuria (n=25)

14(56%) 11(44%)

ORIGINAL ARTICLE

of Medical and Dental Sciences/Volume1/ Issue3/July-Sept 2012



Among symptomatic UTI complicated from urinary obstructions, antibiotic therapy, infections, chronic site of infections(chronic prostatitis or stones) , 14(56%) were

biofilm producers by TCPmethod,12(48%) by TM method,18(72%) by MCRA method, as shown

Table no 3 Above table shows percentage of biofilm & non biofilm forming E.coli

with patient’s condition.


ISOLATES & ITS CORRELATION WITH PATIENT’S CONDITION.

biofilmNonbiofm

MCRA

Catheter associated

infection (n=67)

Asymptomatic bacteriuria

(n=15)

Symptomatic bacteriuria

(n=25)

TM MCRP

nonbiofilm

Biofilm

Nonbiofilm

biofilm

7(10.44%) 60(89.5%) 7(10.44%) 60(89.5%)

15 2(13.3%) 13(86.6%) 2(13.3%)

11(44%) 12(48%0 13(52%) 18(72%)

Sept 2012 Page 171


2(13.3%) produced biofilm&13(86.6%) were non biofilm producer by TM &MCRA method .


hod, as shown

E.coli isolates


Nonbiofm

60(89.5%) 7(10.44%)

2(13.3%) 13(86.6%)

18(72%) 7(28%)

ORIGINAL


Table 4 & chart 4 shows resistance percentage of each antibiotic. These biofilm producingisolates were compared with drug resistance pattern as shown table 5&chart 3. Out of 74 biofilm producing isolates ,60 were catheter associated UTI &14 were from symptomatic UTI. 70( 94.5%) by TCP, 68( 91.5%) by TM method,& 71(87.6%) by MCRA method showedresistance to more than 6 drugs. E coli

drugs. Isolates from symptomatic UTI showed mixed drug resistance pattern.

Antibiotic used

Ampicillin(amp)

Cotrimoxozole

Amoxyclav

Amikacin

Ceftizoxime

Ceftazidme

Norflox

Nitrofurantoin

Tetracycline

Imipenem

Table -4 Resistance percentage

Chart 2 Resistance percentage of each antibiotic drug to E coli isolates.

TCP

Resistance to more than 6 drugs

70(94.5%)

Resistance to 5 to 6 drugs

4(5.4%)

Sensitive to all 0

Total 74

Table 5 The above table shows the relation between biofilm formation and antimicrobial

resistance pattern.

020406080

100120

0

90 82 7558

74

ORIGINAL ARTICLE


Table 4 & chart 4 shows resistance percentage of each antibiotic. These biofilm producingisolates were compared with drug resistance pattern as shown table 5&chart 3. Out of 74 biofilm producing isolates ,60 were catheter associated UTI &14 were from symptomatic UTI. 70( 94.5%) by TCP, 68( 91.5%) by TM method,& 71(87.6%) by MCRA method showed

. E coli isolates from asymptomatic UTI showed sensitive to all drugs. Isolates from symptomatic UTI showed mixed drug resistance pattern.

Number of isolates showed

resistant’s (%) n=107

90(84%)

82(76.6%)

75(70%)

58(54.2%)

74(69.1%)

79(73.8%)

81(75.7%)

78(72.9%)

74(69.8%)

30(28.3%)

4 Resistance percentage of each antibiotic drug to E coli isolates


TM CRM

70(94.5%) 68(91.8%) 71(87.6%)

4(5.4%) 6(8.1%) 6(7.4%)

0 3(4.9%)

74 80


74 79 81 78 74

30

107

Sept 2012 Page 172

Table 4 & chart 4 shows resistance percentage of each antibiotic. These biofilm producing isolates were compared with drug resistance pattern as shown table 5&chart 3. Out of 74 biofilm producing isolates ,60 were catheter associated UTI &14 were from symptomatic UTI. 70( 94.5%) by TCP, 68( 91.5%) by TM method,& 71(87.6%) by MCRA method showed drug

isolates from asymptomatic UTI showed sensitive to all


ORIGINAL


Chart 3The relation between biofilm formation and antimicrobial resistance pattern

Antibiotics

Catheter associated infection N=60

Ampicillin(amp) 60

Cotrimoxozole 60

Amoxyclav 58

Amikacin 50

Ceftizoxime 60

Ceftazidme 60

Norflox 60

Nitrofurantoin 60

Tetracycline 60

Imipenem 24

Table 5 The above table shows correlation between antibiotic resistance pattern with

patient’s condition & biofilm formation. (N=number of biofilm positive isolates).

Chart 4 The above chart shows correlation between patient’s condition ,biofilm

formation & antibiotic resistance pattern. N=number of biofilm positive isolates.

DISCUSSION: Bacterial adhesion has long been considered as virulence factor contributing to infection associated with catheter and other including medical devices.There are two possible explanations for the ability of materials . The first and the bacterial production of polysaccharide slime, the second one is the presence of adhesins for the host matrix proteins that are absorbed on to the biomedical surface.15

There are various methods for biofilm detection

0



Sensitive to all

Total

CRM

ORIGINAL ARTICLE



Catheter associated infection

Symptomatic bacteriuria N=14

Non biofilm Forming Isolates N =33.

14 16

14 8

12 5

8 0

14 0

14 5

14 7

14 4

14 0

6 0



shows correlation between patient’s condition ,biofilm


Bacterial adhesion has long been considered as virulence factor contributing to catheter and other including medical devices.13

There are two possible explanations for the ability of E coli species to colonies artificial materials . The first and the bacterial production of polysaccharide slime, the second one is the

sins for the host matrix proteins that are absorbed on to the biomedical

There are various methods for biofilm detection5,6,7.

20 40 60 80 100

CRM TM TCP

Sept 2012 Page 173



patient’s condition & biofilm formation. (N=number of biofilm positive isolates). shows correlation between patient’s condition ,biofilm


Bacterial adhesion has long been considered as virulence factor contributing to

species to colonies artificial materials . The first and the bacterial production of polysaccharide slime, the second one is the


ORIGINAL ARTICLE


In this study we evaluated 107 isolates from urine samples by three screening methods for their ability to form biofilms .

In our study we found that the majority of biofilm producing bacteria was form catheterised patients (89.5%) similarly , Donlan 2,3 reported in his study the association of biofilm producing bacteria with urinary catheters. In our study we performed TCP and TM by addition of 2% sucrose to BHI broth. Sugar supplementations is essential for biofilm formation 8.This was reported by studies conducted by Mathur T et all.

In modified TCP method extended incubation for 24hrs could lead to a better discrimination between moderate and nonbiofilm producing isolates17. This was also observed in our study.

Biofilm exhibits more resistance to broad Spectrum antibiotics20. This supports that biofilm adds to the virulence profile of microorganism’s biofilm production. 16 The Tube method correlates well with TCP test for strong biofilm production but it was difficult to discriminate between weak and biofilm negative isolates due to the variability is observed results by different observers so in agreement with previous report Tube test cannot be recommended as a general screening test to identify biofilm producing isolates.18

CONCLUSION: By this study we conclude that biofilm forming microorganisms show resistance to many drugs. TM method showed 74 isolates as biofilm formers ,TCP method also showed 74 isolates as biofilm formers but MRCA showed 80 isolates as biofilm formers .Only 74 isolates that showed biofilm formation correlated with patients condition and antibiotic resistance pattern ,by this 6 isolates were false positive by MRCA method .TCP and TM method are more reliable for detection of biofilm formation ,when correlated with patient’s clinical condition and drug resistance pattern of biofilm forming isolates TM method is more subjective ,differs with different observers, so TCP method is more reliable and accurate among all , as CRA method showed false positive. Our study concludes TCP method is better method for screening of biofilm formation as virulence marker in drug resistant E coli isolates. REFERENCES:

Book. 1)Topley And Wilsos 10th edition, bact vol 2;p1379-1380. Journals. 2)Donlan RM(2001).Biofilms and device associated infections.Emerg.infect Dis 7:277-281. 3)DonlanRM,costerton w.Biofilms:survival mechanisms of clinically relevant Microorganisms,clin Microbiol Rev 2002;15(2);167-93. 4)Thomas D,Day F.Biofilmformation by plant associated bacteria.Ann Rev Microbiol2007;61:401-22. 5)Christensen GD,simpsonWA Younger JAet al.Adherance of coagulase negative staphylococci to plastic tissue cultures ;a qualitative model for the adherence of staphylococci to medical devices J Clin Microbiol 1995;22:996 -1006. 6) Christensen GD,simpsonWA.Bisno AL, BeacheyEH Adherance of slime producing strains of staphylococcus epidermidis to smooth surfaces.InfectImmune 1982;37:318 -26. 7) Freeman DJ, Falkiner FR and Keane CT (1989). New method for detecting slime production by coagulase negative staphylococci. Journal of Clinical Pathology., 42 (8): 872-874. 8)T Mathure et al ijmm aug 19 2011, ip;27.7.49.6

ORIGINAL ARTICLE


9)Quantification of biofilm in microtiter plates: Overview of testing conditions and practical recommendations for assessment of biofilm production by staphylococci Stepanović, S., Vuković, D., Hola, V., Bonaventura, G.D., Djukić, S., Ćirković, I., Ruzicka, F.APMIS. 2007; 115(8): 891-899[Pubmed] 10) Stickler DJ (2005) Urinary catheters: ideal sites for the development of biofilm communities. 11)Stickler DJ, Young R, Jones G, Sabubba NA, and Morris NS (2003) Why are Foley catheters so vulnerable to www.sgm.ac.uk/pubs/micro_today/pdf/020505.pdf. Microbiology Today, Feb: 22-25.. 12) Makie & McCartney practical medical microbiology, 14th ed., Churchill Livingstone In., New York 131-149. 13)Madbhusharma, Aparna,Sarita, DOI:10.4103/0377-4929,48960. 14) Montanaro L, Arciola CR, Borsetti E, Brigotti M, and Baldassarri L (1998) A polymerase chain reaction (PCR) method for the identification of collagen adhesin gene (cna) in Staphylococcus-induced prosthesis infections. New Microbiol 21: 359–363. 15)Montanaro L, Arciola CR, Borsetti E, Brigotti M, and Baldassarri L (1998) A polymerase chain reaction (PCR) method for the identification of collagen adhesin gene (cna) in Staphylococcus-induced prosthesis infections. New Microbiol 21: 359–363. 16) Salwa S. Seif El-Din et al Journal of American Science, 2011;7(1) 17) Ludwicka A, Switalski LM, Lundin A, Pulverer G, Wadstrom T. Bioluminescent assays for measurement of bacterial attachment to polyethylene. J Microbiol Methods1985;4:169-77 18) Christensen GD, Simpson WA, Bisno AL, Beachey EH. Adherence of slime-producing strains of Staphylococcus epidermidis to smooth surfaces. Infect Immun1982;37:318-26 19)Anderson GG.Palermo JJ,Roth R,Heuser J, Hultgren SJ.Intracellular bacterial Biofilm- like pods in urinary tract infection.science 2003;301:105-7. 20)Suman E,J Jose,S Varghese,MS Kotian aug 19 2011,IP;27.7.49.6

CASE REPORT


RETROPERITONEAL HYDATD CYST: A RARE PRESENTATION

Dr. Siddesh. Basavaraj. Sirwar, Dr. Amrutha. Swati. Indupalli, Dr. Subhanulla P.

1. Professor, Department of Microbiology. Khajabanda Nawaz Institute of Medical Sciences, Gulbarga. 2. Associate Professor, Department of Community Medicine, Khajabanda Nawaz Institute of Medical Sciences. 3. Professor, Department of Surgery, Khajabanda Nawaz Institute of Medical Sciences, Gulbarga.


Dr. Siddesh. Basavaraj. Sirwar, Mathru Nilaya, Plot No: 11, Siddeshwara Colony, Old Jewargi Road, Gulbarga -02, Karnataka, Email id- [email protected], Ph- 0091 09448320166 / 09902536576. ABSTRACT: Primary retro peritoneal hydatid cyst is extremely rare and only occasional case reports have appeared since first reported this entity in 1958. We report this rare case from KBN Hospital Gulbarga Karnataka diagnosis confirmed post operatively. Mass approached through greater sac which revealed a single cavity in retroperitonium containing enormous number of typical cyst of 2-5cms diameter occupying sub hepatic, epigastria, umbilical and left lumbar regions extending to pelvis. It was never expected that such enormous 2970 cysts would be recovered. Hence, suspicion and ruling out hydatid cyst in every case of retroperitoneal cystic swelling especially in endemic areas, and a careful search for hydatid cysts in other uncommon sites should be cogitated. KEY WORDS: Hydatid Cyst, Retro Peritoneum. INTRODUCTION: Hydatid disease is a parasitic infestation by a tapeworm of the genus Echinococcus. Hydatid cysts are a manifestation of infection at the larval stage of Echinococcus granulosus. Human echinococcosis is a zoonotic infection transmitted by dogs in livestock raising areas.

Developing countries with poor hygiene, where sheep and cattle are raised are high-risk areas of acquiring this disease. Hydatid disease (Echinococcus granulosus) is endemic in the Middle East as well as other parts of the world, Africa, South America, New Zealand, Australia, Turkey and Southern Europe including India1-3, Foci of hydatid disease also exists in India where the highest prevalence is reported in Andhra Pradesh and Tamil Nadu than in other parts of the country4.

Echinococcus granulosus causes cystic echinococcosis in humans. This relatively benign parasitic disease is characterized by slowly growing cysts most commonly in the liver(accounting for 50-70% of cases), followed by the lungs(20-30%), and less frequently the spleen, kidneys, heart, bones, central nervous system, and other organs5.

The annual incidence of hydatid disease has been reported to be 18 to 20 cases per 100.000 inhabitants6. Retroperitoneal localization of hydatid cyst is unusual7 here we are reporting a case of primary retroperitoneal hydatid cyst with unusual number which is a very rare presentation.

CASE REPORT: A female aged 35 year presented with history of abdominal discomfort and distension of 1 year duration, loss of appetite, fever on and off for 3 months. On examination patient looked pallor. There was no jaundice, no edema, vital signs were, pulse 76/min, blood

CASE REPORT


pressure was 110/70 mmHg and mild fever (990F). Chest auscultation revealed normal breath sounds and heart sounds. On Local Examination of abdomen there was diffuse distension confined to upper abdomen, left flank and lower pelvis. Very soft, non tender mass felt more like fluid but no shifting dullness. Borders were indistinct.

INVESTIGATIONS: Hemoglobin-9.5gm%, Hypochromic, normocytic anemia, blood cell count 11.500/mm3, Eosinophil count 550/mm3, erythrocyte sedimentation rate 35 mm/h. The chest and abdominal ultra sound showed normal liver, spleen, kidneys and multiple cystic lesions in the peritoneal cavity occupying upper abdomen, left flank and parts of pelvis. Explorative laparotomy was done through upper midline incision Fig -1 .Liver, spleen, kidneys and peritoneum showed no cysts. Lesion appeared to be more posterior. Mass approached through greater sac which revealed a single cavity in retroperitonium containing enormous number of typical cyst of 2-5cms diameter occupying sub hepatic, epigastria, umbilical and left lumbar regions extending to pelvis . A total of 2970 cysts were delivered Fig-2. Examination of contents of cysts in laboratory revealed numerous hooklets, scolices, many pus cells. Histopathological examination also confirmed the diagnosis. ELISA test was positive for both Ig.M, and Ig.G Echinococcus. DISCUSSION: Hydatid disease in human is one of the oldest diseases known to mankind. Hydatid cysts in humans and animals have been known since Roman times, but, as was true for the other tapeworms, the relationship between the larval cyst and the adult worm was not suspected until the eighteenth century. E. granulosus was described as a separate species in 1850, and its life cycle was worked out with feeding experiments in 18638. Echinococcus granulosus, which commonly has a sheep–dog cycle, but which may also infect goats, cattle, swine, and camels, is the most likely to infect human beings. Human echinococcosis occurs primarily in sheep rearing areas. Dogs ingest cysts in the offal of dead sheep and pass eggs in their feces. Humans acquire the eggs from a dog's fur or from contaminated food or water. The adult worm lives in the proximal small bowel of the definitive host, attached by hooklets to the mucosa. Eggs are released into the host’s intestine and excreted in the feces. Humans may become intermediate hosts through contact with a definitive host (usually a domesticated dog) or ingestion of contaminated water or vegetables. The ovum loses its protective layer as it is digested in the duodenum. Once the parasitic embryo passes through the intestinal wall to reach the portal venous system or lymphatic system, the liver acts as the first line of defense and is therefore the most frequently involved organ. Secondary involvement due to hematogenous dissemination may be seen in almost any anatomic location9. Cysts holding 2 or more liters of fluid and larvae can grow for years in the liver, lungs, brain, or other organs and exert enough mechanical pressure to cause grave or fatal consequences8. The vast majority of abdominal and pelvic cysts are considered to be secondary to prior hepatic involvement following spontaneous rupture or surgical inoculation. Isolated primary retroperitoneal location is exceptional. Haemotagenous or lymphatic spread could account for a solitary retroperitoneal lesion10,11. Dow12 waddle13 had favored air borne transmission and direct implantation of the embryo in the bronchial mucosa, which is another possible mode of entry. This raises the possibility of an embryo of the parasite entering a venule after penetrating the bronchial mucosa and reaching the left side of the heart to involve other sites and thus bypassing the lung. But this remains largely theoretical and needs to be proved14. Preoperative diagnosis is difficult to make unless circumlinear calcification is seen in the plain x-ray of the abdomen. The diagnosis was missed

CASE REPORT


clinically as it was provisionally diagnosed retroperitoneal or peritoneal mass. However after ultra sound examination and during surgery, the possibility of hydatid cyst was considered but it was never expected that such enormous cysts would be recovered. Necessary precautions were taken during the excision and marsupialisation of the entire huge cyst cavity and washed with scolicidal (hypertonic saline) solutions. The rupture will result in anaphylactic shock or systemic metastasis. So the treatment of choice is surgical and complete removal of the cyst is the gold standard but its feasibility is related to the location of the cyst. Hence, one must have a high index of suspicion and rule out hydatid cyst in every case of retroperitonel cystic swelling especially in endemic areas. A careful search for hydatid cysts in other organs of abdomen including liver should be made because secondary retroperitoneal hydatids may out number primary retroperitoneal Hydatids.

FIGURES

Figure1: showing the surgical approach by Explorative laprotomy through upper midline incision to the cyst.

Figure2: Showing unusual number of isolated retro peritoneum Hydatid Cyst.

CASE REPORT


REFERENCES:

1. Goel MC, Agarwal MR, Misra A.: Percutaneous drainage of renal hydatid cyst: early results and follow-up.:Br J Urol: 1995; 75: 724—8.

2. Altinors N, Senveli E, Donmez T, Bavbek M, Kars Z, Sanli M.; Management of problematic intracranial hydatid cysts;. Infection 1995; 23: 283—7.

3. Brown RA, Millar AIW, Steiner Z, Krige JEJ, Burkimsher D, Cywes S.; Hydarid cyst of the pancreas: a case report in a child. Eur J Pediatr Surg; 1995; 5:121—4.

4. Reddy CRRM. Epidemiology of hydatid disease in Kurnool.Ind; J Med Res; 1968; 56:1205-20. 5. Kammerer WS, Schantz PM.; Echinococcal disease. Infect DisClin North Am 1993; 7:605-18. 6. Özdemir N., Akal M., Kutlay H., Yavuzer Ș. Chest Wall Echinoccocosis. Chest, 1994, 105 :

1277-9. 7. Hatipog Lu A. R, Coșkun Í, Karakaya K, Íbiș C. Retroperitoneal Localization of Hydatid Cyst

Disease. Hepato-Gastroenterology, 2001, 48 : 1037-9 8. Patterson, K David, “ Echnicoccosis (Hydatidosis)” The Cambridge World History of Human

Disease. Ed. Kenneth F.Kiple. Cambridge University Press 1993. Cambridge Histories Online. Cambridge University Press 11 September 2012 DOI: 10.1017/CHOL9780521332866.105.

9. Pedrosa I, Saiz A, Arrazola L, Ferreiros J, Pedrosa CS. “Hydatid disease: radiologic and pathologic features and complications.” RadioGraphics 2000;20:795-817

10. Elton C., Lewis M., Jourdan M. H. Unusual site of hydatid disease. Lancet, 1999, 355 : 2132. 11. Balık I. A. A.,Celebi F., Bașog˘LU M, Oren,D, Yıldırgan.I, Atmanalp.S.S.: Intra-abdominal

extrahepatic echinococcosis. Surg Today, 2001,31:881-4. 12. Dow HR Hydatid disease it’s pathology, diagnosis and treatment 1st edition, 1928, 304-315 13. Waddle.N; pulmonary hydatid disease. Aust.N.Z.J Surg, 1950,19:273-78. 14. SekarNN, Madhavan KK, Yadav RV, Katariya RN: Primary retroperitoneal hydatid cyst (A

report of three cases & review of the literature): J. Post grad Med.1982: 28:112-48.

REVIEW ARTICLE


EPIDEMIOLOGY, PREVENTION & CONTROL OF RABIES IN INDIA-

A REVIEW STUDY. Dr. Pranab Jyoti Bhuyan.

1. Assistant Director (Public Health) Department of Health, National Centre for Disease Control, Coonoor

branch, Coonoor.


Dr. P.J. Bhuyan,

NCDC, Coonoor branch.

Coonoor-643101.

The Nilgiris, Tamil Nadu,


Ph- 0091 09442181442.

ABSTRACT: Rabies is a zoonotic disease and its magnitude of problem is underestimated due to

lack of surveillance. In spite of hundred percent fatality, the optimistic view is that it is totally

and absolutely preventable with the aid of effective post-exposure prophylaxis. It is prevalent

mainly in the developing countries like Africa and Asia. Wild carnivorous animals act as

reservoir and domestic/peridomestic warm blooded animals transmit the virus to the human

population. It is popularly known as “Hydrophobia” in human and children are at particularly

risk. More than 3.3 billion people live in regions where rabies is enzootic. Dog bite is the

principal mode of infection in India and lower limb is the most common site of injury. Ineffective

surveillance, shortage of TCV and Immunoglobulin manufacturer and its high cost, peoples

ignorance of first aid measures after bite and the importance of compliance of PEP, uncontrolled

street dog population etc. are the key issues which should be addressed to tackle this problem.

KEYWORDS: Tissue culture vaccine (TCV), Ministry of Health (MOH), Nervous tissue vaccine

(NTV), Post exposure prophylaxis (PEP), Upper limb (U.limb) and Lower limb (L.limb).

INTRODUCTION: This is an infectious disease, also known as hydrophobia caused by Lyssa

virus type I, characterized by acute and profound dysfunction of CNS, nearly always terminating

in the death of the host. All warm blooded mammals are susceptible particularly carnivorous

such as dogs, cats, jackals and wolves and transmitted to man by bites or licks of rabid animals1.

Due to complete absence of any successful medical treatment for clinical rabies and the horrific

nature of the disease, most rabies victims die at home rather than being admitted to a hospital

in abysmal conditions. These circumstances add to the notorious lack of surveillance data

underestimating the health implications of rabies lead many high ranking decision makers in

public health and animal health to perceive rabies as a rare disease of human resulting from a

bite of an uneconomically important animal (dog). Therefore, rabies usually falls between two

stools and is not dealt with appropriately either by MOH or M.O. Agriculture 2.

INDIA: It is endemic in every state of India except Andaman Nicobar Island & Lakshadeep 3.

Some clinico-epidemiological studies are available in India which recorded the types of animal

bite, sites of injury, mode of transmission, usage of PEP etc. NTV has been banned since 2004

due to its life threatening complication and the current cell culture vaccine is quite safe and

effective.

REVIEW ARTICLE


1. MAGNITUDE OF PROBLEM, TREND AND TYPES OF ANIMALS BITE: B.K.Kathuria 4

reported cases of animal rabies from different states of India during the period of 1949-67.

Though the reporting was not regular and uniform, he summarized some important data. In

1967, majority cases of animal rabies were reported from West Bengal (59.89%) whereas 57%

dogs, 38% cattle, followed by Punjab (14.7%) whereas 22% dogs, 55% cattle. The types of the

laboratory positive cases were- dogs (59.72%), Horse & donkey (14.58%), cattle (13.19%),

buffalo (8.33%), Cat (2%), camel (1.38%) and mongoose (0.69%).

The figure 1 has shown the hydrophobia cases as reported from different states from

1956 to 1969-(including nil reporting and under reporting). The peak of the curve signifies that

most of the state reported during that period which indicates lack of reporting in non-peak

period. Admitted cases of rabies from 41 teaching hospitals of India were 247(1965) and

252(1966) 5.

Sarma S.M et.al6 studied rabies in animal with laboratory diagnostic done. The

endemicity of rabid dog was apparent from 78 rabid dog detected out of 83 rabid animals

during the period of July 1982 to June 1983. An increase of rabies in dog was observed from

October 1983 to may 1984 subsequent to detection of rabies in jackals.

Rasina S.K et.al 7 found that 83.7% cases were bitten by dog among which 21.8% was pet dog,

followed by monkey (8.2%) and cat (8.2%).

Acc. to WHO 8, India officially reported 30,000 human rabies deaths (an estimated figure

which remained constant since 1990) and it accounts to 60% of global report of 50,000 deaths

annually. Due to lack of any surveillance and proper reporting there is no report on current

situation of rabies in India. Hence, at the behest of WHO & GOI, APCRI, a registered society was

entrusted this task of doing a National Rabies survey in 2003. The burden and clinico-

epidemiological profiles are clear as per findings of APCRI/WHO study on rabies in India, the

incidence of animal bite is 1.7% with frequency 1 per sec and out of 17 million people only 3

million receive PEP. Incidentally, rabies positivity was reported very rarely in rats, rabbits and

bandicoots, total dog population 28 million; annual man day lost for animal bite 38 million.

The biting animal mainly responsible for human rabies death was dog (96.2%) of which

majority strays (75.2%) followed by pet (11.1%), wild (3.5%); cat accounted for 1.7% of deaths.

The status of biting animal was unknown (46.4%) or killed (28.5%) or dead (23%) and

surprisingly in 2.1% cases it was reported as alive by surviving household members. This might

be that either the people were observing the wrong animal or had forgotten trivial bite by a

rabid animal in the past.

Ichhpujani R.L et al9found that dog bites caused maximum morbidity (92%), followed by

monkey (3.2%), cat (1.8%), fox (0.4%) etc. Most bites were unprovoked (64.3%) by stray

animals (64.7%). Analysis of 192 cases of rabies, from two centres, revealed that dog bites

caused maximum mortality (96.9%).

2. AGE & SEX DISTRIBUTION: Rao Bhanu L.N, Kalaselvan 10studied that main victims were

adults-83.80% and predominantly males (84.42%) affected. Rasina S.K. et.al 7found that the

commonest age group was 6-25 yrs(82.4%). According to WHO & GOI, APCRI survey in 2003 8,

235 Deaths Were investigated at household level by a medical team. Majority of human rabies

were adults (64.7%), men (71.1%) and were from poor income levels (87.6%). Ichhpujani R.L et

al 9 in the study, 72.4% victims were males and 47.5% were children in age group of 2-18 years.

Nearly 40% were children below 15 years of age group and 78.6% were males indicating that it

is an exposure related disease.

REVIEW ARTICLE


3. TYPES OF INJURY: (Fig:2) Rao Bhanu L.N, Kalaselvan 10 found type bites i.e Class III -59.81%,

II-37.7%. RasinaS.K et.al 7studied the common categories of bite were-class II (54.4%) followed

by class I (31.3%) and class III (14.3%). The 78.9% cases completed PEP and the common sites

of bite were U.limb (40.1%) followed by L.limb (36.7%). In the study of WHO & GOI, APCRI

(2003)8, the commonest sites of injury were - lower limb (56.2%) followed by upper limb

(20.9%), hands (17%) and then the head and face (11.5%). Ichhpujani R.L et al (2008)9 found

that 63% had category III exposure as per WHO classification.

4. TREATMENT AFTER BITES: After bite, some people have the practice of washing the wound

with soap-45.6% but other harmful practices are not uncommon like application of chilly

powder (29%), oil (24.5%), turmeric powder (10.9%) etc7. WHO & GOI, APCRI (2003) 8, 39.5%

had wound clean and 47.9% received ARV and even those who had received it mostly had

incomplete/irregular/delayed treatment. The use of RIG was very low (2.1%). In 85% cases,

IP < 6 months; mean IP was lowest (42days) in bites on head & face and highest (107 & 108

days) in those on upper limb (excluding hands) and lower limbs. About 45.3% of victims had

resorted to indigenous treatment like-magico religious followed by herbal therapy, red chili

powder. Ichhpujani R.L et al 9 studied that before coming to ARCs 58.5% people had washed the

wound with water/soap or water alone. Some of the bite victims (10.8%) also applied chillies,

salt, turmeric powder, lime, snuff powder, paste of leaves, acid, ash given by Peer

Baba(magician) etc.

5. RABIES CONTROL IN DOG: A WHO expert consultation meeting on Rabies has identified

mass immunization as single most effective tool for dog rabies control whereas dog culling

alone is ineffective 11. Studies have shown that, in general, 80-90% of the dog population is

accessible for vaccination, thus confirming that the concept of controlling rabies through mass

vaccination is a sound one 12. It has also been recommended the use of oral vaccine as a

complimentary measure in dog in addition to i.m or s.c route. In the light of this oral rabies

vaccine strain, ORA-DPC would offer a major opportunity for rabies control. Better part with

ORA-DPC is that the strain elicits seroconversion too unlike other attenuated rabies vaccine

strains, could be a good indicator to monitor the vaccinated animal in the field as always regd.

by WHO 13. In the majority of industrialized countries, human rabies is under control, mainly

due to oral vaccination of wild animal, mandatory parenteral vaccination of domestic animal

and easy access to modern cell culture vaccine, immunoglobulin for PEP, whereas these are in

short supply & their high cost often prevent their use by those most in need for those product.

In India, Animal Welfare Board of India (AWBI) had successfully implemented Animal Birth

Control (ABC) Programmes among stray dogs in various places including Chennai 14.

6. CONCLUSION: Rabies is a hidden but neglected public health problem in India which affects

mostly the people of lower socio-economic group. Being a zoonotic disease, it cannot be

eradicated but elimination or control is possible with primary health care approach like-

availability of post-exposure prophylaxis, refreshment of recent guideline of PEP, re-exposure

and drop-out management to physicians & medical students; evaluation of technical feasibility

at peripheral level of intradermal route before implementation. Transmission chain will be

broken if herd of at least 75-80% of dog population is immunized on a sustained basis. Recently,

IDSP has introduced its surveillance in the reporting format.

REVIEW ARTICLE


*Fig 1. shows the cases of hydrophobia as reported from different states of India.

Fig-2: shows frequency of Class III bites. Source: Rao Bhanu L.N, Barman S (2000-01 &

2001-02).

REFERENCE:

1. Park K. Rabies- Park’s Textbook of Preventive and Social Medicine 2007; 19: 226-34.

2. WHO Bulletin “Human & animal rabies” Dec , 2008.

3. Seghal and Bhatia R (1985) rabies: Current Status and proposed control programme in India,

NICD, 22 Shamnath Marg, Delhi-54.

4. Kathuria B.K. Studies on rabies-its epizootology and diagnosis. Journal of Comm. Disease

1970; 2: 1-4.

5. Prakash S. Rabies in and around Delhi. J.C.Disease 1970; 2,69-75.

6. Sarma S.M, Sarmah S.B, Saxena SN. Surveillance of Rabies in animals in north India.

J.Com.Disease 1986; 18(1):9-12.

Cases of hydrophobia in diff. states.

0

200

400

600

800

1000

1200

56 57 58 59 60 61 62 63 64 65 66 67 68

Years

No

s. o

f ca

ses.

Frequency of ClassIII bites.

0

500

1000

1500

2000

2500

3000

3500

4000

1995 96 97 98 99 2000April

Years.

Fre

qu

ency

.

Total animal bite cases.

Adult-ClassIII bite.

Child-ClassIII bite.

REVIEW ARTICLE


7. Rasnia S.K, Bhalla S, Khanekar J, Pathi S, Matta S, Singh S. Post exposure management of

animal bite attending a P.H.C of Delhi, J. Com. Disease 2004; 36(3),195-198.

8. APCRI, Assessing burden of rabies in India: WHO National Multicentric Rabies Survey, 2003

9. Ichhpujani R.L, Chhabra M, Mittal V, Singh J, Bharadwaj M, Bhattacharya D, Pattanik SK,

Balakrishnan N et al. –Epidemiology of Animal bites and Rabies cases in India-A Multicentric

study. J.Commun.Dis. 40(1) 2008:27-36.)

10. Rao Bhanu L.N, Kalaselvan J. Epidemiology of Rabies-16 years study at PIIC-Annual Report,

2000-02, 57-60.

11. WHO Techn. Report Series,1973,No 52315.WHO Expert Consultation on Rabies: first report.

Geneva, WHO Technical Report Series, No. 931.

12. The work of WHO. 1986-87,176.

13. Bhubaneswari A, Kilari S, Visser N, Goovarerts D. Oral rabies vaccine, ORA-DPC: Dose

finding studies confirms vaccine efficacy in challenge experiments. APRICON Souvenir, 2009,

17-18.

14. The Hindu, September, 2010, 3. WHO Expert Consultation on Rabies: first report. Geneva,

WHO Technical Report Series, No. 931.

ORIGINAL CASE SERIES STUDY


BENEFICIARIES VIEW POINT AND FACTORS INFLUENCING INDUCED

ABORTIONS IN A RURAL COMMUNITY OF WEST BENGAL. Dr. Debabrata Mallik. Dr. Ranadeb Biswas, Dr. S. Kole, Dr. Manob Dhar, Madhulina Mallik.

1. Assistant Professor, Department of Community Medicine, Bankura Sammilani Medical College. 2. Professor & Head, Department of Community Medicine, AIIH & PH, Kolkata.

3. Assistant Professor, Department of Community Medicine, Bankura Sammilani Medical College.

4. Medical Officer, Department of Community Medicine, AIIH & PH, Kolkata.

CORRESPONDING AUTHOR,

Dr. Debabrata Mallik,

1483, R N Tagore Road.

Dum Dum, Kol-77.

E-mail: [email protected],

Ph: 09433657571.

ABSTRACT:

BACKGROUND: Study of induced abortion in India by considering the complete birth history of

women is lacking. Induced abortion is associated with high mortality and morbidity in India.

OBJECTIVES: The objectives of the study were to find out the Induced abortions ratio and to

identify certain characteristics like perception, health care seeking behavior and the

motivational factors for such an act. METHODS: An exploratory type of investigation (a

retrospective case series study) was carried out among 46 acceptors of induced abortion in a

rural community of west Bengal, between September, 11 to February 12. RESULTS: The ratio of

induced abortions was 20.62 per year per 1000 women of reproductive age group. 89% belongs

to Hindu and 93% of them were married. Unplanned pregnancy (43.47%) and financial problem

(21.73 %) were the main reasons for acceptance of induced abortions. About 71 % of induced

abortions were carried out by qualified person in hospital set up. CONCLUSION: Eventually

induced abortions are increasing universally and several traditional methods are also found to

be life threatening. So exploration of induced abortions is important aspect and explores the

point for entry of further research.

KEY WORDS: Abortion, motivation, unplanned pregnancy, unqualified persons.

INTRODUCTION: Although abortion services in India were liberalized more than three decades

ago, access to safe services remains limited for the vast majority of women. The results

highlights that a host of factors, notably lack of awareness of the legality of abortion services;

limited access to safe services; poor quality of services; and gender roles and norms, lead

women to seek services from untrained providers. In the Indian context, where the preference

for sons is particularly strong, the practice of second trimester sex-selective abortions is

becoming widespread, and thereby also placing women at risk of undergoing unsafe abortion1.

The introduction of new technologies and legislation is expected to make safe abortion services

more accessible. However, the challenge remains in effectively implementing these measures.

An overwhelming proportion of induced abortions (6.7 million annually as per indirect

estimate1) take place in unauthorized centers, which provide abortion services of varying

degrees of safety2. At the same time, in recent years significant changes in the abortion scenario

have been taking place in the country, which have had wide ramifications. Official figures report

that about 0.6 million induced abortions take place annually inIndia2.27 Given that only



approximately 10%of abortions are conducted by qualified providers in approved

institutions,28 and that abortions taking place at registered facilities are grossly under-

reported,1, this represents only a fraction of the total number of induced abortions taking place

in the country. Indirect estimates for the year 1991, using parameters arrived at on the basis of

small-scale study conducted in 1966, project the number of induced abortions annually at 6.7

million3.All the Countries in the World underestimate this abortion is much more than

spontaneous due to medical reasons, victims of sex behaviors, rape etc4.Despite the fact that, in

India these induced abortion is legalized under certain condition & facilities but evidently the

quantum of induced abortion are not matching with the such records of the Governments &

private organizations because widespread of unqualified & untrained practitioners are very

much prevalent in rural & urban society5.Among all these contraceptive failure is a unique

example of falsification & gateway of criminal abortion by the unqualified & untrained

personnel & maiming the lives of the victims due to lack of protocol of maintenance of asepsis. .

The hidden cost of contraception–such as shame, command, resistance from seniors & loss of

social prestige are the prime concern in a country where the number of children count the

prosperity of rural couple by acquiring human manpower6. Scientific advancement made these

treatment behaviors as gender specific to avoid much more harassment of life events of a girl

child. In view of ever increasing priority, quantity, context & coverage of RCH services across the

country but this induced abortion is quite paradoxical7. Needless to say that the mortality

declines of newborn & early child hood are spectacular & reduction of maternal death also

convincingly decline. Therefore to safeguard the health of the mothers & newborn it is

imperative to focus couples own perceptions & compulsions & there by appropriate modalities

for reversal of the trends should also be looked into8.

MATERIALS AND METHODS: It was an exploratory type of investigation for seeking

information regarding induced abortions to acquire certain characteristics. The study was

conducted at Diarrah village with a population of 2230 (2011 census), under Singur block at the

district of Hooghly, West Bengal. Ethical consideration was undertaken from the All India

Institute of Hygiene & public Health. The duration of the study was six months from Sep 11 –

Feb 12. Last five years records of the acceptors of induced abortions were verified from the

Singur BPHC after obtaining informed written consent from the BMOH. From the records a

check list of Diarrah village was prepared which include address of the acceptors of induced

abortions. Similar type of check list was also prepared from the Two Quack practitioners’ after

obtaining informed written consent assuming full confidentiality. Total 53 acceptor’s addresses

were framed for obtaining information. After the questionnaire was finalized, informed written

consent was taken from the Formal Leaders (Gram Panchayat) of the Community. Then the

entire clients were interviewed with the predesigned open ended questionnaire after obtaining

the written consent with assured full confidentiality. Out of 53 acceptors of induced abortion 7

were absent so the total study subjects were 46.

RESULTS: It was noted that total number of population of the study village was 2230 (2011

census) of which total number of women of reproductive age groups (15-45) were 446 (20% of

total population). The study revealed that total number of induced abortion during last 5 years

was 46.And the average induced abortion per year was 46/5=9.2. So the inducedabortion rate

per year per 1000 of women of Reproductive age group was 9.2 #1000/446 =20.62.From the

study it was noted that majority of study subjects 54.3 %( 25) belongs to younger age groups i.e.



15-24 yrs. About 89.1% (41) belongs to Hindu community. 97.4% (43) acceptors of induced

abortion were married. About 67%respondent’s percapita incomes were bellow or equal to

Rs.350. Regarding literacy status only 15 % were illiterate rest of the accepters were literate.

Out of 43 married clients about 88% (38) were getting married before the age of 18 years &

majority (95.34%) gave birth within 2 years of marriage. About 80% acceptors birth spacing

was less than 2 years. It was noted from the study that about83% (36) have 2-3 children but a

considerable 16% have 4-5 children. Majority of the abortion was done 73% (34) within 2-3

month of age of the foetus. Regarding their contraceptive practice 44% (19) did not practice any

methods of contraception while rest of the acceptors practices other methods of contraception.

On enquired about the reason of such an act it was noted that 43% (20) induced abortion was

unwanted pregnancy followed by financial ground 20% & contraceptive failure 19%

respectively. Most the abortion were conducted 71% by the qualified doctors at health center.

But only 28% were conducted by the unqualified personals at their chambers. On enquired

about the reasons of their preference of act for the unqualified persons about 43% (20) replied

that maintained confidentiality was their prime concern. Other important reasons were less

harassment which constitutes about 21%. Besides those monitory problems, less time required

resistance from seniors were others reasons of less priority.

DISCUSSION: The retrospective qualitative survey was include both married and unmarried

women and the data was collected both the Govt. Hospital and untrained practitioners so the

induced abortion ratio was to some extent high.Similar findings were found in NFHS survey for

induced abortion (1998-99)9&DLHS survey (iii) GOI. (2007-08).10The study explore that

women’s age, unplanned and unwanted pregnancy, less acceptance of contraceptive methods,

financial reasons number of living children’swere the major determinants of induced abortion.

Similar findings was also found in a rural community of Maharastra (A cohort

study).11&Tamilnadu (Rabindran &Balasubramanian,2004)12The study explore that maintained

confidentiality, less harassment and less time requirement were another determinants for

accepting abortion of untrained personnel.

CONCLUSION: Traditional practitioners & untrained or ill-trained M.B.B.S practitioners, widely

perform abortion in the rural community. The complications at their hands are frequent & often

serious. Assurances of keeping secrecy attract the ignorant rural people to them. Contraceptive

acceptance is far from the requirement & sterilization acceptance is far from the requirement

acceptance is poor & often late. Repeated & early child birth, inadequate spacing, high parity

along with financial & other relevant problems need availability of M.T.P side by side with

contraceptives & sterilization in the years ahead. Rural people need awareness about the

problem of population expansion, the needs & benefits of contraceptive & sterilization & the

dangers of illegal abortions. Simultaneous publicity about M.T.P services needs to be promoted.

A comprehensive guideline thus evolved from this abortion may be replicated in several socio

economic classes & regions. Instead of indiscriminant intervention, a logical solution locally

derived agreed upon & sharing that benefit will definitely be rewarding. Last of course not the

least, that the exploration of induced abortion is important as it opens some important aspect &

explore the point of entry for further research.

ACKNOWLEDGEMENTS: We are grateful to the Director of AIIH&PH, Kolkata whose support

and guidance has been critical for conduction of the study. We are also indebted toMr.Madan



Das and Mr.SukantaPandit for providing us necessary help in conducting the study. We also

extend our gratitude to the staffs of Singur BPHC and the community people through which

information were collected.

Table-1: Socio demographic characteristics of the Acceptors of Induced abortion (n=46)

Table: 2 Obstetric pattern of the Study subjects.

Socio demographic character Number Percentage

Age in years

15-24

25-34

35-44

Religion

Hindu

Muslim

Marital status

Married

unmarried

Per capita income

<350

=

>350

=

Literacy status

Primary

Secondary

Higher Secondary

Graduation

Illiterates

25

18

3

41

5

43

3

31

15

19

10

8

2

7

54.3

39.1

6.5

89.1

10.9

97.4

6.6

67.4

32.6

41.4

21.7

17.4

4.3

15.2



Variables numbers percentages

Age at marriage(n=43)

<18 yrs.

First child birth <2 yrs.

Spacing <2yrs

<3yrs

No of living children 2-3

4-5

Month of abortion

1-1/2

2

2-1/2

3

>3

Contraceptive acceptance. (n=43)

Safe periods

Condom

Cup-T

OC

Nil

Sterilization

38

41

34

9

36

7

8

11

14

9

4

5

6

7

4

19

2

88.37

95.34

79.06

20.94

83.72

16.28

17.4

23.9

30.4

19.6

8.7

11.6

13.9

16.3

9.3

44.2

4.6

Table: 3 Reasons for acceptance of induced abortions.

Variables Numbers percentages #

Reasons

Financial/for well being

Unplanned pregnancy

Forced by husband

Contraceptive failure

10

20

4

9

21.7

43.4

8.7

19.5



# --- Multiple responses possible

REFERENCES:

Unmarried

Performers

Qualified personals

Unqualified personals

Place of abortion.

Hospitals

Chambers of unqualified

personnel’s

Reasons for acceptance

By Unqualified personals

Maintained confidentiality

Less harassment

Monitory problems

Less time required

To avoid so many test &

Conditions by the Govt.

setup.

Resistance from seniors

To take Govt. facilities

3

33

13

33

13

20

10

4

5

3

4

6.5

71.7

28.3

71.7

28.3

43.4

21.7

8.7

10.9

6.5

8.7



1. Chhabra, R. and S.C. Nuna. 1994. Abortion inIndia: An Overview. New Delhi:

VeeremdraPrinters.

2. Government of India (GOI). 2002. The MedicalTermination of Pregnancy (Amendment) Bill

(BillNo. XXXV).

3. Mallik, R. 2002. India -Recent Developments Affecting Women’s Reproductive Rights. Centre

for Health and Gender Equity (CHANGE).

4. Ministry of Health and Family Welfare (MOHFW).2003. Notification, Medical Termination of

Pregnancy Rules.http://mohfw.nic.in/MTP%20Rules.htm

5. Ministry of Health and Family Welfare (MOHFW).2000. National Population Policy, 2000. New

Delhi: Government of India.

6. Oomman, N. and B.R. Ganatra. 2002. Sexselection: The systematic elimination of

girls.Reproductive Health Matters, 10(19): 184-88.

7. Government of India (GOI). 2003. The Pre-NatalDiagnostic Techniques (Regulation and

Prevention of Misuse) Amendment Act (Act. No. 14).

8. Coyaji, K. 2002. Medical Abortion. Paper

9.M.Barsharani.Correlates of Spontaneous and Induced Abortion in India: An Investigation using

a Nationwide Large Scale Survey Data.

http://paa2011.princeton.edu/download.aspx?submissionId=111333.

10. PallikadavnathS,William Stones R. opportunites and choices programme working paper;

21;2005.

11. www.biomedcentral.com/1471-2458/12/543.

12.Rabindran TKS&Balasubramanian P, Yes to No Abortion.2004; 12: 88-99

ORIGINAL ARTICLE


THE MICROBIOLOGICAL PROFILE OF VENTILATOR ASSOCIATED

PNEUMONIA. Dr. Poonam C. Sharma, Dr. S. S. Raut, Dr. S. R. More, Dr. V. S. Rathod, Dr. V. M. Gujar.

1. Post Graduate Student, Department of Microbiology, Dr. Shankar Rao Chavan Government Medical College &

Sri Guru Gobind Singhji Memorial Hospital, Nanded. 2. Professor & Head of Department, Department of Microbiology, Dr. Shankar Rao Chavan Government

Medical College & Sri Guru Gobind Singhji Memorial Hospital, Nanded.

3. Associate Professor, Department of Microbiology, Dr. Shankar Rao Chavan Government Medical College &

Sri Guru Gobind Singhji Memorial Hospital, Nanded.

4. Assistant Professor, Department of Microbiology, Dr. Shankar Rao Chavan Government Medical College &





Dr. Poonam Chanderlal Sharma,

501, Abhilasha Mahal Co. Op. Hsg. Scty,

Opp. Bhatia Hospital, Ulhasnagar Dist.

Thane, Maharashtra- 421005


Ph: 08888096033.

ABSTRACT: BACKGROUND- Nosocomial infections (NI) are responsible for increased

morbidity and mortality in hospitalized patients. Hospital acquired pneumonia is the

second most common nosocomial infection. AIM : To isolate and identify the organisms

causing Ventilator associated pneumonia and to know their resistance pattern. METHOD :

We conducted the study in the Intensive Care Unit of our Hospital over a period of one

year. All patients on mechanical ventilation for more than 48 hours were included in this

study. The pathogens were identified based on the standard bacteriological procedures

including Gram's stain, colony morphology on Blood agar, MacConkey agar and SDA and

biochemical reactions. FINDINGS- 50 out of 128 samples were culture positive, the

incidence being 39.06%. Out of 50 cases, 33(45.2%) were males & 17(30.9%) were

females. 50% of the cases ventilated for respiratory cause developed VAP while only

20.8% of the cases ventilated for non-respiratory cause developed VAP. Out of 50 cases,

20(40%) were early onset VAP cases, while 30(60%) were late onset VAP cases.

CONCLUSION : P. aeruginosa was the predominant organism isolated followed by E.coli

with maximum sensitivity to Imipenem.

KEYWORDS: Ventilator associated pneumonia, Pseudomonas aeruginosa, Imipenem.

INTRODUCTION: Ventilator associated pneumonia(VAP) is defined as pneumonia occurring

after 48 hours of endotracheal intubation and initiation of mechanical ventilation. VAP is

categorized as early onset VAP which occurs within four days of endotracheal intubation

whereas late onset VAP occurs after four days of endotracheal intubation. Early onset

VAP is caused by Str. pneumoniae, H. influenza, Moraxella catarrhalis, MSSA, etc. While

Late onset VAP is caused by P. aeruginosa, Acinetobacter, Enterobacter species, MRSA,

etc. VAP is frequently polymicrobial and Gram negative bacilli are the predominant

organisms isolated.[3]

ORIGINAL ARTICLE


CLINICAL DIAGNOSTIC CRITERIA FOR VAP ARE:

Clinical suspicion of pneumonia with a new or progressive chest radiographic infiltrates

after 48 hours of patient’s mechanical ventilation and one of the following

Fever >38.3oC

Leukocytosis > 12000/cmm or leukopenia < 4000/cmm

Purulent respiratory secretions with gram stain demonstration of bacteria and

polymorphs

Cultures with growth >105 cfu/ml [3]

AIM: To isolate and identify the organisms causing Ventilator associated pneumonia and

to know their resistance pattern.

METHODS:

SETTING AND SUBJECTS: We conducted the study in the Intensive Care Unit of our

hospital over a period of one year from 1st July 2011 to 30th June 2012. All patients on

mechanical ventilation for more than 48 hours were included in this study. Patients with

pneumonia prior to mechanical ventilation or within 48 hours of mechanical ventilation

were excluded.

STUDY DESIGN AND DATA COLLECTION: From each patient the following data was

collected- Name, age, sex, primary diagnosis, date of admission in the hospital and ICU.

The patients fulfilling both the clinical and microbiological criteria were diagnosed to be

suffering from VAP. Microbiological criteria included positive Gram stain (>10

polymorphonuclear cells/ low power field and ≥1 bacteria/ oil immersion field with or

without the presence of intracellular bacteria). Clinical criteria included modified Clinical

Pulmonary Infection Score (CPIS) > 6

ORIGINAL ARTICLE


IDENIFICATION OF VAP PATHOGENS: The pathogens were identified based on the

standard bacteriological procedures including-

- Gram’s stain

- Colony morphology on Blood agar , MacConkey agar and SDA

- Biochemical reactions. [10]

FINDINGS

INCIDENCE: 50 out of 128 samples were culture positive, the incidence being 39.06%

Characterisics of the patients-

Incidence in males and females- Table I

Incidence differences due to various causes of ventilation- Table II

Incidence due to early onset and late onset pneumonia- Table III

DISCUSSION: The incidence of VAP in our study was 39.06% which was similar to a

study conducted by Shalini et. al.(35.78%) and Rakshit et. al.[4][8] In males incidence of

VAP was 45.2% and that in females was 30.9% which was similar to the study

conducted by Gadani et. al.[11] 40% of cases were early onset VAP and 60% were late

onset VAP which tallies to other studies conducted by Chastre et. al. and Kollef et. al.[5][6]

Incidence in patients ventilated for respiratory cause was 50% and that due to non-

respiratory cause was 20.83%, which co-relates to the study conducted by Akash Deep et.

al.[7] Pseudomonas was the predominant organism in our study (31.48%) similar to that

conducted by Joseph et. al. (21.3%) and Gadani et. al. (43.24%)[9][11]

CONCLUSION: Pseudomonas aeruginosa was the predominant micro organism isolated

with maximum resistance to Tobramycin. E. coli was the second most common micro

organism with maximum resistance to Ampicillin. While both were 100% sensitive to

Imipenem. Microbiologial surveillance facilitates the monitoring of changes of dominant

microorganisms and antibiotic susceptibilities helping in the decision of empirical

treatment regimes and as a result, selecting the right antibiotics.

ACKNOWLEDGEMENTS : Staff of Microbiology Department and Medicine Department,

Study patients.

FUNDING: None

TABLE I:

Gender No. of VAP

cases

No. of cases in

whom VAP

absent

Total no. of

cases

Male 33 (45.2%) 40 (54.8%) 73 (100%)

Female 17 (30.9%) 38 (69.1%) 55 (100%)

Χ2 =2.69

P value > 0.1 (not significant)

ORIGINAL ARTICLE


TABLE II

Cause of

ventilation

No. of VAP

cases

No. of cases in

whom VAP

absent

Total no. of

cases

Respiratory cause 40 (50%) 40 (50%) 80 (100%)

Non respiratory

cause

10 (20.8%) 38 (79.2%) 48 (100%)

Χ2 =10.72

P value <0.01 (highly significant)

TABLE III

Duration of ventilation No. of VAP cases Total no. of cases

Early onset 20 (40%) 50 (100%)

Late onset 30 (60%) 50 (100%)

Χ2 =4

P value < 0.05 (significant)

FIGURE 1 Causative Agents-

31.48%

16.67%14.81%

12.96%

9.26%

3.70%1.85% 1.85%1.85%1.85%

3.70%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

ORIGINAL ARTICLE


FIGURE 2

Resistance Pattern of P. aeruginosa-

FIGURE 3

Resistance Pattern of E. coli

CONFLICT OF INTEREST: None

48%

33%

26%22%

5%

0%0%

10%

20%

30%

40%

50%

60%

95%

67%

50% 50%

20%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ampicillin Cefazolin Tobramycin Amikacin Gentamicin Imipenem

ORIGINAL ARTICLE


REFERENCES:

1) Steven M. Koenig and Jonathon D. Truwit Ventilator-Associated Pneumonia:

Diagnosis, Treatment, and Prevention. PubMed Central Clin Microbiol Rev. October 2006;

19(4): 637–657.

2 ) Bailey & Scott’s Diagnostic Microbiology Eleventh Edition, Mosby Inc. Betty A. Forbes,

Daniel F. Sahm, Alice S. Weissfeld ISBN 0-323-01678-2

3) Girish L. Dandagi Nosocomial pneumonia in critically ill patients Lung India Jul-Sep

2010; 27(3)

4) Rakshit P, Nagar V S, Deshpande A K Incidence, clinical outcome, and risk stratification

of ventilator-associated pneumonia- a prospective cohort study. Indian J Crit Care Med

2005 9(4): 211-216

5) Chastre J and Fagon J Y Ventilator associated pneumonia. Am J Respir Crit Care Med

2002 165: 867-903.

6) Kollef M H Ventilator-associated pneumonia. A multivariate analysis. JAMA 1993; 270:

1965-1970.

7) Akash Deep, R. Ghildiyal, S. Kandian and N. Shinkre Clinical and Microbiological Profile

of Nosocomial infection in the PICU. Indian Pediatrics 2004 41: 1238-1246

8) Shalini S, Kranthi K, Gopalkrishna Bhat K Microbiological profile of infections in ICU. J

of Clinical and Diagnostic Research 2010 4: 3109-3112

9) Noyal Mariya Joseph, Sujatha Sistla, Tarun Kumar Dutta, Ashok Shankar Badhe,

Subhash Chandra Parija. Incidence and risk factors of VAP. J Infect Dev Ctries 2009

3(10): 771-777

10) Mackie & McCartney Practical Medical Microbiology. J. G. Collee, A. G. Fraser, B. P.

Marmion, A. Simmons. Churchill Livingstone, Fourteenth Edition, ISBN 0 443 049068

11) Gadani H, Vyas A, Kar A K. A study of ventilator-associated pneumonia: Incidence,

outcome, risk factors and measures to be taken for prevention. Indian J Anaesth 2010;

54:535-40.

ORIGINAL ARTICLE


BACTERIOLOGICAL PROFILE OF CELL PHONES OF HEALTHCARE

WORKERS AT TERTIARY CARE HOSPITAL. Dr. Chinjal A. Panchal, Dr. Mitesh N. Kamothi, Dr. Sanjay J. Mehta,

1. Post Graduate Student, Department of Microbiology, C.U. Shah Medical College & Hospital, Surendranagar. 2. Assistant Professor, Department of Microbiology, C.U. Shah Medical College & Hospital, Surendranagar.

3. Professor & Head, Department of Microbiology, C.U. Shah Medical College & Hospital, Surendranagar.


Dr. Chinjal Arvindbhai Panchal, C. U. Shah Medical College and Hospital, Surendranagar – 363001, E-mail: [email protected], Ph: 09898576504.

ABSTRACT: BACKGROUND AND OBJECTIVES: Cell phones are increasingly used by healthcare

workers. They can harbour potential bacterial pathogens and can become an exogenous source

of nosocomial infections. Aim of this study was to identify microbial colonisation and their

antimicrobial sensitivity; from cell phones used by healthcare workers.

MATERIALS AND METHODS: A total of 100 samples were collected from cell phones of

clinical and para-clinical staff and non-medical personnel. Specimens were collected and

subjected to culture and sensitivity as per the standard guidelines.

RESULTS: Bacterial species were isolated from 65 (65%) out of total 100 samples. Coagulase

Negative Staphylococcus (42) was the most commonly isolated organism. Isolates included

Methicillin resistant Staphylococcus aureus (10), Methicillin sensitive Staphylococcus aureus

(3), Bacillusspp(15), Pseudomonas spp(4),Moraxella spp(2), E. coli (1), Klebsiella spp (1) and

Acinetobacterspp (1).

CONCLUSION: The carriage rate of bacterial isolates was higher in the clinical staff (92%)

in comparison to para-clinical staff (56%) and non-medical personnel (20%). Cell phones

may serve as potential source of nosocomial infections.

KEYWORDS: Bacterial pathogens, Multidrug resistance, Healthcare workers, Nosocomial

infections

INTRODUCTION: The global system for mobile telecommunication (GSM) was established in

1982 in Europe with a view of providing and improving communication network. Cell phones

have become one of the most indispensable accessories of professional and social

life.1Today,India has 500million Cell phone users. Cell phones increase the speed of

communication and contact within health care institutions, making health care delivery more

efficient; hence, Cell phones are increasingly used by healthcare workers.2Cell phones are

frequently used in hospital wards, casualty, laboratories, ICUs and operation theatres.3However,

Cell phones which are seldom cleaned and often touched during or after the examination of

patients without hand washing, can harbour various potential pathogens and become an

exogenous source of nosocomial infections for hospitalized patients.4Nosocomial infections are

important problem in all hospitals. These infections are increasing day-by-day and can affect

rate of mortality and morbidity. In this study, Cell phones of non-medical personnel were also

included as it represents an environment of community. Therefore bacterial isolates from Cell

ORIGINAL ARTICLE


phones of HCWs may vary in numbers and antibiotic sensitivity, to that found on Cell phones of

non-medical personnel.5

MATERIALS AND METHODS: The study was conducted at the Department of Microbiology, C.

U. Shah Medical College and Hospital, Surendranagar, Gujarat fromAugust 2011 to March 2012.

1) COLLECTION OF SAMPLES: Total of 100 Cell phones of healthcare workers of clinical and

para-clinical staff and non-medical personnel were randomly selected for the study.Sterile

swabs moistened with peptone water were used to collect specimens from the front, sides and

back of the Cell phones.

2) PROCESSING OF SAMPLES: Swabs taken from Cell phones were inoculated on nutrient agar,

blood agar and MacConkey agar. The culture plates were incubated at 37⁰C for 24 hours.

Isolation and identification of bacterial species were done as per standard guidelines.

Antimicrobial susceptibility testing, including detection of Methicillin Resistant Staphylococcus

aureus (MRSA) and Extended Spectrum ß-Lactamase (ESBL) was performed for potential

pathogenic isolates by disc diffusion method as per the Clinical and Laboratory Standards

Institute (CLSI) guidelines.6

RESULTS: Out of 100 Cell phones, bacterial growth was obtained in 65 (65%) Cell phones;

which includes 46 from clinicalstaff,14 from para-clinical staff and 5 from non-medical

personnel; as shown inChart-1. The carriage rate was 92% in clinical staff, 56% in para-clinical

staff and 20% from non-medical personnel.

Out of 65 Cell phones which yielded bacterial growth, 51 (78.46%) had single bacterial

isolate and 14 (21.54%) had two bacterial isolates making total of 79 isolates.

Out of total 79 isolates, 42 were Coagulase Negative Staphylococci (CONS), 15 were

Bacillusspp, 13 were S. aureus and 4 were Pseudomonas spp. Various organisms isolated

from clinical, para-clinical and non-medical personnel are shown in Table-1.

Out of 13 S. aureus, 10 and 42 CONS,21were Methicillin resistant, as shown inChart-2.AllE. coli

(1), Klebsiella spp(1), Pseudomonasspp(4) and Acinetobacterspp (1)isolates were multidrug

resistant as shown in Table – 2.

Chart – 1Growth obtained from Cell phones.

50

25 25

46

14

5

0

10

20

30

40

50

60

Clinical Para- clinical Non medical

Total

Growh obtained

ORIGINAL ARTICLE


Table – 1 Distribution of bacterial isolates

Organism Clinical Para - clinical Non medical Total

CONS 29 (69.04%)

11 (26.19%)

2 (4.76%)

42

Bacillus sp. 10 (66.67%)

1 (6.66%)

4 (26.67%)

15

S. aureus 10 (76.92%)

3 (23.08%)

0 13

Pseudomonas sp.

4 (100%)

0 0 4

Moraxella sp. 2 (100%)

0 0 2

Acinetobacter sp.

1 (100%)

0 0 1

Klebsiella sp. 1 (100%)

0 0 1

E. coli 1 (100%)

0 0 1

Total 58

(73.42%)

15

(18.99%)

6

(7.59%)

79

Chart – 2 Methicillin resistance among Staphylococcus species

Table - 2Percentage incidence of antibiotic sensitivity of bacterial isolates

Organism Total AS BA CH RC TE GM CX CF

CONS 42

38 (90.48%)

23 (54.76%)

33 (78.57%)

28 (66.67%)

30 (71.42%)

32 (76.19%)

21 (50%)

16 (38.09%)

S. aureus 13 11 (84.62%)

5 (38.46%)

5 (38.46%)

7 (53.85%)

7 (53.85%)

9 (69.23%)

3 (23.08%)

3 (23.08%)

Pseudomonas

spp

4 2 (50%)

1 (25%)

1 (25%)

1 (25%)

- 3 (75%)

1 (25%)

-

Moraxella

spp

2 1 (50%)

1 (50%)

1 (50%)

1 (50%)

- 1 (50%)

- -

Klebsiella spp 1 1 (100%)

- 1 (100%)

1 (100%)

- 1 (100%)

- -

E. coli 1 1 (100%)

1 (100%)

1 (100%)

1 (100%)

- 1 (100%)

- -

Acinetobacter

spp

1 1 (100%)

- - 1 (100%)

1 (100%)

1 (100%)

- -

13

42

10

21

0

10

20

30

40

50

S.aureus CONS

Nu

mb

er

of

org

an

ism

s

Organisms

Total

Methicillin Resistant

ORIGINAL ARTICLE


AS – Ampicillin/ Sulbactum,CH – Chloramphenicol,TE – Tetracycline,CX –Cefoxitn,

BA – Cotrimoxazole,RC – Ciprofloxacin,GM – Gentamycin,CF - Ceftiaxone

DISCUSSION: The study shows that bacterialpathogensarepresent oncellphones. The carriage

rate of bacterial isolates was 65 %, which was higher in clinical (92%) staff than in para-

clinical (56%) staff and non- medical personnels (20%). Similar pattern was observed by

Arora U. et al 2. Table-3 shows carriage ratesof bacterial isolates oncellphones reported by

various authors.Bacterial isolates from cellphones of HCWs were varying in their numbers and

antibioticsensitivity, to that found on cellphones of non-medical personnels.

Coagulase NegativeStaphylococci(CONS)were found to be the most common colonizing organisms in the present study. Similar pattern have been reported by different authors as shown inTable-4. Many bacterial pathogens isolated from cellphones of healthcare workers were also multidrug

resistant. 21(50%) Coagulase NegativeStaphylococciand 10 (76.92%)S. aureuswere methicillin

resistant.All E. coli, Klebsiella spp, PseudomonassppandAcinetobactersppwerealsomultidrug

resistant.

Table –3 Comparison of carriage rate with other studies

Study Organisms

isolated

Clinical Para -

clinical

Non-

medical

Kabir O. et al – 2009 (1) 62.00% 15.30% - 66.45% Arora U. et al - 2009(2) 40.62% 44.78% 37.77% - Jayachandra T. et al - 2011(3) 84.30% - - - Jayalakshmi J. et al - 2008(7) 91.67% 90.40% 93.30% - Bhat S.- 2011(8) 98.50% - - - Datta P. – 2009 (9) 59.60% - - 10.00% Present study 65.00% 92.00% 56.00% 20.00%

Table – 4 Comparison of CONS carriage rate with other studies

Study CONS

Kabir O. et al – 2009 (1) 42.70% Arora U. et al – 2009 (2) 27.55% Jayalakshmi J. et al-2008 (7) 47.16% Bhat S. et al-2011 (8) 21.78% Fatma U. et al – 2009 (10) 58.96% Present study 53.16%

CONCLUSION: The overall carriage rate of Cell phones was found to be 65% in the present

study. It was higher in the clinical staff (92%) as compared to para-clinical staff (50%) and non-

medical personnel 20 (20%). Cell phones harboured potential pathogens, which included

multidrug resistant strains.

Restriction of Cell phones seems impractical, prevention of nosocomial pathogens is important,

use of antibacterial agents to clean Cell phones and strict adherence to infection control

measures like hand washing and good hygienic practice can reduce the risk of spread of

nosocomial pathogens.3,9

ORIGINAL ARTICLE


ACKNOWLEDGMENT: We are sincerely thankful to the Dean, Dr. H. H. Agravat and

Superintendent Dr. K.G. Patel of C.U. Shah Medical College& Hospital for their permission to

carry out this study.

REFERENCES:

1) Kabir O, Audu D, Olabisi O, Akitoye O. The potential roleof mobile phones in spread of

bacterial infections.JinfectDevCtries2009; 3(8):628-32.

2) Arora U, Pushpa D, Chadha A, Malhotra S. Cell phones amodernstayhouse for bacterial

pathogens. JK Science2009;11(3):127-9.

3) Jayachandra T, LakshmiprasannaT, Venkateswar A. Astudy on isolation and

identificationofbacteria causing nosocomial infections on mobile phones of health care

workers. CalicutMedical Journal 2011; 9(1):1-6.

4) SrikanthP, Rajaram E,Sudharsanam S, Lakshmanan A, UmamaheswariS, Kalyani J. The

mobile phone in a tropical setting – emerging threat for infection control. Sri

Ramachandra Journal of Medicine 2009;2(2):18-20

5) Chawla K, Mukhopadhayay C, Gurung B, Bhate P, Bairy I. Bacterial ‘Cell’ Phones: Do

cell phones carry potential pathogens?Online J Health AlliedScs.2009; 8(1):8-12.

6) Clinical and Laboratory Standards Institute. Performance standard for antimicrobial

susceptibility testing;20thinformational supplementM100-S20,Vol 30 No 1. Clinical and

Laboratory Standards Institute, Wayne,PA, USA; 2010.

7) Jayalakshmi J, Appalaraju B, Usha. Cell phonesas reservoirs of nosocomial pathogens. J

AssocPhy India 2008;56:388-9.

8) Bhat S, Hegde S, Salian S. Potential of mobile phones to serve as a reservoir in spread of

nosocomial pathogens. Online JHealth AlliedScs. 2011;10(2):14-20.

9) Datta P, Rani H,ChanderJ, Gupta V. Bacterial Contamination of Mobile Phones of

HealthCare Workers. Ind J Med Microbiol 2009; 27(3):279-81.

10) Ulger F, Esen S, Dilek A, Yanik K, Gunaydin M, Leblebicioglu H. Are we aware how

contaminated our mobile phones with nosocomial pathogens?Annals of Microbiology

and Antimicrobials2009,8:7.

ORIGINAL ARTICLE


STUDY OF HEMATOLOGICAL PARAMETERS AMONG NEONATES

ADMITTED WITH NEONATAL JAUNDICE. Dr. Amar Shah, Dr. C. K Shah, Dr. Venu Shah.

1. Assistant Professor, Department of Pathology, Pramukhswami Medical College, Karamsad, Anand, Gujrat.

2. Professor, Department of Pathology, Smt. NHL Medical College, Ahmedabad.

3. Assistant Professor, Department of Community Medicine, GCS Medical College, Ahmedabad.


Dr. Amar Shah,

Pramukhswami Medical College,

Karamsad, Anand, Gujarat,

E-mail: [email protected], Ph: 09909927725.

ABSTRACT: INTRODUCTION: Jaundice is most common problem faced by neonates in the first

week of life. Although physiological jaundice is more frequent as compared to pathological

jaundice it is very important to differentiate between the two as pathological jaundice may lead

to kernicterus and subsequently brain damage. There are various modalities of investigations

e.g. Serum bilirubin, Direct and indirect coomb’s test, Blood group, G-6PD deficiency,

reticulocyte count by which we can reach at diagnosis. Treatment is also dependent upon the

amount of serum bilirubin and various other laboratory investigations. Thus laboratory workup

is very important for diagnosis and prevention of neonatal hyperbilirubinemia in newborn.

With this background present study was conducted to study the clinicopathological profile

among infants with neonatal hyperbilirubinemia. METHODOLOGY: A prospective study was

carried out for the duration of 1 year in one of the teaching hospitals. RESULTS: Altogether 63

babies were enrolled in the study. Male babies out numbered the female (58.7% vs.

41.3%).Mean age of the study population was 2.97 days with standard deviation of 1.2 days.

Percentage of Pre-term babies was 30.1. Neonates having low birth weight were 17(26.9%).

Physiological jaundice constituted (40)62% cases of Neonatal hyperbilirubinemia. ABO

incompatibility was the commonest cause of pathological jaundice followed by septicemia.

Statistically significant rise in the serum bilirubin was noted in pathological jaundice as

compared to physiological jaundice. C-reactive protein (CRP) was found to be positive in all the

cases of septicemia. Direct and indirect Coomb’s test was positive in all the cases with Rh

incompatibility. CONCLUSION: Neonatal hyperbilirubinemia is associated with various other

clinical morbidities. Causes of hyperbilirubinemia should be investigated comprehensively. ABO

and Rh typing should be done along with Coombs Test, reticulocyte count and G6PD screening.

KEY WORDS: neonates, hyperbilirubinemia, hematological parameters.

INTRODUCTION: Neonatal hyperbilirubinemia is a very common condition in newborn

sometimes leading to kernicterus causing brain damage. There are various conditions, both

physiological and pathological leading to hyperbilirubinemia in newborn. Neonatal

hyperbilirubinemia, defined as a total serum bilirubin level above 5 mg per dL (86 µmol per L),

is a frequently encountered problem in developed as well as developing countries. Although up

to 60 percent of term newborns have clinical jaundice in the first week of life, few have

significant underlying disease.1 It is very important for pathologists and pediatricians to

differentiate the physiological and pathological causes of hyperbilirubinemia. Treatment is

ORIGINAL ARTICLE


dependent upon the amount of serum bilirubin and various other laboratory investigations. So

there is very important role of the pathologist in this condition to classify the neonatal

hyperbilirubinemia.

The most common cause of neonatal hyperbilirubinemia in India is physiological

jaundice. Various other conditions in decreasing order are preterm infant, blood group

incompatibility, Neonatal septicemia, G-6PD deficiency, cephalhematoma, drug induced, RBC

membrane disorders and many others.

Though the history and clinical presentation of the newborn plays a major role, the

laboratory plays an important role in diagnosing the cause of hemolysis in is also helpful in

diagnosing antenatally by amniocentesis and other recent available modality thereby

preventing the hemolytic sequel in newborn. There are various modalities of investigations e.g.

Direct and indirect coomb’s test, Blood group, G-6PD deficiency, reticulocyte count by which we

can reach at diagnosis. Thus laboratory workup is very important for diagnosis and prevention

of neonatal hyperbilirubinemia in newborn. With this background present study was conducted

to study the laboratory profile among infants with neonatal hyperbilirubinemia admitted to the

hospital.

OBJECTIVES:

1. To study different causes of neonatal hyperbilirubinemia

2. To study laboratory profile of neonatal hyperbilirubunemia

MATERIAL AND METHODS: A prospective cross sectional study on neonatal

hyperbilirubinemia was conducted at one of the teaching institutes of Ahmedabad. Infants

admitted with significant neonatal jaundice in first week of life are included in the study.

Significant Jaundice was defined as total serum bilirubin exceeding 15mg/dl or even between 5

mg/dl and 15 mg/dl within 24 hour of birth or the same persisting beyond one week of life.

Total 63 such cases of newborn were admitted during the study period of August 2007 to

October2008.Written informed consent were taken from the guardian of neonates. Detailed

history of baby and mother was taken. Following investigations were done in all cases.

BLOOD GROUP (ABO/RH) OF MOTHER, FATHER AND BABY: The blood grouping was done

by using known antisera with slide and tube methods

SERUM BILIRUBIN ESTIMATION OF BABY: It has been done on auto analyzer by Diazo

method of Pearlman and lee.

COMPLETE BLOOD COUNT WITH PERIPHERAL SMEAR EXAMINATION: It included

haemoglobin, total count, different count, band cells, peripheral smear examination and

reticulocyte count.

DIRECT AND INDIRECT COOMB’S TEST OF BABY AND MOTHER RESPECTIVELY

RETICULOCYTE COUNT: Reticulocytes count has been done by stain –Briliant cresyl blue.

TEST FOR G-6-PD DEFICIENCY: Test for G-6-PD deficiency has been carried out by using SPAN

Diagnostic Reagent Kit from the red cell hemolysate.

C-REACTIVE PROTEIN OF BABY: has been carried out by Latex agglutination method

Data was entered and analyzed by using appropriate statistical software. t test was used as a

test of significance to find out the probability value.

RESULTS AND OBSERVATION: The present study includes 63 cases of newborn admitted in

one of the tertiary care institutes. Various laboratory investigations of neonatal jaundice were

ORIGINAL ARTICLE


carried out. Out of 63 neonates, almost two thirds (63.5%) were 2 to 3 days old. Mean age of the

neonates was 2.97 days with standard deviation of 1.2 days. 37(58.7%) were male while

26(41.3%) were females. Percentage of Pre-term babies was 30.1. Neonates having low birth

weight were 17(26.9%). (Table 1) Physiological jaundice constituted (40) 62% cases of

Neonatal hyperbilirubinemia. ABO incompatibility was the commonest cause of pathological

jaundice and Septicemia is second commonest cause of pathological jaundice. (Table 2) Among

half of the cases (33, 52.4%) range of serum total bilirubun was found between 15 and 19.9

mg/dl. 5(7.9%) were having the serum total bilirubin more than 25 mg/dl.(Figure 1)

Hemoglobin level was lowest (12.1 gm %) in Rh incompatibility. Highest level of serum bilirubin

was found in Rh Incompatibility whereas highest level of reticulocytes was noted in G-6PD

Deficiency. Pre-term and low birth weight babies were having higher levels of serum total

bilirubin but the difference was not significant (P>0.05) (Table 3) The rise in serum bilirubin

level was found to be more in pathological jaundice as compare to physiological jaundice.

Difference was significant statistically with p value of <0.05. (Table 4) Direct Coomb’s test and

Indirect Coomb’s test were found to be positive in all case in Rh incompatibility while they were

positive in 77% of cases in ABO incompatibility. (Table 5) In cases of septicemia CRP was found

to be positive in 100% of cases. CRP was found to be positive in a few cases of ABO

incompatibility (22.2%) and physiological jaundice (5%). (Table 6)

DISCUSSION: Study included 63 cases of Neonatal hyperbilirubinemia cases. Mean age of the

neonates was 2.97 ±1.2 days. Among them 37(58.7%) were male while 26(41.3%) were

females. In the study of Choudhury Habibur Rasul2 male-to-female ratio among the neonatal

jaundice cases was 1.3:1 and mean age at the appearance of jaundice was 4.5±2.3days. Neonatal

hyperbilirubinemia was more common in male babies as compared to female babies in two

different studies done by Mantani et al 3(62% vs. 38%) and Sharma et al 4(1.3:1)

In present study, percentage of Pre-term (<37 weeks) babies was 30.1 and neonates

having low birth weight (<2.5 kg) were 17(26.9%). In the study of Nepal D et al5 LBW babies

constituted 19.2%. Where as in the study of Choudhury Habibur Rasul2 42% patients with

neonatal jaundice had low birth weight and 37% were preterm.

In our study out of 63, 40(62%) cases were diagnosed as having physiological jaundice

by while others were having ABO incompatibility (15%), Rh incompatibility(8%),

septicemia(12%) and G-6 PD deficiency(3%). In the study of Nepal D et al5 they noted that

clinical sepsis as defined by WHO criteria was found in 86.3% of babies. Nearly 1/3rd (32.9%)

babies were ABO incompatible and 4.1% babies were Rh incompatible. Choudhury Habibur

Rasul et al2 mentioned that Physiological jaundice was most common and was diagnosed in

114(26.7%) cases. In their study Prematurity (20.9%) and sepsis (17.6%) were also

major causes of jaundice. C. N. Onyearugha6 concluded in their study that septicaemia followed

by prematurity were the leading aetiological factors of neonatal jaundice. Joshi et al7 reported

that in Septicemia, ABO incompatibility, Rh incompatibility were observed in 36.36%, 31.8%,

4.54% cases of neonatal jaundice respectively.G-6 PD deficiency was there in 3 percent of cases

in present study. Singhal et al reported almost similar finding (G-6 PD deficiency in 5% of cases)

in their study.8

In present study mean Hb level was 14.2+/- 1.7 gm/dl with range of 10-18gm/dl.

Similar findings were noted in the study carried out by Joshi et al7. The findings of their study

showed Mean Hb level of 13.87+/- 3.59gm/dl with a range of 8– 19.4 gm/dl.

ORIGINAL ARTICLE


In any infant, 24 hours old any jaundice is considered pathologic and requires evaluation. This

evaluation should minimally include a serum bilirubin and workup for hemolytic disease.

Guidelines for therapy depend upon the serum concentration of bilirubin and the patient’s age.

Also serum bilirubin is most important investigation to judge severity and management of

patient. In present study serum bilirubin was highest in ABO incompatibility and Rh

Incompatibility. Among half of the cases (52.4%) range of serum total bilirubun was found

between 15 and 19.9 mg/dl. Same results were observed in the study of Nepal D et al5. They

mentioned that maximum number (67.1%) of infants' peak serum bilirubin fell in the range of

15-19.9 mg/dl.

DCT and ICT were positive in 100% cases of Rh incompatibility while in ABO

incompatibility they were found to be positive in 77% of cases. The reason for this difference

may have been that “A” and “B” antigens are weaker antigens and the distance between a/b

antigen sites on the fetal red cells as compared to adult red cells is more. In all cases of

septicemia CRP was positive in present study. It is an acute phase reactant; is synthesized by the

liver and it becomes positive after any inflammation. It is a very reliable indicator.

To conclude, most of the cases were having idiopathic jaundice although septicemia and

ABO-Rh incompatibility were not exceptional. Peak serum bilirubin levels were found to be

more among the pathological jaundice. Also prematurity and low birth weight were having

higher levels of s. bilirubin. Special care must be given to them in order to avoid future

complications of hyperbilirubinemia

ACKNOWLEDGEMENT: We are thankful to parents/guardians of all the neonates for their

cooperation while carrying out the study.

TABLE-1 Demographic profile of Neonatal Hyperbilirubinemia cases

Variables No. Percentage

Age (in Days)

1 5 7.9

2 19 30.2

3 21 33.3

4 13 20.6

5 2 3.2

6 2 3.2

7 1 1.6

Sex

Female 26 41.3

Male 37 58.7

Gestational Age

Pre-Term 19 30.1

Term 44 69.9

Birth weight

Normal 46 73.1

LBW 17 26.9

TABLE-2 Etiology wise distribution of Neonatal Hyperbilirubinemia

Etiology No. Of Cases Percentage

Physiological Jaundice 40 62

Suspected ABO Incompatibility 09 15

ORIGINAL ARTICLE


Septicemia 08 12

Rh Incompatibility 04 08

G-6PD deficiency 02 03

Total 63 100

TABLE-3 Mean level of Hemoglobin, Serum bilirubin and Reticulocyte count in Neonatal

hyperbilirubinemia

Etiology Mean Hb

(gm %)

Mean serum

Bilirubin level

(mg/dl)

Mean

Reticulocyte

count (%)

Physiological

Jaundice 14.8 15.5 2.53

ABO

Incompatibility 14.2 19.6 3.77

Rh Incompatibility 12.1 18 5.5

Septicemia 12.6 20.2 4.6

G-6PD deficiency 13.7 19.2 6

TABLE-4 Mean Serum bilirubin value: physiological Vs Pathological Neonatal Jaundice

Neonatal Jaundice Mean Level of S. Bilirubin(mg/dl) t- value P value

Physiological(n=40) 15.4± 2.8

4.6 <0.05 Pathological(n=23) 19.5± 4.1

TABLE-5 Result of Coomb’s test in Rh and ABO incompatibility

DCT ICT

+ve -ve Total +ve -ve Total

Rh

incompatibility

4 (100%) 0 4 4 (100%) 0 4

ABO

incompatibility

7(77%) 2(23%) 9 7(77%) 2(23%) 9

TABLE-6 Result of C - reactive protein in Neonatal Septicemia

Etiology CRP positive

n(%)

Total No. of Cases

Septicemia 08 (100) 08

Physiological

Jaundice

02(5) 40

ABO

Incompatibility

02(22.2) 09

Rh Incompatibility 00(00) 04

G-6PD deficiency 00(00) 02

ORIGINAL ARTICLE


Figure: 1 Level of serum total bilirubin (mg/dl) among the neonatal jaundice cases

REFERENCES:

1. American Academy of Pediatrics. Report of the committee on infectious disease

(Redbook).Elk Grove Village III: AAP, 24th Ed.1997, p5054.

2. Choudhury Habibur Rasul, Md Abul Hasan, Farhana Yasmin. Outcome of Neonatal

Hyperbilirubinemia in a Tertiary Care Hospital in Bangladesh Malaysian J Med Sci. Apr-

Jun 2010; 17(2): 40-44

3. Mantani M, Patel A, Renge R, Kulkarni H. Prognostic value of direct bilirubin in Neonatal

Hyperbilirubinemia. Indian J Pediatr 2007; 79: 819-22.

4. Sharma P, Chhangani NP, Meena KR, Jora R, Sharma N, Gupta BD. Brainstem Evoked

Response Audiometry (BAER) in neonates with hyperbilirubinemia. Indian J Pediatr

2006; 73: 413-16.

5. Nepal D, Banstola D, Dhakal AK ,Mishra U, Mahaseth C Clinico-Laboratory Profile and

Immediate Outcomes of Hyperbilirubinemic Babies Admitted in Kanti Children

Hospital Journal of Nepal Paediatric Society; January-June, 2010/Vol 30/Issue 1

6. C. N. Onyearugha, B. N. Onyire and H. A. A. Ugboma. Neonatal jaundice: Prevalence and

associated factors as seen in Federal Medical Centre Abakaliki, Southeast Nigeria.

Journal of Clinical Medicine and Research Vol. 3(3) pp. 40-45, March 2011

7. Joshi BD, Singh R, Mahato D and Prasad R. Clinico-Laboratory Profile of Neonatal

Hyper-bilirubinemia in Term Babies at B.P. Koirala Institute of Health Sciences

(BPKIHS), Dharan, Nepal. Journal of Nepal Health Research Council Vol. 2 No. 2 October

2004

8. Singhal PK, Singh M, Paul VK, Deorari AK, Ghorpade MG. Spectrum of neonatal

hyperbilirubinemia: An analysis of 454 cases. Indian Pediatr 1992; 29: 319-325.

27.0

52.4

12.77.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

<15 15-19.9 20-24.9 >25

Per

cent

age

Levels of serum total bilirubin (mg/dl )

ORIGINAL ARTICLE


ESBL DETECTION: PREVALENCE & COMPARISON WITH NEW CRITERIA Dr. Ashwini Manhas, Dr. Prerna Aggarwal, Dr. Manju Bala, Dr. Satish Gupte.

1. Assistant Professor, Department of Microbiology, Giansagar Medical College, Patiala (Punjab).

2. Associate Professor, Department of Microbiology, Giansagar Medical College, Patiala (Punjab).


4. Professor, Department of Microbiology, Giansagar Medical College, Patiala (Punjab).

CORRESPONDING AUTHOR

Dr. Ashwini Manhas

Giansagar Medical College,Ramnagar,

Rajpura,Dist. Patiala (Punjab) Pin code-140601


Ph: 09888473208.

ABSTRACT: AIM: To study the prevalence of ESBL producing organisms in our area both by

phenotypic method and latest CLSI breakpoints. Effect of change in break points on predicting

ESBL was also studied. MATERIAL & METHODS: Successive clinical isolates were tested by

phenotypic assay and zone diameters compared by Kirby Bauer’s disc diffusion method.

RESULTS: Total 231 clinical isolates were studied of which 81.8% were ESBL producers.

Cefotaxime had high sensitivity (97.91%), specificity (97.43%) and positive predictive value

(99.47%). Cefpodoxime had strikingly 100% specificity and positive predictive value but a very

poor negative predictive value. Aztreonam had a very high sensitivity (99.4%) and negative

predictive value (97.61%) CONCLUSION: Cefotaxime was found to be the most appropriate

antibiotic when used as single agent.

KEYWORDS: ESBL, Double Disc Synergy Test, Drug Resistance

INTRODUCTION: Since their first description more than twenty years ago, pathogens

producing extended-spectrum β- lactamases (ESBLs) have become an increasing cause of

clinical concern for several reasons1-3. First, systemic infections due to ESBL-producing

Enterobacteriaceae are associated with adverse clinical outcomes. Second, initially restricted to

certain, these enzymes have spread globally and their prevalence varies geographically. Third,

primarily characterized in limited bacteria such as Escherichia coli and Klebsiella spp., ESBLs

have been spreading and reaching other genera, principally Enterobacter and Proteus spp.

Finally, besides the growing species diversity, ESBL phenotypes have become more complex

due to the production of multiple enzymes including inhibitor-resistant ESBL variants, plasmid-

borne AmpC, production of ESBLs in AmpC - producing bacteria, production of ESBLs in KPC-

producing bacteria, enzyme hyperproduction and porin loss1-4.

A strong relationship exists between third-generation cephalosporin use and acquisition

of an ESBL producing strain5. Other antibiotic classes associated with infections due to ESBL-

producing organisms include quinolones, trimethoprim-sulphamethoxazole, aminoglycosides

and metronidazole.6 In some centers from India as many as 86 percent of Klebsiellae have been

found to be ESBL producers7.

Despite Clinical and Laboratory Standard Institute’s (CLSI) recommendations 6,8 that

clinical microbiology laboratories perform specialized tests for detection of ESBLs, many of

them make no effort to detect ESBL production or are ineffective at doing so. In India there is no

regulation regarding performance and reporting of ESBL isolates from various hospitals and

ORIGINAL ARTICLE


clinical laboratories. Many laboratories lack sufficient expertise to identify and report ESBLs.

There is a need for simple yet effective methodologies which can be routinely used for

monitoring the prevalence of ESBL producing organisms.

The most common method of testing for extended spectrum β-lactamases (ESBLs) is

screening for reduced susceptibility to cefpodoxime/ cefotaxime/ ceftriaxone/ ceftazidime/

aztreonam followed by phenotypic confirmatory testing by demonstrating a synergistic effect

between an indicator cephalosporin and a β-lactamase inhibitor i.e., clavulanic acid 9,10. The

sensitivity of screening for ESBLs can vary depending on the type of antimicrobial agent

tested.11, 12 According to Clinical Laboratory Standards Institute (CLSI) M100-S13 guidelines,10

use of more than one of the five indicator cephalosporins suggested for screening improves the

sensitivity of ESBL detection. Some studies have reported that if it should be necessary to rely

on a single screening antibiotic, cefpodoxime or ceftazidime is the recommended antibiotic for

ESBL detection in Klebsiella spp.11, 12 Phenotypic methods are easier to perform as compared to

genotypic and at the same time they are indicative of gene expression. If criteria for ESBL

detection could be incorporated in routine susceptibility testing the detection and

interpretation would become simpler.

So a study was planned to estimate the prevalence of ESBL producing organisms in our

area both by phenotypic method and latest CLSI breakpoints. The isolates studied belonged to

family Enterobacteriacae.

MATERIALS & METHODS: The study was conducted in Giansagar Medical College and Hospital

which is a 600 bedded tertiary care hospital. A prospective study on successive clinical isolates

of family enterobacteriacae was undertaken. All isolates were screened for ESBL production by

Kirby- Bauer’s disc diffusion method demonstrating reduced susceptibility to cefpodoxime (30

μg), cefotaxime (30μg), ceftazidime (30 μg), and aztreonam (30 μg). Cut-off zone sizes as an

indicator of potential ESBL producer for K. pneumoniae, K. oxytoca & E. coli were ≤ 27 mm for

cefotaxime, ≤ 22 mm for ceftazidime, ≤ 27 mm for aztreonam and ≤17 mm for cefpodoxime. For

P. mirabilis the zone size cut offs were cefotaxime ≤ 27 mm, ceftazidime ≤ 22 mm, aztreonam ≤

27 mm and cefpodoxime ≤ 22 mm. Escherichia coli ATCC 25922 & Klebsiella pneumoniae ATCC

700603 (ESBL positive) were used as quality control for ESBL detection.

Phenotypic confirmatory test was performed for confirmation. The combined disk

method was used to confirm the presence of ESBL on all the isolates of enterobacteriacae family

by placing a disk of ceftazidime (30 μg) and ceftazidime (30 μg)/ clavulanic acid (10 μg) besides

cefotaxime (30 μg) and cefotaxime (30 μg)/ clavulanic acid (10 μg) on a Mueller-Hinton agar

plate as recommended by CLSI. A ≥ 5 mm increase in zone diameter for either antimicrobial

agent tested in combination with clavulanic acid vs its zone when tested alone was considered

ESBL producer. CLSI has reviewed the interpretation criteria as shown in Table 2.18 If new

interpretation criteria are being used then the screening test need not be performed. Penicillins,

cephalosporins and aztreonam should be reported as found on susceptibility testing without

altering susceptibility status as recommended earlier.

RESULTS: Altogether 231 clinical isolates were studied. The most prevalent isolate was E. coli

(78.3%) followed by Klebsiella spp.(12.1%), Proteus mirabilis (4.3%), Citrobacter spp. (2.1%) &

others (Table 1). Overall ESBL producers were 81.8% and ESBL non producers were 18.2%.

Outpatient clinics contributed to 65 isolates of total 231 isolates. Amongst them the prevalence

of ESBLs was 75.38% (49/65). From inpatients 166 isolates were obtained amongst which the

prevalence of ESBLs was 84.34% (140/166) (Table 3).

ORIGINAL ARTICLE


TABLE 1: Species distribution

Species No. of isolates ESBL producers

Escherichia coli 181 (78.3%) 150 (82.8%)

Klebsiella species 28(12.1%) 22 (78.5%)

Proteus mirabilis 10 (4.3%) 8(80%)

Citrobacter species 5 (2.1%) 5(100%)

Serratia species 4 (1.7 %) 3(75%)

Enterobacter

species

1 (0.4%) 1 (100%)

Morganella

morganii

1 (0.4%) 1(100%)

Salmonella typhi 1(0.4%) 0(0%)

TABLE 2: Revised CLSI zone diameter (in mm)

Sensitive Intermediate Resistance

Cefotaxime ≥26 23-25 ≤22

Ceftazidime ≥21 18-20 ≤17

Aztreonam ≥21 18-20 ≤17

Cefpodoxime ≥21 18-20 ≤17

TABLE 3: In patient & outpatient distribution

Isolates ESBL producers Non ESBL

producers

Out patient 65 49 (75.38%) 16 (24.61%)

In patient 166 140 (84.34%) 26 (15.66%)

Total 231 189 (81.80%) 42(18.18%)

TABLE 4: Comparison of old and new CLSI criteria for ESBL detection

Sensitivity Specificity Positive

predictive value

Negative

predictive value

Old

criteria

New

criteria

Old

criteria

New

criteria

Old

criteria

New

criteria

Old

criteria

New

criteria

Cefotaxime 97.91% 97.91% 97.43% 97.43% 99.47% 99.47% 90.47% 90.47%

Ceftazidime 91.45% 95.72% 78.12% 77.27% 96.29% 94.7% 59.52% 80.95%

Aztreonam 89.9% 99.4% 91.3% 66.12% 98.94% 88.88% 50% 97.61%

Cefpodoxime 96.89% 82.17% 94.73% 100% 99.94% 100% 85.71% 2.38%

The species distribution of ESBLs amongst the various isolates was as shown in Table 1. Using

phenotypic methods the highest number of ESBLs was contributed by E. coli followed by

Klebsiella spp. and Proteus mirabilis. Citrobacter spp. though had only 5 isolates but alarmingly

all of them were ESBL producers. The drugs that were tested for ESBL production were

cefotaxime, aztreonam, ceftazidime & cefpodoxime. We also compared the zone diameters

ORIGINAL ARTICLE


according to old and current CLSI criteria to see if a single drug was better predictor of ESBL

activity when used in the absence of ESBL phenotypic assay.

The effect of change in CLSI criteria on predicting ESBL production is shown in Table 4.

For cefotaxime the sensitivity, specificity, positive predictive value and negative predictive

value was 97.91%, 97.43%, 99.47% & 90.47% respectively. Upon testing with ceftazidime the

sensitivity was 95.72% and positive predictive value was 94.7%. A fall in specificity (77.27%)

and negative predictive value (80.95%) was observed. With ceftazidime 182 isolates were

confirmed ESBL producers, 25 were ESBL non producers and 24 were doubtful. Out of these

isolates 17 were later found to be non ESBL producers and 7 were ESBL producers. With

aztreonam 187 isolates were confirmed ESBL producers, 21 were non ESBL producers and 23

were doubtful. Of these 23, 21 isolates were found to be non ESBL producers but 2 were ESBL

producers. Aztreonam showed improved sensitivity (99.4%) and negative predictive value

(97.61%) but reduced specificity (66.12%) and positive predictive value (88.88%). For

cefpodoxime the current criteria resulted in 100% specificity and positive predictive value but a

poorer sensitivity (82.17%) and negative predictive value (2.38%).

DISCUSSION: ESBL producing bacteria have become quite prevalent in Indian hospitals and

community. Different studies from India have quoted variable ESBL detection rates. According

to multicentric SMART study conducted in Asia Pacific region during the year 2007 ESBL rates

in India for E. coli, Klebsiella pneumoniae, and Klebsiella oxytoca were 79.0%, 69.4%, and

100%, respectively13. Another study found ESBL producing E. coli increase from 40 per cent in

2002 to 61 per cent in 2009, with a significant (P<0.05) rise in resistance to cefotaxime (75 to

97%). This study also found the resistance directly related to high antibiotic usage.14 A study

from central India reports the incidence of 69% and 41% ESBL producing isolates of E. coli and

Klebsiella pneumoniae respectively.15 Another study from Vellore in South India found 50.29 %

of inpatients and 45.86 % of outpatients harboring ESBL producers.16 A study from

Northwestern India found ESBL production as 23.83% in E. coli strains and 8.69% in Klebsiella

strains17. We observed that 81.8% of clinical isolates were ESBL producers. From outpatient

clinics the reporting of ESBL producers was 75.38% whereas from inpatient clinics it was

84.34%.

Though ESBLs are prevalent in our hospitals and community they are not specifically

reported by Microbiology labs. For certain reasons there is also a wide variability in prevalence

reporting of ESBLs. The possible factors could be different geographical locations, variable

proficiency levels of microbiology trained technical staff, different antibiotic cut offs being used,

different guidelines being followed (as they differ between different infectious diseases unions

throughout the world) and different techniques being used for ESBL detection.

In developing countries like India it is desirable to incorporate both ESBL detection and

antimicrobial susceptibility testing. Different drugs have been used to detect ESBLs but no

single antibiotic has been perfect at ruling -in or -out an ESBL producer. CLSI has recently

changed the breakpoints of for aztreonam, cefotaxime and ceftazidime for routine testing.

Criteria for cefotaxime to be used for ESBL detection have remained unchanged. With

high sensitivity, specificity and positive predictive value it remains the best drug for ESBL

detection. Ceftazidime has remained almost equally sensitive and specific as old criteria with

improvement in negative predictive value from 59.52% to 80.95% with almost sustained

sensitivity, specificity and positive predictive value. Aztreonam had shown improved sensitivity

ORIGINAL ARTICLE


from 89.9% to 99.4% but reduction in specificity from 91.3% to 66.12%. Its positive predictive

value drops from 98.94% to 88.88% with significant increase in negative predictive value to

97.61%. Therefore, to improve the interpretation aztreonam remains additional preferred agent

besides cefotaxime. Cefpodoxime has shown reduced sensitivity from 96.89% to 82.17% with

sustained improvement in specificity and positive predictive value to 100%. The most striking

observation was a very poor negative predictive value. This will result in need to perform

additional confirmatory tests if used as single agent.

Overall we found that cefotaxime was the single most appropriate antibiotic for

predicting ESBL production. Cefpodoxime can be considered a good agent due to high specificity

and positive predictive value. However, it has a very poor negative predictive value. Therefore,

no single agent can be recommended for predicting ESBL production.

CLSI has so far not given any specific criteria with the use of above mentioned four

antibiotics for detecting ESBLs while performing routine susceptibility testing. At the same time

it recommends that with the current criteria antibiotics should be reported as observed on

susceptibility testing. Earlier it recommended the reporting of all drugs as resistant when it was

observed as resistant to any one drug of the four. These guidelines are based on PK/PD analysis.

More clinical studies are needed to support the current recommendation which is based

on PK/PD measurements of the above mentioned drugs. Therapeutic failure or success of

antibiotic therapy when one drug is sensitive and other resistant in vitro needs to be studied in

parallel with clinical outcome of cases.

To conclude, cefotaxime was found to be the most appropriate drug when used as single

agent with both old as well as current criteria. Adding Aztreonam to the interpretation

improves the detection of ESBL. The current criteria definitely reduce the need for ESBL

screening test due to increased sensitivity and negative predictive value with at least three out

of four antibiotics. However, the need for using more than one drug for predicting ESBL activity

continues to be there as before.

ACKNOWLEDGEMENT: “We are thankful to the Management & Principal, Giansagar Medical

College, Patiala for approving and facilitating the study.”

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4. Tsakris A, Poulou A, Themeli-Digalaki K, Voulgari E, Pittaras T, Sofianou D, Pournaras S,

Petropoulou D. Use of boronic acid disk tests to detect extended spectrum beta-

ORIGINAL ARTICLE


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lactamase-producing Escherichia coli and Klebsiella pneumoniae: risk factors for

infection and impact of resistance on outcomes. Clin Infect Dis 2001; 32: 1162-71.

6. Paterson DA, Bonomo RA. Extended-spectrum b-lactamases: a clinical update. Clin

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7. Jain A, Mondal R. Prevalence & antimicrobial resistance pattern of extended spectrum

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susceptibility testing. 13th Informational Supplement. Wayne, Pennsylvania. CLSI

Document M100-S13: 2003.

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microbiology laboratory, therapy, and infection control. J infect 2003; 47 : 273 -95.


susceptibility testing; 16th Informational Supplement; Wayne, Pennsylvania. CLSI

Document M100-S16; 2006.

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SHV-derived extended spectrum beta-lactamase detection. Clin Microbiol Infect 2002; 8:

715-24.

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extended spectrum beta-lactamases and their prevalence among Escherichia coli and

Klebsiella species in Hong Kong. APIMS 2000; 108: 237-40.

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of high levels of extended-spectrum-ß-lactamase-producing gram-negative bacilli in the

Asia-Pacific region: data from the Study for Monitoring Antimicrobial Resistance Trends

(SMART) program, 2007. Antimicrob Agents Chemother. 2009; 53: 3280–4

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44


susceptibility testing; 21st Informational Supplement; Wayne, Pennsylvania. CLSI


ORIGINAL ARTICLE


PREDICTION OF OUTCOME OF PATIENTS WITH PERFORATION

PERITONITIS ON THE BASIS OF APACHE-II SCORING SYSTEM Dr. S. K. Katiyar, Dr. S. K. Gahlot.

1. Assistant Professor, Department of Surgery, Rama Medical College Hospital & Research Centre, Kanpur.

2. Assistant Professor, Department of Anesthesiology, Major S.D. Singh Memorial Medical College & Hospital,

Farrukhabad.


Dr. S. K. Katiyar

M.S., FIAGES,

675, Singhpur Kanpur-208017,


Ph: 09415044878

ABSTRACT: Peritonitis is the inflammation of the peritoneum and is most commonly due to

localized or generalized infection. It is most common surgical emergency in India. Most common

causes in India are perforated gastric /duodenal ulcer. Any type of peritonitis can be very

serious and life threatening if not evaluated and treated properly. Prognosis in peritonitis is

decisively influenced by the health status of the patients at beginning of treatment. Accurate

prediction of the outcome of the disease can initially be made on the basis of the prognostic

scoring systems, currently several scoring systems are employed.

The APACHE prognostic scoring system for measuring severity of illness in critically ill

patients was developed in 1981 by William A Knaus1. APACHE - II introduced in 1985 was a

simplified modification of original APACHE. APACHE - II was further refined to APACHE - III in

1991. It is important for surgeons to develop at least a rudimentary knowledge of scoring

system for perforation peritonitis, as it will play an increasing role to explain the prognosis of

the disease. Aims & objectives of study are to predict the outcome of the patients with

perforation peritonitis on the basis of APACHE - III scoring system. This study was conducted on

72 patients, admitted to emergency ward of Rama Medical college hospital & Research centre,

Mandhana Kanpur, who were diagnosed as cases of perforation peritonitis from January 2009 –

January 2011. All the patients were evaluated according to APACHE - III scoring system within

24 hours of admission. All the patients admitted in emergency ward initially examined clinically

then required investigations were done. Total APACHE III score range for (0-299). Patients with

lower scores have more favourable prognosis than patients with higher scores. Thus it was

concluded from this study that patients with low scores have favourable outcome as compared

to patients with high scores.

KEYWORDS: Peritonitis, APACHE, Prognosis, Outcome.

INTRODUCTION: Peritonitis is the inflammation of the peritoneum and is most commonly due

to localized or generalized infection. Currently Peritonitis is organized into three divisions

based upon the source and nature of microbial contamination.

1. Primary peritonitis is diffuse bacterial infection without loss of integrity of GI tract, and

is most commonly caused by Streptococcus pneumonia.

ORIGINAL ARTICLE


2. Secondary peritonitis occurs due to acute peritoneal inflammation resulting from GI

tract perforation , infected pancreatic necrosis, perforations of other infected viscera e.g.

hepatic abscess or pyometra and penetrating abdominal injuries.

3. Tertiary peritonitis develops following treatment failure of secondary peritonitis.

Peritonitis is most common surgical emergency in India. Most common causes in India are

perforated gastric /duodenal ulcer followed by appendicitis, GIT perforation due to blunt

trauma, typhoid fever and tuberculosis.

Signs and symptoms of peritonitis are-

1. Severe pain in abdomen and worsened by movement

2. Abdominal distention

3. Board like rigidity

4. Fever and chills

5. Nausea and vomiting

6. Inability to pass flatus & faeces

7. Low BP

8. Limited urine output

Any type of peritonitis can be very serious and life threatening if not evaluated and treated

properly.

Prognosis in peritonitis is decisively influenced by the health status of the patients at

beginning of treatment accurate prediction of the outcome of the disease can initially be made

on the basis of the prognostic scoring systems, currently several scoring systems are employed.


patients was developed in 1981 by William A Knaus1, Statistical detail on the predictive power

of APACHE was published in 1983, which showed that by using estimated equation to forecast

death rates for independent data, APACHE allowed accurate estimates of death rates for groups

of patients.

APACHE - II introduced in 1985 was a simplified modification of original APACHE. The

APACHE - II scores consisted of three parts –

1. 12 acute physiological variables (0-60) points

2. Age (0-6) points

3. Chronic health status (0-5) points

The probability of death can be calculated from the individual APACHE - II total scores (0-71)

points. APACHE - II scores has received far more attention in the literature than any other

prognostic model. APACHE - II was further refined to APACHE - III in 1991, Five new variables –

1. Blood urea nitrogen

2. Urine output

3. Serum bilirubin,

4. Serum albumin

5. Glucose

It is important for surgeons to develop at least a rudimentary knowledge of scoring


the disease.

Aims & objectives of study are to predict the outcome of the patients with perforation

peritonitis on the basis of APACHE - III scoring system.

ORIGINAL ARTICLE


MATERIAL AND METHODS: This study was conducted on 72 patients, admitted to emergency

ward of Rama Medical college hospital & Research centre, Mandhana Kanpur, who were

diagnosed as cases of perforation peritonitis from January 2009 –January 2011. All the patients

were evaluated according to APACHE - III scoring system within 24 hours of admission.

All the patients admitted in emergency ward initially examined clinically then required

investigations were done.

• Plain x-ray abdomen

1. Erect view

2. Supine view

• USG whole abdomen

• Aspiration of peritoneal fluid

The following acute physiological parameters of APACHE III scoring system were assessed and

recorded at the time of admission-

1. Pulse rate

2. Respiratory rate

3. Mean arterial pressure (mm of Hg)

4. Temperature ( 0C)

5. Urine out put ( 24 hr ).

6. Hematocrit (%)

7. White blood cell count

8. Serum sodium (mmol./L)

9. Serum creatinine (mg/dl)

10. Serum albumin (g/dl)

11. Serum bilirubin (mg/dl)

12. Blood urea nitrogen (mg/dl)

13. Blood sugar (mg/dl)

14. Arterial pH

15. Oxygenation (PaO2 in mm of Hg with FiO2 <0.05)

16. Glasgow coma score

These values were scored in accordance to the APACHE III chart scoring for abnormally

high or low range. Zero score represents a normal value. These parameters represent Acute

physiology Score.

(A) Acute Physiology score (0-252)

1. Pulse rate 0 – 17

2. Mean B.P. 0 – 23

3. Temperature 0 – 20

4. Respiratory rate 0 – 18

5. PaO2 /AaDO2 0 - 15 / 0 - 14

6. Hematocrit 0 - 3

7. WBC 0 - 19

8. Creatinine 0 - 10

9. Urine output 0 - 15

10. BUN 0 - 12

11. Sodium 0 - 4

ORIGINAL ARTICLE


12. Albumin 0 - 11

13. Bilirubin 0 - 16

14. Glucose 0 - 9

15. pH 0 - 12

16. GCS 0 – 48

(B) Age points (0-24)

1 < 44 0

1 45 – 59 5

1 60 - 64 11

1 65 – 69 13

1 70 – 74 16

1 75 – 84 17

1 > 85 24

(C) Chronic health points (0-23)

1. None 0

2. Cirrhosis 4

3. Immunosupression 10

4. Leukemia/multiple myeloma 10

5. Metastatic cancer 11

6. Lymphoma 13

7. Hepatic failure 16

8. AIDS 23

APACHE III Score = (A) + (B) +(C)

= 252 +24 + 23

= 299

Total APACHE III score range for (0-299)

RESULTS:

TABLE –I

CAUSES OF PERFORATION PERITONITIS ( n = 72)

SI.

No.

Cause

Patients

Male

Female

1. Gastric / Duodenal

40 55% 35 87.5% 5 12.5%

2. Small bowel

Perforation

15 20.8% 9 60%

6 40%

3. Colon perforation 2 2.7% 1 50%

1 50%

4. Appendicular

Perforation

3 4.1% 2 66%

1 33%

5. Gall bladder

Perforation

2 2.7% 0 0% 2 100%

6. Blunt abdominal

Trauma

8 11% 6 75%

2 2.5%

7. Stab injury

Abdomen

1 1.3% 1 100%

0 0%

ORIGINAL ARTICLE


8. Firearm injury

Abdomen

1 1.3% 1 100% 0 0%

TABLE – II

DISTRIBUTION OF PATIENTS WITH POST OPERATIVE COMPLICATION ACCORDING TO

APACHE - III SCORE

SI. No.

APACHE III

Score

No.of

Cases

Wound

Infection

Septicemia Burst

Abdomen

Fecal

fistula

1.

0 - 30 35 9 1 3 0

2.

31 – 60 25 6 2 5 2

3.

> 60 12 3 5 3 0

TABLE – III

DISTRIBUTION OF PATIENTS WITH OUTCOME ACCORDING TO APACHE – III SCORE

SI.

No.

APACHE

III score

No. of

patients

Survived Expired LAMA Observed

Mortality

1.

0 – 30 35 33 1 1 2.8%

2.

31 – 60 25 22 2 1 8%

3.

>60 12 7 5 0 41.6%

TABLE – IV

COMPARISON OF OBSERVED AND PREDICTED MORTALITY

SI.

No.

APACHE

III score

No. of patients Expired Mortality

Observed

predicted

1. 0 - 30

35 1 2.8% 7.5%

2. 31 – 60 25 2 8%

25.2%

3. > 60 12 5 41.6%

42.6%

DISCUSSION: Perforation peritonitis is a frequently encountered surgical emergency in tropical

countries like India. In majority of cases presentation to hospital is late with well established

generalized peritonitis with purulent / faecal contamination and varying degree of septicemia.

ORIGINAL ARTICLE


Clinical presentation of patients varied according to site of perforation. Abdominal distension

was found in 84% along with vomiting in 50% and constipation in 60% cases. 15% patients

were in shock at the time of admission. Only 64% patients had evidence of pneumoperitoneum

on chest X- ray done in erect posture.

The most elaborate study on APACHE III prognostic system and the risk prediction has

been conducted by knaus et al 2, where they prospectively collected data on 17,440 medical /

surgical ICU patients and found that a 5 points increase in APACHE III score ( range 0 – 299 ) is

independently associated with a statistically significant increase in the relative risk of hospital

death. We categorised patients into 3 groups according to APACHE – III score of 30 points each

and found an increase in the mortality risk as the scores increased from < 30 to > 60.

Perforations of proximal gastrointestinal tract are more common than of distal gastrointestinal

tract as has been noted in earlier studies from India70 , which is in sharp contrast to studies

form developed countries like United States71 and Japan72

Rajender Singh Jhobta et al3 in their study concluded that most common cause of

perforation was perforated dupdenal ulcer (57%) followed by appendicitis (11%) and blunt

trauma (9.1%). These findings are similar to present study in which most common cause of

perforation was gastric / duodenal ulcer (55%), blunt trauma (8%) and appendicitis (3%). A

study done by Mathkere LR et al4 also showed perforation of peptic ulcer was most common

cause of peritonitis (64%). Not only the site but the etiological factors also show a wide

geographical variation. Khanna et al5 from Varanasi studied 204 consecutive patients of

gastrointestinal perforation and found that over half (100 cases ) were due to typhoid. Duodenal

ulcer (58), appendicitis (9), amoebiasis (8) and tuberculosis (4). These figures show the

importance of infection and infestation in third word. At the other end of spectrum, Noon et al6

from Texas studied 430 patients of gastrointestinal perforations and found 2010 cases to be due

to penetrating trauma. This shows the importance of trauma in developed countries.

The mean length of hospital stay was 13 days. For survivors mean length of stay was

17.8 days as comparable to 18 days in the study by Bohnen et al7. The study by Adesunkanmi et

al8 showed an incidence of postoperative complications of 42.4% similar to present study with

an incidence of 54% patients having higher APACHE – III score had higher incidence of

postoperative complications. In this series, the major cause of postoperative morbidity were

wound infection (25%), wound dehiscence (15.2%), septicemia (11%) and faceal fistula (2.7%)

as compared to series by Rajender Singh Jhobta et al9 in their study wound infection rate was

(25%), wound dehiscence (9%) and septicemia (18%). Markgrof R et al51 done a

showed that hospital morality rate was higher than predicted for APACHE III

score > 60 is 41.6% as compared to predicted mortality rate of 42.5%.

CONCLUSION: All the patients were evaluated according to APACHE –III scoring system within

24 hours of admission. Age is a significant factor contributing to survival. Majority of survivors

belong to age group 20- 60 yrs. In this series, male patients were 55 (76%) and female patients

were 17 (23%). Mortality was higher in females (23.5%) as compared to male (7.2%). Most

common cause of perforation peritonitis was gastric / duodenal perforations (55%) followed by

small bowel perforations (20%), blunt abdominal trauma (11%), appendicular perforation

(4%), colon perforation (2.7%), gall bladder perforation (2.7%), stab injury abdomen (1.3%)

and firearm injury abdomen (1.3%). Most of the patients (72%) were managed with primary

repair of perforations. Mean duration of hospital stay is 13 days. Major causes of postoperative

complications were wound infection (25%), wound dehiscence (15%), septicemia (8%) and

ORIGINAL ARTICLE


faecal fistula (2.7%). Patients with lower scores have more favourable prognosis than patients

with higher score. Observed mortality rate was 41.6% in the group with APACHE –III score of

>60, which was comparable to predicted mortality of 42.6%.

Thus it was concluded from this study that patients with low scores have favourable

outcome as compared to patients with high scores. And APACHE III score, as measured before

the treatment of perforation peritonitis, correlates significantly with the outcome of disease

with respect to both morbidity and mortality.

REFERENCES:

I. W.A. Knaus. APACHEs The development of a quality assurance system based on

prognosis: Milestones and personal reflections. Arch Surg 137 (2002), pp. 37 –

41.

II. Kanus W.A., Wagner D.P: Individual patients decision. Chaper 6, Crit Care Med.

17 : S204 – 209.

III. Rajender Singh Jhobta, Ashok Kumar Attri, Robin Kaushik, Rajeev Sharma and

Anupam Jhobta : Spectrum of perforation peritonitis in India – review of 504

consecutive cases. World Journal of Emergency Surgery 2006, 1 : 26.

IV. Mathikere Lingaish Ramachandra, Beellary Jagadesh, Sathees BC Chandra :

Clinical study and management of secondary peritonitis due to perforated hollow

viscous. Arc Med Sci. 2007 ; 3, 1: 61-68.

V. Khanna AK, Mishra MK : Typhoid perforation of the gut. Postgraduate Medical

Journal 1984, 60 : 523.

VI. Noon GP, Beall AC, Jorden GL : clinical eveluation of peritoneal irrigation with

antibiotic solution. Surgery 1967, 67 : 73.

VII. Bohnen JM, Mustard RA, Oxhalm SE, Schouten BD: APACHE II score and

abdominal sepsis. Arch Surg. 1988; 123 : 225 - 229.

VIII. Adesunkanmi ARK, Badmus TA, Fadiora FO, Agbakwuru EK: Generalised

peritonitis secondary to typhoid ileal perforation : Assessment of senerity using

modified APACHE II score. Indian J Surg 2005; 67 : 29 – 33.

IX. MR Capoor, D Nair, MS Chintamani, J Khanna, P Aggarwal, D Bhatnagar : Role of

enteric fever in Ileal perforations: An overstated problem in tropics ? Indian J

Med Microbiol 2008 ; 26 : 54 - 57.

X. A. Horiuchi, y. Watanable, T. Doi, K. Sato, S. Yukumi, M. Yashida, Y. Yamamoto, H.

Sugishita, K. Kawachi : Evaluation of prognostic factors and scoring in colonic

perforation. World J Gastroenterol 2007; 13(23): 3228 – 3231.

XI. A.Y. Ukewenya, Ilyasu Muhammad and P.T. Nmadu: Assessing severity of

intraabdominal infections ; the value of APACHE II scoring system. Nigerian

Journal of Surgical Research, Vol 8, No. 1-2, 2006, pp. 24-29.

ORIGINAL ARTICLE


ALTERATIONS OF SERUM ENZYMES IN PROTEIN ENERGY

MALNUTRITION Dr. A. K. Tadas, Dr. A. N. Jadhao, Dr. S. A. Tadas.

1. Associate Professor, Department of Biochemistry, Government Medical College, Nagpur. 2. Junior Resident, Department of Biochemistry, Government Medical College, Nagpur.

3. Assistant Professor, Department of Physiology, Government Medical College, Nagpur.


Dr. A.K. Tadas,

437 A, Hanuman Nagar,

Nagpur – 440009,


Ph: 09423100663.

ABSTRACT: OBJECTIVES: To study the correlation of serum enzymes (alkaline phosphatase,

aspartate aminotransferase, alanine aminotransferase, amylase) abnormalities in protein

energy malnutrition and to assess their clinical significance. MATERIAL AND METHOD: 30

cases of PEM admitted to the pediatric wards of Government Medical College and Hospital,

Nagpur were studied from 5 Jan 2011 to 15 August 2011. 30 age and sex matched controls were

selected from children of normal weight for age attending OPD or wards. All the clinical details,

along with the relevant clinical history were noted. Venous blood sample was collected for

estimation of alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and

amylase. RESULTS AND OBSERVATIONS: Patients with PEM had reduced serum alkaline

phosphatase. Amylase was found to be reduced in kwashiorkor while it remained unchanged in

marasmus. Increase in aspartate aminotransferase, alanine aminotransferase was found in PEM.

Serum amylase in kwashiorkor is lower than marasmus. DISCUSSION: In patients with PEM, we

found higher levels of AST and ALT ,as there is increased tissue breakdown in PEM to

metabolise the amino acids released by protein catabolism, the process of transamination is

enhanced leading to increased activity of related enzymes AST and ALT. Reduced serum

Alkaline phosphatase may be due to impairment of protein synthesis. Many of these

alternations of enzymes may be due to metabolic readjustment resulting from protein

deficiency.

KEY WORDS: Protein Energy Malnutrition, Enzymes, Alanine Aminotransferase, Aspartate

aminotransferase,Alkaline phosphatase,Amylase.

INTRODUCTION: The World Bank estimates that after Bangladesh, India is ranked 2nd in

number of children suffering from malnutrition (in 1998), where 47% of the children exhibit a

degree of malnutrition. The prevalence of underweight children in India is among the highest in

the world, and is nearly double that of Sub-Saharan Africa with dire consequences for mobility,

mortality, productivity and economic growth1. The UN estimates that 2.1 million Indian children

die before reaching the age of 5 every year – four every minute – mostly from preventable

illnesses such as diarrhoea, typhoid, malaria, measles and pneumonia. Every day, 1,000 Indian

children die because of diarrhoea alone1. According to the 1991 census of India, it has around

150 million children, constituting 17.5% of India's population, who are below the age of 6 years.

Enzymes being proteins, disturbances in their functions and levels in the body are

expected to occur in PEM of any severity 2. Our aim is to determine if any biochemical

ORIGINAL ARTICLE


parameters could be helpful in early diagnosis of PEM and to understand the correlation of

abnormalities of serum enzymes (alkaline phosphatase, aspartate aminotransferase, alanine

aminotransferase, amylase) in protein energy malnutrition and to assess their clinical

significance.

METHODS: The study was carried out in 60 children of six months to five years of age of both

sexes. Group A includes 30 children suffering from various grades of PEM were selected as

experimental group and excludes hepatobiliary and other disease by history, physical

examination and investigations i.e. serum bilirubin and ultrasonography of abdomen.. Group B

includes 30 age and sex matched healthy children. The exclusion criteria for group A was

children suffering from any systemic disease other than PEM, but minor association like

diarrhoea, cough and cold was included in the study .Protocol of study had been accepted by

the Ethical Committee. After taking the informed consent from the mothers and guardians they

were asked a pre-coded questionnaire to collect data related to the study.

By aseptic precautions 5 ml of blood was drawn from patient’s dorsal hand or wrist vein

and collect with a smaller gauge needle (22g or 23g) .Serum was separated immediately by

centrifugation at 3000 rpm for 10 min. Estimation of enzyme was carried out immediately

METHODS: Enzymes were estimated by kinetic method.

ALKALINE PHOSPHATASE BY KIT METHOD8

PRINCIPLE: Alkaline phosphatase cleaves p-nitrophenyl phosphate (p-Npp) into p-nitrophenol

and phosphate. p-nitrophenol is a yellow colour compound in alkaline medium and absorbs

light at 405nm.The rate of increase in absorbance at 405 nm is proportional to alkaline

phosphatase activity in specimen.

p-nitrophenyl phosphate � p-nitrophenol + phosphate

ASPARTATE AMINOTRANSFERASE(AST) BY KIT METHOD9

PRINCIPLE:- L-Asparate + α-ketoglutarate AST Oxaloacetate + L-Glutamate

Oxaloacetate + NADH + H+ MDH L-Malate + NAD+

This conversion of NADH to NAD+ is proportional to the concentration of AST in serum and is

measured at 340 nm, as rate of decrease in absorbance.

ALANINE AMINOTRANSFERASE(ALT) BY KIT METHOD10

PRINCIPLE:-SGPT catalses the transfer of amino group from L-alanine to 2-oxoglutarate with

the formation of pyruvate and L-glutarate.The pyruvate so formed is allowed to react with

NADH to produce L-lactate.The rate of this reactioin is monitored by an indicator reaction

coupled with LDH(lactate dehydrogenase) in the presence of NADH.The oxidation of NADH in

this reaction is measured as a decrease in the absorbance of NADH at340nm,which is

proportional to SGPT activity

L-alanine + 2-oxoglutarate ALT pyruvate + L-glutamate

Pyruvate + NADH LDH L-actetate + NADH

AMYLASE BY KIT METHOD11

PRINCIPLE: Amylase test involves use of a chromogenic substrate Gal G2 –α CNP (2-chloro -4-

nitrophenyl linked with galactosylmaltosid).The direct action of amylase with this substrate

results in the release of more than 90% of 2-chloro -4-nitrophenol, which can be monitored by

ORIGINAL ARTICLE


kinectic assay at 405 nm.The increase in absorbance is directly proportional to the amylase

activity in sample.

Gal G2 –α CNP α- amylase CNP + Gal G2

STATISTICAL ANALYSIS

� Data was analysed using primer software..

� The values were quoted in the form of mean ± standard deviation.

Statistical analysis of the result was done by unpaired student “t”-test.

� The p value (p< 0.05) was used to find the significance.

RESULTS: In our study, the mean values of transaminases (ALT&AST) levels were significantly

increased in PEM than in controls ( table I).

Table I .Comparision of ALP, AST and ALT Between group A (PEM) and Group B (Control)

Enzyme (units) Group A PEM ( N =30 )

.Mean ± SD

Group B CONTROL ( N =30 )

.Mean ± SD

P value

ALP (IU/L)

6.77*** ± 0.23 12.82 ± 0.27

<0.001

AST(IU/L)

73.43*** ± 2.73 31.83 ± 1.16

<0.001

ALT(IU/L)

82.96*** ± 2.11 29.43 ± 0.90

<0.001

The mean values of Alkaline phosphatase leve(ALP) was significantly higher in PEM than

controls shown in table I.

Table II. Comparison of serum amylase between group A (Kwashiorkor) and Group B

(Control)

Kwashiorkor

Enzyme (units) PEM ( N =17) CONTROL ( N =17 ) P value

AMYLASE (U/L) 47.64*** ± 10.97 80.17 ± 9.04 <0.001

The mean values of serum amylase was significantly higher in kwashiorkor than controls ( table

II).

Table III. Comparision of serum amylase between group A (marasmus) and Group B

(Control)

Marasmus


AMYLASE (U/L) 79.30**± 7.66 81± 6.97 >0.05

The mean value of serum amylase was significantly higher in marasmus than controls ( table

III).

ORIGINAL ARTICLE


DISCUSSION: In our study, serum AST and ALT levels in PEM were significantly higher than that

of controls. Similar findings were reported by Kumari R et al 2 that the mean serum values of

aspartate aminotransferase, alanine aminotransferase in patients with PEM were significantly

higher than the controls. Similerly our findings also mimics with study conducted by McLean

AEM 3 in his study he showed that the activity of alanine aminotransferase in serum was

increased, and that greater the value greater was the mortality. Our finding also resembles with

Rao A et al 4 in their study, the aminotransferase elevated. Our study also coinside with

Karmacharya K et al5 .It is suggested that the moderate rise in aminotransferases found in

PEM is not due to damage to the liver. There is increased metabolism of amino acids released

from increased tissue breakdown. Thus process of transamination is enhanced leading to

increased activity of ALT and AST 13.

Serum alkaline phosphatase level in PEM was significantly lowered than controls.

Similar findings were reported by Karmacharya K5,Singh R.S et al7 and Schwartz R6 In PEM,

lowering of serum values of ALP could be explained on the basis of generalized protein

deficiency leading to impaired synthesis. Failure of bone growth may also contribute to the

lowering ALP value14.

Serum amylase in kwashiorkor was lower than marasmus.The low levels of amylase in

serum are accompanied by a reduced output of pancreatic enzymes into the gut, as pancreas is

the first organ to get damaged leading to degeneration and atrophy12.

CONCLUSION: The present study shows that any type of PEM can be associated with alteration

in levels of serum enzymes. Many of these abnormalities are probably due to metabolic

readjustment resulting from PEM. The ultimate practical objective of the enzyme studies which

have been described is to help in the management of PEM, as it is often supposed that this is a

practical problem for which new scientific knowledge is not needed.

Above mentioned view is a superficial. We are faced with the possibility that 'marginal

malnutrition' in childhood may cause a permanent impairment, and yet we cannot recognize or

define this 'marginal malnutrition' with any precision. But this can be done with the enzyme

studies described above.

REFERENCES:

I. 1."World Bank Report". Source: The World Bank (2009).

http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/

0,,contentMDK:20916955~pagePK:146736~piPK:146830~theSitePK:223547,0

0.html. Retrieved 2009-03-13. "World Bank Report on Malnutrition in India"

II. Kumari R., Rao Y.N., Talukdar B. et.al., Serum Enzyme Abnormalities in Protein

Energy Malnutrition, Indian Pedtr 1993;30:469-473.

III. McLean AEM. Heptic Failure in Malnutrition. Lancet 1962,2; 1292-1294.

IV. Rao A., Cherian A., Onuora C.U. Suvarnabai P.C. Serum Amonitransferases and r-

glutamyl transferase in Protein Energy Malnutrition. Trop Geogr Med. 1985,

37:11-14.

V. Karmacharya K, Islam MN, Role of Serum Alanine Aminotransferase Aspartate

Aminotransferase and Alkaline Phosphatase in Early Detection of Protein Energy

ORIGINAL ARTICLE


VI. Malnutrition, J. Nepal Paediatr. Soc. Vol 27, No. 2.

VII. Schwartz R. Alkaline Phosphatase Activity in Kwashiorkor, Journal Clin Path

1956, 9:333

VIII. Singh R.S, Agrawal S.P. & Dikshit S.K., Serum Enzymes in Nutritional Muscular

Wasting. Ind J. Pedtr. 1972, 39:299: 383-388.

IX. 8.Autozyme new alkaline phosphatase enzymatic, manufactured by Accurex

Biomedical private limited, Thane, India. Kit.

X. 9.Autozyme new aspartate aminotransferase enzymatic, manufactured by

Accurex Biomedical private limited, Thane, India. Kit.

XI. Autozyme alanine aminotransferase enzymatic, manufactured by Accurex


XII. Autozyme infinite amylase enzymatic, manufactured by Accurex Biomedical

private limited, Thane, India. Kit.

CASE REPORT


CLEAR CELL MYOEPITHELIAL CARCINOMA OF OROPHARYNX : A CASE

REPORT Dr. Adil S. A. K, Dr. G. Nataraju, Dr. Ravi Kumar T.

1. Assistant Professor, Department of Pathology, Mysore Medical College & Research Institute, Mysore.

2. Professor, Department of Pathology, Mysore Medical College & Research Institute, Mysore.

3. Post Graduate Student, Department of Pathology, Mysore Medical College & Research Institute, Mysore.


Dr. S.A.K. Adil,

# 259, 5th Main,

Bannimantap, ‘C’ Layout, Mysore, E-mail: [email protected], Ph: 09019691259.

ABSTRACT: Myoepitheliomas are rare neoplasms. We present a case of clear cell myoepithelial

carcinoma arising from submucosal minor salivary glands of oropharynx.The significance of this

lesion is that it is a recent entity1,2 and it shares morphological similarities with many

neoplasms that pose a challenge in the diagnosis.

It has to be distinguished from benign myoepitheliomas and neoplasms with

predominantly clear cells like mucoepidermoid carcinoma, clear cell carcinoma, acinic cell

carcinoma, metastatic renal cell carcinoma etc. Imaging studies were unremarkable and

immunohistochemistry was crucial for the diagnosis.

KEYWORDS: Myoepithelial Carcinoma- clear cell variant, minor salivary gland, Oropharynx.

INTRODUCTION: Primary myoepithelial tumors in oral cavity are rare neoplasms.1 Clinically,

they commonly present as painless mass.

Clear cell myoepithelial carcinoma is very rare and it is recently considered as a separate

tumour entity2.Awareness of this lesion is important as the differential diagnosis of this lesion

can be extensive. These neoplasms diagnostically require evidence of myoepithelial

differentiation.

In this report, we present a rare case of clear cell myoepithelial carcinoma arising from

minor salivary glands in oropharynx.

CASE HISTORY: A 75-year-old male, presented with difficulty in swallowing not associated

with pain since one month. No history of known malignant diseases was present. Clinical

examination revealed a proliferative growth of 4x3 cm in the oropharynx on the posterior

pharyngeal wall.X-ray chest and ultrasonographic study of abdomen was found to be normal.

PATHOLOGICAL FINDINGS: Grossly, the specimen consisted of an irregular brown bit of tissue

measuring 1x0.5 cms. Cut section was grey white. The entire tissue was taken for processing.

Microscopically the sections showed a neoplasm comprising of monomorphic population of

clear cells arranged in solid nodules separated by fibrous septa. These cells contain abundant

amount of cytoplasm and bland nucleus, which was central to eccentrically placed.Occasional

cells showed granular eosinophilic cytoplasm.The neoplasm showed invasion into the adjacent

stroma.Necrosis was not evident and mitotic figures were rare. Immunohistochemical studies

CASE REPORT


confirmed the nature of the tumor. The cells showed immunopositivity for cytokeratins, p63, S-

100 and caldesmon.

DISCUSSION: Myoepithelial carcinoma has been recently recognised as a separate tumour

entity1,2.. Clear cell variant of myoepithelial carcinoma is comparatively much rarer than other

variants and only few cases have been reported in literature.

It has a wide age distribution ranging from 14-86yrs1 and is usually encountered in the

parotid gland, nasopharynx, paranasal sinus, nasal cavity and breast. Clinically, they usually

present as painless mass.

The neoplasm exhibits a wide spectrum of cytomorphologic features and the tumour

cells often are spindled, stellate, epithelioid, plasmacytoid (hyaline), or, occasionally, vacuolated

With signet ring like appearance.1,5.

Clear cell tumours are a challenge to diagnosis as variety of lesions have similar

morphological features. Myoepithelial carcinoma can be distinguished from benign

myoepithelial tumours by invasion of the neoplasm into the adjacent stroma1, which was

evident in our case.

The neoplasm showed monomorphic population of clear cells similar to clear cell-rich

salivary gland tumors which include mucoepidermoid carcinoma, pleomorphic adenoma, acinic

cell carcinoma, clear cell carcinoma.

Mucoepidermoid carcinoma consists of mucin containing cells, squamous cells, and

intermediate cells. Pleomorphic adenoma is identified by the distinct chondro/fibromyxoid

stroma and acinic cell carcinoma and clear cell carcinoma stain negatively for myoepithelial

markers.

Imaging studies were undertaken to exclude any renal mass.

Immunohistochemistry plays a critical role in the diagnosis of this tumour.

Cytokeratin expression indicated the epithelial nature of this neoplasm and the

myoepithelial markers p63, caldesmon and S-100 which were positive in our case,confirmed the

diagnosis as myopithelial carcinoma.

Literature search reveals the therapy options for this lesion are conservative excision

with a margin of uninvolved tissue or radiation and chemotherapy which also has resulted in a

significant shrinkage of the tumour.5, 6, 7.

CONCLUSION: Clear cell myoepithelial carcinoma can share morphological features with

various clear cell entities and pathologists should be aware of this lesion.

New immunohistochemical markers for myoepithelial cells which are crucial for

accurate diagnoses of this neoplasm are p63, and caldesmon along with S-100.

CASE REPORT


fig1 Malignant cells with clear cytoplasm

and bland nucleus(H & E,X 40)

Fig 3- Tumor cells showing cytoplasmic

positivity for cytokeratin

immunostain(X 20)

5- Tumor cells showing cytoplasmic

positivity for caldesmon immunostain(X

10)

Fig 2- Malignant cells infiltrating into

stroma(H & E,X 20)

Fig 4- Tumor cells showing nuclear

positivity for p63 immunostain(X 20)

6- Tumor cells showing variable nuclear

and cytoplasmic light intensity stain in

myoepithelial cells for S- 100 (X 40)

REFERENCES:

I. Barnes L, Eveson J. W, Reichart P, and Sidransky D. World Health Organization

Classification of Tumours. Pathology and Genetics of Head and Neck Tumours,

IARC Press, Lyon, France, 2005.p242-243

II. Wang B,Brandwein M, Gordon R, Robinson R, Urken M, Zarbo R J. Primary

Salivary Clear Cell Tumors-A Diagnostic Approach. Arch Pathol Lab Med. 2002;

CASE REPORT


Vol126 (6):676-685

III. Savera A T, Sloman A, Huvos A G, Klimstra D S. Myoepithelial carcinoma of the

salivary glands: a clinicopathologic study of 25 cases. Am J Surg Pathol. 2000; vol

24(6):761-74.

IV. Fletcher.C.D.M. Diagnostic pathology of tumors, 2ndedition, Vol.1, London;

Churchill Livingstone, 2000.p250-251

V. Rosai.J.Rosai and Ackerman's Surgical Pathology.9thedition.Vol 1

India;Elsevier, 2011.p888-89

VI. Ren J,Liu Z,Liu X,Li Y,Zhang X , Li Z,Yang Y,Yang Y,Chen Y,Jiang S Primary

myoepithelial carcinoma of palate. World J Surg Oncol.2011; 9:104

doi10.1186/1477-7819-9-104.

VII. Mills S.E,Carter.D,Greenson.K.J,Oberman.A.H, Reutar.V,Stoler.M.H.Sternbergs

Diagnostic Surgical Pathology.Vol 2.U.S.A.Lippincott Williams &Wilkins.2004.pp 943-944.

ORIGINAL ARTICLE


A COMMUNITY BASED STUDY ON INFANT AND YOUNG FEEDING

PRACTICES IN A RURAL AREA OF KARNATAKA. Dr. Sharvanan Udayar E. Dr. Angadi M. M, Dr. Rekha Udgiri, Dr. Santosh Patil D.

1. Assistant Professor, Department of Community Medicine, PES Institute of Medical Science and Research,

Kuppam. 2. Professor & HOD, Department of Community Medicine, BLDEU’s Shri B. M. Patil Medical College, Bijapur.

3. Professor, Department of Community Medicine, Shri. B. M. Patil Medical College, Bijapur.

4. Assistant Professor, Department of Community Medicine, Shri B. M. Patil Medical College, Bijapur.


Dr. Sharvanan. E,

PES Institute of Medical Science and Research,

Kuppam, Chittoor Dist, Andhra Pradesh-517425,


Ph: 09618292770/08095515455.

ABSTRACT: BACKGROUND: Adequate nutrition during infancy and early childhood is critical

to the development of children’s full human potential. OBJECTIVE: The main objective was to

assess the Infant and Young Child Feeding (IYCF) practices and associated socio demographic

variables among children aged less than two years in rural areas METHODS: A community

based, cross sectional descriptive study was done during Sept 09-Aug 2010 which is the rural

field practice area of Shri. B. M. Patil Medical College SBMPMC. The data was computed and

analyzed using SPSS statistical package (version 13.0). RESULTS: During the study period 264

mothers of infants and young children interviewed with the questionnaire and 159 out of 264

had received prelacteal feeds (males 64 % and females56.3 %). Illiterate mothers (69.7%)

practiced more prelacteal feeding than the literate mothers (54.6%). 36% received exclusive

breast feeding for a period six months. Majority of the illiterate mothers were practicing early

(31.4%) and delayed weaning (32.5%).Poor socioeconomic status, illiteracy, birth spacing and

cultural beliefs had significant effect on infant and young children feeding practices.

CONCLUSIONS: The study re-emphasized the need for conducting continued infant and child

feeding intervention programmes especially for the mother during antenatal and postnatal

checkups.

KEY WORDS: Exclusive breast feeding, Weaning, Infant and Young children.

INTRODUCTION: Adequate nutrition during infancy and early childhood is critical to the

development of children’s full human potential. Poor Infant and Young Child Feeding (IYCF)

practices, coupled with high rates of infectious diseases, are the proximate causes of

malnutrition during the first two years of life. The second half of an infant’s first year is an

especially vulnerable time, when breast milk alone is no longer sufficient to meet his or her

nutritional requirements and complementary feeding should start1. Of the 19 million infants in

the developing world who have low birth weight (< 2,500 grams), 8.3 million are in India. This

means that approximately 43 per cent of all the world’s infants who are born with a low birth

weight are born in India. Malnutrition is an underlying cause in up to 50 per cent of all under-

five deaths. About 55 million, or one-third, of the world’s underweight children under age five

live in India.

ORIGINAL ARTICLE


Children need complementary foods in addition to breast milk from the age of six

months. In India, common problems include the provision of poor quality complementary foods,

insufficient amounts of complementary foods, insufficient breastfeeding, detrimental feeding

practices, and contamination of complementary food and feeding utensils. In addition, if

complementary foods are given too early or too frequently, they displace breast milk, which is of

higher nutritional value than other foods. Various social, economic and cultural factors in rural

areas will also influence the IYCF practices2.

The timely introduction of complementary feeding can prevent almost 6% of under-five

mortality. It was estimated that, if 90% of infants are covered with a package of intervention to

protect, promote, and support the optimal IYCF practices, almost one-fifth of overall under-five

mortality can be averted. The World Health Organization (WHO) and other various

international agencies recommended exclusive breastfeeding for the first six months of life with

early initiation and continuation of breastfeeding for two years or more together with

nutritionally-adequate, safe, age-appropriate complementary feeding starting at six months3.

With this background, the present study was undertaken to assess the IYCF practices and

associated socio demographic variables among children aged less than two years in rural areas

of Bijapur, District, Karnataka.

METHODS: A community-based, cross-sectional descriptive study was conducted in Shivanagi

during Sept 09-Aug 2010 which is the rural field practice area of Shri B.M.Patil Medical College,

situated 27km away from Bijapur and has population of 7060.4A house to house survey was

done and mothers with children aged less than two years were included in the study. Those who

were not permanent residents and not willing to participate were excluded and Modified

B.G.Prasad socioeconomic classification5 was used classifying socioeconomic status.

ETHICS: The Institutional Ethics Committee of the Shri B.M.Patil Medical College approved the

study.

STATISTICS: Analysis was done using the SPSS software (version 13.0), Simple proportions

were calculated for each IYCF practice. The differences in the feeding practices and

sociodemographic variables if any were noted using chi-square test.

RESULTS: In the present study 264 infants and young children up to 2 years were studied of

whom 136 were males and 128 were females.159 out of 264 had received prelacteal feeds

(males 64 % and females 56.3%).Illiterate mothers (69.7%) practiced more prelacteal feeding

than the literate mothers (54.6%) and the observed difference according to education of the

mother was not statistically significant in our study (p=0.015). 53.3% of nuclear families

were giving more prelacteal than three generation (62%) and joint family (63%) (Table1).

However the difference in type of family and prelacteal practices was not

statistically significant in our study (p=0.38). The study also found that the practice of prelacteal

feeding was more prevalent in lower socioeconomic group than in higher class and this

difference was found to be statistically significant(P<0.001).

Only 36% received exclusive breast feeding for a period six months and less than half of

the infants and young children belonged to Hindu and Muslim families received exclusive breast

feeding, literate mothers (41.9%) were more aware about it as compared to illiterate

mothers(26.3%).Statistically significant difference was observed according to socioeconomic

ORIGINAL ARTICLE


status and exclusive breastfeeding (p<0.001).Similarly with the birth interval (p=0.07) (Table

2).

With respect to weaning, majority of the illiterate mothers were practicing early

(31.4%) and delayed weaning (32.5%).Only literate mothers (56.9%) initiated it at the age of 6

months as per the WHO guidelines5. Poor socioeconomic status (p=0.001) and birth interval

(p=0.002) also had an effect on initiation of weaning.

DISCUSSION: In our study more than half of the infants and young children had received

prelacteal feeds and it was high in children with illiterate mothers belonging to poor

socioeconomic status and most important reason for this was family customs and relatives

advice. Similar findings were observed in a study by Devang raval6 (2001) in which 61.9% of

infants had received prelacteal feeds. According to NFHS-3 report7 (2005-2006) 57% newborns

received prelacteal feeds (57.3% male and 57% female) and 67.5% of the illiterate mothers

gave prelacteal feeds. Saurav et al8(2003) also reported similar findings.

Exclusive breastfeeding by mothers as derived from our study is much lower than the

values reported by Devang raval6, Chatterjee Saurav et al8 and however this when compared to

study by Vyas Shaili et al 9 in rural areas of Uttarakhand was much higher. This may be because

of the low literacy levels and customs and many of the mothers gave reasons as insufficient

breast milk and could not able to feed during illness.

Majority of the mothers practiced early and delayed weaning and this trend observed

higher among illiterate mothers. The findings from the present study clearly highlights the

importance of educating the women on infant and child feeding practices and the knowledge

may be imparted even at the school or college level. The Government of India recommends that

children should be exclusively breastfed for the first six months of life (that is, they should be

given only breast milk with no other liquids or food). There are many reasons for

recommending exclusive breastfeeding for the first six months. First, breast milk is nutritionally

superior to other liquids and solid foods. Second, when a child consumes other liquids and solid

foods, the intake of breast milk is reduced, which in turn decreases the mother’s supply of milk.

Third, feeding young infants liquids and solid foods increases their exposure to pathogens,

putting them at greater risk of contracting diarrhoeal disease. There is also need for conducting

infant and child feeding intervention programmes especially for the mother during antenatal

and postnatal checkups.

Practices such as early or delayed inititation of weaning should be discouraged and

women organizations need to be associated for active dissemination of information on infant

and child feeding practices to educationally deprived women.

ORIGINAL ARTICLE


Table 1: Distribution of Prelacteal feed practices in infants and young children (n=264).

Parameters

Prelacteal

feed given n=159

percent (60.3%)

Prelacteal

feed not given

n=105 percent

(30.7%)

Chi

square

Gender

Male136 (51.8)

Female128 (48.2)

87 (64.0)

72 (56.3)

49(36.0)

56(43.7)

Chi

sq.:1.61

p=0.2

Religion

Hindu 236 (89.7)

Muslim28 (10.3)

147(62.3)

12(43.0)

89(37.7)

16(57.0)

Chi

sq.:3.99

p=0.04

Education

of Mother

Illiterate99 (37.5)

Literate165 (62.5)

57(69.7)

82(54.6)

42(30.3)

83(45.4)

Chi sq.:

1.6

p>0.5

Type of Family

Nuclear 62 (23.5)

3gene 105 (40.0)

Joint 97 (36.5)

33(53.0)

65(62.0)

61(63.0)

29(47.0)

40(38.0)

36(37.0)

Chi sq.:

1.68

p=0.43

Socio

Economical class

Class I 7 (2.90)

Class II 7 (2.9)

Class III 66 (25.10)

Class IV 89 (33.75)

Class V 95 (35.40)

2(28.6)

6(85.8)

23(34.9)

63(70.8)

65(68.4)

5(71.4)

1(14.2)

43(65.1)

26.(29.2)

30(31.6)

Chi

sq: 24.64

p<0.001

ORIGINAL ARTICLE


Table 2: Distribution of exclusivebreastfeeding practices in infants and young

children (n=264).

Parameters

EBF given

n=95 percent

(36.0%)

EBF not given

n=169 percent

(64.0%)

Chi square

Gender

Male136 (51.8)

Female128 (48.2)

40(29.4)

55(42.3)

96(70.6)

73(57.7)

Chi sq.:5.4

p=0.02

Religion

Hindu 236 (89.7)

Muslim28 (10.3)

87(36.9)

8(28.6)

149(63.1)

20(71.4)

Chi sq.:0.68

p=0.38

Education

of Mother

Illiterate99 (37.5)

Literate165 (62.5)

29(26.3)

66(41.9)

70(73.7)

99(58.1)

Chi sq.: 3.06

P=0.07

Type of Family

Nuclear 62 (23.5)

3gene 105 (40.0)

Joint 97 (36.5)

24(38.7)

32(30.5)

39(40.2)

38(61.3)

73(69.5)

58(59.8)

Chi sq.: 2.33

p=0.31

Socio

Economical class

Class I 7 (2.90)

Class II 7 (2.9)


Class IV 89 (33.75)

Class V 95 (35.40)

2(28.5)

5(71.4)

38 (57.6)

23 (25.9)

29(30.6)

5(71.5)

2(28.6)

28(42.4)

66(74.1)

66(69.4)

Chi sq: 19.9

p<0.001

Birth interval

<1yr 45 (17.3)

1-2 yr 143(54.3)

>3yrs 76(28.4)

28(62.2)

51(35.7)

34(44.8)

17(37.8)

92(64.3)

42(55.2)

Chi sq: 10.0

p=0.007

ORIGINAL ARTICLE


REFERENCES:

I. Improving Complementary Feeding Practices: A Review of Evidence from South Asia .

Evidence review series march 2008; Available from

http://www.intrahealth.org/~intrahea/files/media/maternal-neonatal-and-childrens-

healthfamily-planning/ER_Brief_CF%202.pdf.

II. Cooperative for Assistance and Relief Everywhere(CARE). Infant and Young Child

Feeding Practices. Collecting and Using Data: A Step-by-Step Guide.2010.Available from

http://windowofopp.files.wordpress.com/2010/12/final-iycf-guide-iycf-practices.pdf.

III. Apurba S, Dipta KM, Tanmay KP, Asit BS, Nirmal KM, Akhil BB. Infant and Young Child

feeding Practices in Bankura District, West Bengal, India. J Health Popul Nutr

2010Jun;28(3):294-299.

IV. Govt.of India (2001).Census of India 2001, Provisional Population Totals, Paper-1 of

2001.

V. Insurance worker volume XLVII, No.12, Dec 2008 and Insurance worker volume XLVIII

No. 10, Oct 2009.

VI. World Health Organization (WHO). Maternal, newborn, child and adolescent health:

Indicators for assessing infant and young child feeding practices – part I: definition;

2008.

Availablefromhttp://www.who.int/maternaments/9789241596664/en/l_child_adolesc

ent/docu.Accessed latest on 28-08-2012.

VII. Devang R, Jankar DV, Singh MP. A study of breast feeding practices among infants

living in slums of Bhavnagar city, Gujarat, India. healthline Jul-Dec 2011; 2(2):73-82.

VIII. National Family Health Survey 2005-2006 (NFHS-3). Mumbai: International Institute of

Population Sciences.Available from: http://www.nfhsindia.org.

IX. Chatterjee Saurav , Saha Sandhita: A study on KP of mothers regarding infant feeding

and nutritional status of Under 5 children attending immunization clinic of Medical

college 2008.Avalable from http://www.ispub.com/journal/the-internet-journal-of-

nutrition-and-wellness/archives.html.Accessed latest on 29-08-2012.

X. Vyas S, Sharma P, Kandpal S D, Semwal J, Srivastava A, Nautiyal V. A community based

study on breastfeeding practices in a rural area of Uttarakhand. National J Commuity

Med Apr-jun2012;3(2):283-287.

ORIGINAL ARTICLE


ATHEROGENIC INDEX OF PLASMA IN MYOCARDIAL INFARCTION IN

RURAL POPULATION OF MARATHWADA REGION

Dr. Ganesh D Ghuge, Dr. Rahul Zine.

1. Associate Professor, Department of Biochemistry, Rural Medical College, Loni, Ahmednagar, Maharashtra.

2. Assistant Professor, Department of Biochemistry, Indian Institute of Medical Sciences and Research, Jalna,

Maharashtra.


Dr. Ganesh D Ghuge, Associate Professor, Department of Biochemistry,

Rural Medical College, Loni, Taluka- Rahata,

District- Ahmednagar, Maharashtra 413736.


Ph: 91-9850694964, 91-7588846300.

ABSTRACT: BACKGROUND: Extensive research work by mankind over several decades has

concluded that cure as well as the treatment of CAD is very difficult hence attention towards

prevention of such ischemic events is of utmost importance. METHODS: The present study was

conducted with an aim to study the Atherogenic Index and various lipid levels of plasma in

Acute Myocardial Infarction (AMI) and to compare lipid profile and Atherogenic Index of plasma

in the patients of Myocardial Infarction with healthy controls. RESULTS: A total of 150acute

Myocardial Infarction (AMI) patients for the study were selected from the Medicine Ward, ICU,

and OPD. Normal healthy person of matched number, age and sex of the study group were used

as control. Serum cholesterol, TGVLDLc, LDLc and AIP were significantly higher in AMI patients

as compared. CONCLUSION: Atherogenic Index of plasma is very useful research tool to assess

the effect of risk factors pertaining cardiovascular diseases.

KEYWORDS: Atherogenic index, lipid profile, myocardial infarction, triglycerides.

INTRODUCTION: Coronary Artery diseases (CAD) are the most frequent cause of death in

developing country like India (1). Extensive research work by mankind over several decades

has concluded that cure as well as the treatment of CAD is very difficult hence attention towards

prevention of such ischemic events is of utmost importance. The famous Framingham study

firmly established cholesterol as an important risk factor for CAD and now we have a clear

perception of the inter-relationship between serum lipids, Atherosclerosis & Ischemic Heart

Disease (IHD) (2). Therefore research laboratories have made conflicting claims to the helpful

serum lipid level predictor for detecting and managing IHD with emphasis on the measurement

of levels of serum cholesterol, lipoproteins and Triglycerides. The Atherogenic index of plasma

defined as log (TG / HDLc) has recently been proposed as a marker of plasma atherogenicity

(3). It is increased in people at higher risk of CAD .Tan et al used the AIP, calculated as log (TG /

HDLc) with TG and HDLc expressed in molar concentration(4). Value of AIP corresponds closely

to those of esterification rate in apo-B-lipoprotein – depleted plasma and to lipoprotein particle

size. AIP reflects the delicate metabolic interactions within the whole lipoprotein complex (3).

The present study was conducted with an aim to study the Atherogenic Index and various lipid

levels of plasma in Acute Myocardial Infarction (AMI) and to compare lipid Profile and

Atherogenic Index of plasma in the patients of Myocardial Infarction with healthy controls.

ORIGINAL ARTICLE


MATERIALS AND METHODS: The present study was conducted in Department of

Biochemistry, S R T R Medical College Ambejogai, Maharashtra, India. A total of 150 Acute



as control.

COLLECTION OF SAMPLE: The fasting blood sample was obtained in plain bulb from the study

group and control group from antecubital vein with all aseptic precaution.

ESTIMATION OF LIPID PROFILE: The blood samples collected from the study and control

group were estimated for lipid profile by a routine biochemical Kits methods using ERBA Chem

5+ Semi-automated machine. Estimation of Serum Cholesterol was done by (Enzymatic)

Dynamic extended stability CHOD – PAP method, End point with Lipid clearing agent. Serum

HDL cholesterol was estimated by Phosphotungstic Acid Method, End Point. Estimation of

Serum Triglyceride was done by Dynamic extended stability End point with Lipid clearing agent,

Trinder Method. VLDLc and LDLc are calculated parameters and they calculated using

Friedwald’s Formula, TG/5 where TG is less than 400 mg/dl, LDLc was calculated as : TC -

(HDLc + VLDLc) these two are calculated parameters. AIP calculated as log (TG/HDLc) when

expressed in molar concentration. Conversion factor for Cholesterol –mg% X 0.026 = mmol/lt.

Conversion factor for Triglyceride - mg% X 0.0113 = mmol/lt (Glycerol phosphate oxidase).

RESULT: As shown in table 1 Serum cholesterol, TG, VLDLc, LDLc and AIP were significantly

higher in AMI patients as compared to controls while HDLc was significantly lower in AMI

patients as compared to controls.

DISCUSSION: The coronary atherosclerosis is the major cause of IHD, which is chief single cause

of death both in developed and developing countries. Early diagnosis of coronary

atherosclerosis can reduce the mortality and morbidity. There are several biochemical ratios

indicating the risk of atherosclerosis. Gaziano et al reported that the ratio of triglyceride to

HDLc was a strong predictor of MI (5). As the search for the risk factor responsible for the CAD

goes on many ratio of the lipid have been described as better predictor of CAD. These ratios are

total cholesterol / HDLc, LDLc / HDLc and HDLc2 / HDLc3. Result of the Lipid Research Clinics

Prevalence Study showed that the ratio of Total Cholesterol / HDLc was better predictor of CAD

(6). Tan et al found AIP to be a suitable and statically reliable for evaluating the atherogenicity

index (4). Although an independent, inverse relationship between HDLc and cardiovascular risk

has been demonstrated beyond any doubt. TG has also been proposed to be a major

determinate of cholesterol esterification / Transfer and HDL remodeling in human plasma (7).

Fraction etherification rate of cholesterol and ratio of TG / HDLc are powerful predictor of

positive finding on coronary angiography (8) .The plasma parameter of log ( TG / HDLc ) as an

atherogenic index has correlation with lipoprotein particle size and esterification rate in apo B –

lipoprotein depleted plasma ( FER HDL ) (5). There is a high significant association between

FER HDL and AIP, suggesting that AIP reflects the delicate metabolic interaction with in the

whole lipoprotein complex (9). AIP provides information about the atherogenicity of plasma.

Application of AIP to data from earlier trials may offer new insights. The authors, Tan et al

should be complimented for evaluating this Atherogenic Index to test it’s significance and

statistical reliability in a large study with 1669 Diabetic patients (10). Nwagha and Ikekpeazy

also reported AI of plasma as an useful predictor of cardiovascular risk among postmenopausal

ORIGINAL ARTICLE


women in Enugu, Nigeria (11). They found AIP to be a suitable reliable. AIP may be an

important tool for analyzing the results of clinical trials. The association of TGs and HDLc in this

simple ratio theoretically reflects the balance risk and protective lipoprotein forces, and both

TGs and HDLc are widely measured and available (12, 13).

CONCLUSION: Atherogenic Index of plasma can now easily measured in humans and is very

useful research tool to assess the effect of risk factors. Although AIP assumes to play a

predominant role in evaluation of AMI and developing coronary atherosclerosis, more research

is needed on measurement of AIP to be used as clinically useful tool.

Table.1 Lipid profile and Atherogenic index of plasma in patients with AMI and controls.

Parameter Healthy Control AMI Cases

Total cholesterol 145.24 ± 25.42* 232.04 ± 65.23*

Triglyceride 123.94 ± 39.38 * 206.44 ± 101.10 *

HDLc 51.12 ± 8.45* 30.50 ± 8.01*

VLDLc 24.67 ± 8.11* 40.08 ± 20.36*

LDLc 91.54 ± 26.41* 161.10 ± 61.00*

AIP 0.470 ± 0.308* 0.24 0.30*

* indicates p < 0.05.

ƢƢƢƢ All values were expressed in mg/dl ± SD Number of subjects is 50. While calculating AIP

values were expressed in mmol/lt.

REFERENCES:

1. Kundu S C, Bhattachajee T D: Profile in Myocardial Infarction among the rail road

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detection, evaluation and treatment of high blood cholesterol in adults. Arch. Inter. Med.

1988; 148: 36-69.

3. Dobiáová M, Frohlich J. The plasma parameter log (TG/HDL-C) as an atherogenic index:

correlation with lipoprotein particle size and esterification rate in apoB-lipoprotein-

depleted plasma (FERHDL). Clin Biochem 2001; 34:583-588.

4. Tan MH, Johns D, Glazer NB. Pioglitazone reduces atherogenic index of plasma in

patients with type 2 diabetes. Clin Chem 2004; 50:1184-1188.

5. Gaziano JM, Hennekens CH, O’Donnell CJ, Breslow JL, Buring JE. Fasting triglycerides,

high-density lipoprotein, and risk of myocardial infarction. Circulation 1997; 96:2520-

2525.

6. Dobiáová M, Stíbrná J, Pritchard PH, Frohlich J. Cholesterol esterification rate in plasma

depleted of very low and low density lipoproteins is controlled by the proportion of

HDL2 and HDL3 subclasses: study in hypertensive and normal middle-aged and

septuagenarian men. J Lipid Res 1992; 33: 1411-1418.

ORIGINAL ARTICLE


7. Frohlich J, Dobiáová M. Fractional esterification rate of cholesterol and ratio of

triglycerides to HDL-cholesterol are powerful predictors of positive findings on

coronary angiography. Clin Chem 2003; 49:1873-1880.

8. Dobiáová M, Ralová K, Rauchová H, Vohnout B, Ptáková K, Frohlich J. Atherogenic

lipoprotein profile in families with and without history of early myocardial infarction;

fractional esterification rate of cholesterol in plasma depleted of apoB lipoproteins

(FERHDL) and logarithmically transformed ratio of triglycerides to HDL-cholesterol.

Physiol Res 2001; 50: 1-8.

9. Dobiáová M. Atherogenic Index of Plasma [Log (Triglycerides/HDL-Cholesterol)]:

Theoretical and Practical Implications. Clin. Chem 2004; 50: 1113-1115.

10. Lehto S, Ronnemaa T, Pyorala K, Laakso M. Cardiovascular risk factors clustering with

endogenous hyperinsulinaemia predict death from coronary heart disease in patients

with type II diabetes. Diabetologia 2000; 43:148-155.

11. Nwagha UI, Ikekpeazy EJ. Atherogenic index of plasma as useful predictor of

cardiovascular risk among postmenopausal women in Enugu, Nigeria. Afr. Health Sci

2010; 10(3):248-252.

12. Hokanson JE, Austin MA. Plasma triglyceride level is a risk factor to cardiovascular

disease independent of high-density lipoprotein cholesterol level: a meta-analysis of

population based prospective studies. J Cardiovasc Risk 1996; 3:213-219.

13. Guérin M, Le Goff W, Lassel TS, Van Tol A, Steiner G, Chapman MJ. Proatherogenic role of

elevated CE transfer from HDL to VLDL1 and dense LDL in type 2 diabetes. Arterioscler

Thromb Vasc Biol 2001; 21:282-289.

ORIGINAL ARTICLE


SPECIES DISTRIBUTION AND ANTIFUNGAL SUSCEPTIBILITY PROFILE

OF CANDIDA SPECIES ISOLATED FROM BLOOD STREAM INFECTIONS Sachin C. Deorukhkar, Dr. Santosh Saini.

1. Assistant Professor and PhD Student, Department of Microbiology, Rural Medical College, Loni,

Ahmednagar, Maharashtra.

2. Professor and Head, and PhD guide, Department of Microbiology, Rural Medical College, Maharashtra.


Sachin C Deorukhkar,

Assistant Professor, Department of Microbiology,




Ph: 91-9545181908, 91-9850775564.

ABSTRACT: BACKGROUND: Candidemia remains as one of the major cause of morbidity and

mortality in health care setting. Over the last two decades, the proportion of blood stream

infection (BSI) due to non-albicans Candida (NAC) species has increased. Several NAC spp. are

inherently resistant to commonly used antifungal drugs. The increased isolation rates of NAC

spp. and a gradual shift in the antifungal susceptibility profile underlines the need of early and

accurate diagnosis of infecting Candida spp. along with antifungal susceptibility testing for

selecting the most appropriate antifungal agent for therapy. AIM: The Aim of the present study

was to investigate the distribution pattern of Candida spp. isolated from candidemia patients

and evaluate its antifungal susceptibility pattern. SETTING AND DESIGN: The present study

was conducted in the department of Microbiology for a period of six years (January 2006 to

December 2011) which included, 194 Candida spp. isolated from the cases of candidemia.

MATERIALS AND METHODS: Candida isolates were speciated by conventional techniques and

HiCandida identification kit. Antifungal susceptibility test was performed using two disc

diffusion methods. Clinical details and risk factors were recorded and analyzed. RESULTS AND

CONCLUSIONS: Isolation of NAC spp. was significantly higher than Candida albicans. The most

important risk factor associated with candidemia was intensive care unit stay, followed by

diabetes and HIV infection. Azole resistance was more in NAC species as compared to C.

albicans. The early and accurate diagnosis of infecting Candida spp. along with antifungal

susceptibility testing plays a pivotal role in preventing morbidity and mortality associated with

Candida BSI. Disc diffusion technique for antifungal susceptibility using glucose methylene blue

Mueller- Hinton (GM-MH) agar was found to be simple, cost effective and sufficiently accurate

for the routine testing of antifungal susceptibility of Candida spp. in resource constrained

microbiology laboratories.

KEY WORDS: Candidemia, Candida albicans, NAC species, antifungal resistance

INTRODUCTION: Candida blood stream infection (BSI) has become a major problem in tertiary

care hospital worldwide 1. Despite some improvement in fungal BSI diagnosis during recent

years, diagnosis of candidemia remains difficult 2. Candidemia has been associated with many

risk factors like long- term hospitalization, antibiotic therapy, use of intravascular catheters, and

underlying diseases like diabetes and malignancy. Although Candida albicans continues to be

ORIGINAL ARTICLE


the most common cause of Candidal BSI, the epidemiology of species causing candidemia is

changing. Recent longitudinal studies have detected an increase proportion of BSI by non-

albicans Candida (NAC) species 3, 4.

Importantly many NAC spp. have decreased susceptibility to antifungal agents.

Specifically C. krusei and C. glabrata demonstrate decreased susceptibility to fluconazole 5. The

changing epidemiology of Candida BSI has generated concern about the emergence of azole

drug resistance and its clinical relevance.

Clinicians now depend on identification of Candida to the species level in order to

optimize the selection of antifungal agents allowing them to provide the best possible patient

care 6. Therefore there is a need for continuous surveillance to monitor trends in incidence,

species distribution and antifungal drug susceptibility profiles of Candida BSI.

The Clinical and Laboratory Standards Institute (CLSI) (previously National Committee

for Clinical Laboratory Standards (NCCLS)) after collaborative efforts with various laboratories

has recommended an in-vitro standardized macro broth dilution antifungal susceptibility

testing technique for yeasts 7. CLSI has recommended alternative techniques like ATB fungus,

API, Vitek and disc diffusion to address issues in different laboratories. These methodologies

give reproducible results.8 Disc diffusion procedure appears to be generally acceptable as a

simple, in house standardized procedure for antifungal susceptibility of yeasts 9.

The present study was carried out in a rural tertiary care hospital with an aim to

determine the distribution of Candida spp. isolated from the cases of candidemia and to

compare the efficacy of yeast nitrogen base with glucose (YNBG) media and glucose methylene

blue Mueller- Hinton (GM-MH) agar for the antifungal susceptibility testing of Candida isolates.

MATERIALS AND METHODS: The present study is part of a PhD thesis and was approved by

the Institutional Ethics Committee (Registration No.FN.32/2010). A total 194 Candida spp.

isolated from the blood of patients was included in the study.

The culture was considered true candidemia only when Candida spp. was isolated from

at least two blood culture samples or from a clinically significant single blood culture sample

among hospitalized patients 10. Patient's demographic features such as age, sex, ward, date of

admission, underlying illness, various associated risk factors like presence of urinary catheter,

respiratory ventilation, central line insertion, duration of antibiotic therapy and antifungal

prophylaxis if any, were recorded and analyzed.

SPECIES IDENTIFICATION: Speciation of Candida isolates was done by conventional

techniques and colony colour on Chrom agar 11 Hicandida identification kit (Himedia

Laboratories Pvt. Ltd Mumbai, India) was used for the identification of isolates which could not

be identified by conventional techniques.

ANTIFUNGAL AGENTS: The antifungal agents used were amphotericin B (10 µg), fluconazole

(25 µg), and itraconazole (10µg). Antifungal discs were procured from Himedia Laboratories

Pvt. Ltd Mumbai, India.

ANTIFUNGAL SUSCEPTIBILITY TESTS:

Antifungal susceptibility tests were performed using 2 disc diffusion methods.

1. Yeast Nitrogen base with glucose (YNBG) media.

2. Glucose methylene blue Mueller- Hinton (GM-MH) agar.

ORIGINAL ARTICLE


ANTIFUNGAL SUSCEPTIBITY TESTING USING YNBG MEDIA:9 YNBG media was prepared

using yeast nitrogen base 10g and glucose 10g, dissolved in 100ml of distilled water and filter

sterilized. Susceptibility test against azoles was performed with addition of 1.5% L-asparagine

to YNBG media. YNBG media mixed with 2% sterile Difco agar (Difco, USA) was poured into 9cm

diameter Petri dishes. Inoculum size of 106 Candida cells/ml was inoculated in one half with the

control strain (C. kefyr Y/16). The cell density was spectrophotometrically adjusted to 0.5

McFarland standard. Inoculation was done by swabbing from the edge of the plate to the centre

using a sterile swab. Discs were placed in the centre of the control and test organism with the

help of sterile forceps. After incubation of the plate at 370C for 48 hours the diameter of

inhibition was read.

The result of the disc diffusion method was interpreted according to the following

criteria: test strain was considered sensitive when the zone diameter was ≥ 80% of the zone

diameter of control strain; intermediate when the zone diameter was < 80% but there was

visible zone of the inhibition; resistant, when there was no zone of inhibition.

2. BY USING GM-MH AGAR: Mueller-Hinton (MH) agar was solidified after addition of 2%

glucose and 0.5ug of methylene blue. Inoculum was prepared by picking five distinct colonies of

approximately 1mm from 24 hours old culture grown on Sabouraud's dextrose agar (SDA).

Colonies were suspended in 5ml of sterile 0.85% saline. This suspension was vortexed to adjust

the turbidity yielding 1x106-5x106 cells/ml and streaked on the entire surface of GM-MH agar.

The antifungal disc was placed 24mm apart from each other. The plates were incubated at 37oC

for 24 hours. If insufficient growth was observed after 24 hours the plates were read after 48

hours. Zone diameters were interpreted as per the approved CLSI /NCCLS (M44-A) guidelines 12. The quality control test was performed by using C. parapsilosis (ATCC 22019), C. krusei

(ATCC 6258), and C. albicans (ATCC 90028).

RESULTS: Between January 2006 to December 2011, out of 4984 blood culture samples

processed in Department of Microbiology, Candida spp. were isolated from the blood culture of

194 patients. Male predominance was noted in our study (n=126/194) 64.9%. Candidemia was

common in more than 50 years age group in males (n=58/126) 46.03%, whereas in females it

was with 0-10 years age group (n=22/68) 32.35% (Figure.1). The most important risk factor

associated with candidemia was ICU stay (49\194) 25.25%, followed by diabetes (40\194)

20.61% and HIV infection (38\194) 19.58% (Figure.2). In this study predominant isolates were

NAC spp. C. albicans was isolated from 78 (40.2%) cases. Among the NAC species, C. tropicalis, C.

glabrata and C. krusei were the major isolates. (Figure.3). All 194 isolates recovered were tested

for antifungal susceptibility by using YNGB medium and GM-MH agar. Their pattern of

resistance is summarized in Table 1. NAC spp. showed more resistance to antifungal agents as

compared to C. albicans.

DISCUSSION: In the last twenty years, various factors like the AIDS epidemic, increase in the

number immunosuppressive therapy recipients and the use of long term antibiotic therapy

have altered the epidemiology of invasive mycoses in general and of candidemia in particular.

Candida spp. is the fourth most common pathogens isolated from the blood of hospitalized

patients13. More recently, NAC spp. has been recovered with increasing frequency. Linked with

this is a recent increase in treatment failure of these infections to standard antifungal therapy,

largely due to the emergence of drug resistance in fungi.

ORIGINAL ARTICLE


In our study the Candida spp. were isolated from 3.9% of total blood cultures processed

in the Department of Microbiology. Lot of variation in the prevalence and incidence of

candidemia have been reported from India. Kumar et al14 from South India reported an

incidence rate of 5.7% for candidemia among children with onco-haematological malignancies.

Verma et al 15 reported an incidence rate of 1.61% whereas, Xess et al 16 found a prevalence rate

of 6% for candidemia. A study by Sahni et al 17 from Maulana Azad Medical College, New Delhi,

found an incidence rate of 6.9% for Candida spp.

The age and sex distribution of the patients in our study correlates with the observation

of other researchers like Verma et al 15 and Hajjeh et al 18. The importance of risk factors analysis

cannot be over emphasized for infection like candidemia so that preventive measures and

prophylactic therapy can be initiated for patients at risk. Many studies have established

independent risk factors for candidemia on the basis of multivariate analyses. The ICU stay

followed by diabetes and HIV infection was the major risk factors responsible for candidemia in

our study. This was also an observation of other researchers like, Shivaprakasha et al 10, Verma

et al 15and Sandven et al 19. This might be because of severely ill and immunocompromised

patients being cared for in the unit with most of them being on life support systems. Wenzel and

Gennings 20 and Shorr et al 21 have tried to develop risk assessment strategies and calculate

“Candida scores” to predict the true risk of disease in patients admitted in ICU. Candida risk

scores may help clinician to rule out candidemia and to identify the patients at high risk of

developing Candida BSI in the hospital stay. Al- Attas et al 22 have reported high Candida spp.

colonization in diabetic patients compared to control subjects. Isolates colonizing diabetic

patients have also been found to show a greater degree of resistance to antifungal agents than

strains isolated from control subjects.

Our study also underlines the importance of HIV infection as factor contributing to

candidemia. In the United State the proportion of candidemia cases varied from 10% to 15% 23.

The contribution of HIV infection as a predisposing risk factor for candidemia is further

emphasized by a report from Italy, where Candida spp. was the third most common cause of

blood stream infections in HIV patients 24. From India Chowta et al 25 also reported HIV as one of

the major predisposing risk for candidemia. The duration of hospital stay, antibiotic prophylaxis

and treatment, level of immunosuppression, presence of other opportunistic infection and other

clinical types of candidiasis increases the risk of candidemia in HIV infected patients.

The emergence of new species Candida as potential pathogens is a reflection of the

changing scenario in medicine since 1960s. More than 17 species of Candida have been

implicated in human infections till date. However, the list of new species continues to grow. The

use of automated identification system in addition to conventional methods and increase in the

number of HIV infected patients can explain this fact. The incidence of BSI caused by NAC spp.

was higher than C. albicans at our hospital. Among the NAC spp., C. tropicalis followed by C.

glabrata and C. krusei predominately caused BSI. A number of international surveillance

programs like ARTEMIS Antifungal Surveillance Study conducted in 127 health-care centres in

39 countries have documented increased prevalence of NAC species like C. tropicalis and C.

parapsilosis 26.

Epidemiological studies from India reports C. tropicalis as aetiological agent in as many as

67-90% cases of candidemia. Shivprakasha et al 10 found C. tropicalis to be the most common

isolate from candidemia patients. Other workers have also documented the similar observation 16. The increased use of fluconazole has been determined to be the major reason for

predominance of C. tropicalis over C. albicans.

ORIGINAL ARTICLE


C. glabrata has emerged as an important opportunistic pathogen worldwide. It is the

second most common yeast isolated as part of normal flora and its role as a pathogen has only

been recognized in the past few decades. Trick et al 27reported a considerable increase in the

incidence in the rate of isolation of C. glabrata from BSI patients. There is concern over an

increase in azole resistance among strains of C. glabrata.

With the increased incidence of candidemia and the growing number of antifungal

agents, laboratory aids to guide in the selection of antifungal therapy have gained greater

attention. The standardized broth micro dilution method is expensive, laborious and

cumbersome for use in clinical microbiology laboratories. Recently, a disc diffusion method has

been approved by CLSI for antifungal susceptibility testing of yeast.

In the present study we performed disc diffusion method for antifungal susceptibility

testing of Candida isolates. In our study Fluconazole resistance was noted in 19.07% of Candida

isolates, 11.9% showed resistance to itraconazole and 4.63% of Candida isolates showed

resistance to amphotericin B. In India, there is lack of multicentric studies regarding antifungal

susceptibility pattern. Goel et al 28 and Capoor et al 29 reported less incidence of resistance to

fluconazole. On the other hand, workers like Kumar et al 14, Kothari et al 30 and Gupta et al 31

reported high incidence of resistance to fluconazole.

The resistance to fluconazole is of great concern because it is the most common azole

used for treatment of disseminated candidiasis including candidemia. It is available in both

intravenous and oral formulation with high bioavailability and is more cost effective than other

antifungal agents. Although Amphotericin B is effective against most strains of Candida species,

it is not the first choice for the treatment of candidemia because of nephrotoxicity associated

with it. Itraconazole is used for treatment of mucosal candidiasis 32. Studies regarding its role in

treatment of candidemia are less. In a study by Kothari et al 30 24% of Candida isolates were

resistant to itraconazole.

In the present investigation, resistance to antifungal agents was observed more in NAC

spp. as compared to C. albicans. Fluconazole resistance was high in C. tropicalis and C. glabrata.

Itraconazole resistance was more in C. tropicalis. Amphotericin B resistance was higher in C.

glabrata isolates. Other researchers have also documented high antifungal resistance among

NAC spp as compared to C. albicans 1, 3.

We have compared the efficacy of YNBG medium and GM-MH agar for the antifungal

susceptibility testing of Candida isolate. Trailing phenomena around the zone margin were

infrequent and minimal on the GM-MH agar. Zone edges with this method were frequently

definite and clear, facilitating the measurement of zone sizes and minimizing subjectivity in

zone size measurements. The occurrence of the macrocolonies near the center of the clear zone

was also less with this method. The methylene blue in this medium stained the Candida colony

facilitating the identification. Our study showed that there is less variation in the result of GM-

MH agar and YNBG medium. Therefore GM-MH agar can be recommended as simple, cost

effective and sufficiently accurate medium for the routine testing of antifungal susceptibility of

Candida spp.

To conclude, the spectrum of Candida BSI has shifted dramatically from C. albicans to

NAC spp. Hence, it is essential that an early and accurate diagnosis be made of infecting species

of Candida, since each species varies markedly in susceptibility to the currently used antifungal

drugs. It is imperative that antifungal susceptibility testing be carried out routinely in the

laboratory. This will aid the clinician in timely institution of the appropriate and accurate

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/July

antifungal drug to be used and will restrict the empirical use of antifungal

commonly done today.

Figure 1. Age and sex distribution of candidemia patients.

Figure 2. Risk factors predisposing

0

20

40

60

80

100

120

140

0-10 years

11-20 years

26

5

22

6

38

15

12

8

8

86

6 4

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/July-Sept 2012

antifungal drug to be used and will restrict the empirical use of antifungal agents, as being

sex distribution of candidemia patients.

Figure 2. Risk factors predisposing Candidemia.

21-30 years

31-40 years

41-50 years

>50 years

Total

413

20

58

126

4 9 12 15

68

Male Female

49

40

ICU stay

Diabetes

HIV infection

Urinary catheter

Ventilator

Renal failure

Central line

Neonate

Malignancy

surgery in last 3 months

Dialysis

Sept 2012 Page 246

agents, as being

ORIGINAL ARTICLE


Figure 3. Species distribution of Candida isolates obtained from candidemia patients.

Table 1 Comparison of antifungal resistance pattern of Candida isolates using YNBG

medium and GM-MH agar.

Isolate Total Amphotericin B Fluconazole Itraconazole

YNBG GM-MH YNBG GM-MH YNBG GM-MH

C. albicans 78 02 02 07 07 04 03

C. tropicalis 52 02 02 19 19 20 21

C. glabrata 27 05 04 08 08 05 05

C. krusei 20 - - 02 02 02 02

C. guilliermondii 10 - - 01 01 01 01

C. parapsilosis 05 - - - - - -

C. dubliniensis 02 - - - - - -

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ORIGINAL ARTICLE


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ORIGINAL ARTICLE


ASSESSMENT OF UMBILICAL CORD BLOOD IRON AND TIBC LEVELS IN

NEONATES OF ANAEMIC MOTHERS Dr. Durdana Sayeed, Dr. Ghouse M Ali, Dr. Arshiya Masood Osmani, Dr. Rohini N.

Dr. MD. Siddique Ahmed Khan.

1. Assistant Professor, Department of Biochemistry, Dr. VRK Women’s Medical College & Allied Hospitals,

Hyderabad.

2. Professor and HOD, Department of Biochemistry, Dr. VRK Women’s Medical College & Allied Hospitals,

Hyderabad.


Hyderabad.


Hyderabad.

5. Associate Professor, Department of Biochemistry, Dr. VRK Women’s Medical College & Allied Hospitals,

Hyderabad.


Dr. Durdana Sayeed,

H.NO-10-1-128/1/2/E,

”ALIMANOR” MASAB TANK,

Hyderabad. AP-500028,


Ph: 9848502341/9866226286.

ABSTRACT: The most common cause of anaemia in pregnancy is Iron deficiency which can

affect the newborns. This study was done to compare the serum Iron & Total Iron Binding

Capacity (TIBC) levels in the 20 newborns of non–anaemic and anaemic mothers each.

Results showed that Haemoglobin % was significantly lower (P≤ 0.001) in newborns of anaemic

mothers. Serum Iron levels did not show any significant difference (P = 0.1) & TIBC levels were

significantly higher (P≤ 0.01) in newborns of anaemic mothers as compared to newborns of

non- anaemic mothers.

KEYWORDS: Umbilical Cord blood, Iron deficiency anaemia, pregnancy, Serum Iron, S. TIBC.

INTRODUCTION: Anaemia is one of the most common conditions prevalent in our country. The

most common cause of anaemia in pregnancy is Iron deficiency.

WHO defines anaemia in pregnancy when Hb % is ≤ 11 gm/dl1.

Hb % ≤ 11 gm/dl especially in late pregnancy should be considered abnormal and due to Iron

deficiency rather than due to hypovolemia of pregnancy2.

The mean Hb level in cord blood is 13.5 – 20.5 gm/dl and Hb % ≤ 14 gm/dl at birth is

considered abnormal2.

AIM: This study was done to compare the Haemoglobin, serum Iron & TIBC levels in 20

newborns of non-anaemic mothers and anaemic mothers each.

MATERIALS & METHODS: The study done by the approval of ethical committee of Dr.

VRKWMC, Teaching Hospital & Research Centre. The study group is comprised of 20 pregnant

women without anaemia and their 20 newborns (Group I). The control group included 20

pregnant women with anaemia (Hb levels < 10 gm/dl) and their 20 newborns (Group II). Cord

ORIGINAL ARTICLE


blood was collected from the newborns’ end of the umbilical cord within 5 minutes of the

delivery.

FOR ESTIMATION OF HAEMOGLOBIN – We followed Cyanmethaemoglobin method3.

FOR ESTIMATION OF SERUM IRON & TIBC – We followed Dipyridyl method4.

The instrument used was Spectrophotometer (Elico sl 159).

RESULTS:

TABLE I-SHOWING Hb, IRON AND TIBC LEVELS IN NEWBORNS OF NON-ANAEMIC

MOTHERS (GROUP I)

Hb in gm% S. Fe in ugm% TIBC ugm%

MEAN 14.7 107.5 256.3

S. D +/_ 0.91 30.61 114.04

S.E +/_ 0.2 6.84 25.4

TABLE II – SHOWING Hb, IRON and TIBC LEVELS IN NEW BORNS OF ANAEMIC MOTHERS

(GROUP II)


MEAN 12.6 99.7 301.45

S.D +/_ 0.96 34 56.31

S.E +/_ 0.22

TABLE III – COMPARISSION of Hb, IRON AND TIBC LEVELS B/W GROUPS I & II


t-value 6.93 0.76 1.59

p-value < 0.001 = 0.1 ≤0.01

Df 38 38 38

The stastical analysis done was done using SAS Version of software.

Newborns of anaemic mothers showed

I. Significantly lower levels of Hb(P<0.001) when compared to newborns of non anaemic

mothers.

II. Serum Iron did not show any significant difference (P = 0.1).

III. Serum TIBC levels were significantly higher (P ≤0.01) in

New borns of anaemic mothers as compared to new borns of non- anaemic mothers.

ORIGINAL ARTICLE


DISCUSSION: In our study comparison of newborns of non-anaemic and anaemic mothers

showed

� Haemoglobin of Group I is 14.7gm% and that of Group II is 12.6gm % with p value

(<0.001).

� Serum Iron showed Group I is 107.5µgm/dl and that of Group II is 99.7 µgm/dl with p

value (=0.1).

� Serum TIBC of Group I is 256.3 µgm/dl and that of Group II is 301.45 µgm/dl with p (≤

0.01).

A significant difference in all parameters except SERUM IRON reflects the metabolic demands

created by the foetus for erythropoiesis and foetus draws its full requirement from the mother.

Iron deficiency anaemia in mother is considered as a risk factor for Iron deficiency in infancy 5,6

Chitra Upadhyaya et al7 , found that there was a significant decrease in Hb% in the new borns of

anaemic groups when compared to the newborns of nonanaemic mothers. Similarly serum iron

levels was also having a significant difference .Where as in our study there is no significant

difference in serum iron levels.

TABLE IV – COMPARISSION B/W REFERENCE STUDY & OUR STUDY

NEWBORNSOFANAEMIC

MOTHERS

Hb in gm% S.IRON(µgm/dl) TIBC(µgm/dl)

REFERENCE STUDY 14.9 108.0 288.9

OUR STUDY 14.7 107.5 256.3

NEWBORNS OF NON-

ANAEMIC MOTHERS


OUR STUDY 12.6 99.7 301.45

CONCLUSION: Compared to previous study7, our study shows that serum iron does not show

any significant difference in the newborns of non-anaemic and anaemic mothers,whereas Hb &

TIBC showing significant difference.

In the socio-economic conditions of our country , people are scared of nutritional deficiency for

the newborn children. But it has been observed in our study that the newborns of anaemic

mothers have no iron deficiency inspite of being born to anaemic mothers.

LIMITATIONS OF THE STUDY:

i) Samples for study has to be collected only from those cases which are

delivered before noon, because S.iron levels show a diurnal variation-S.iron

levels decline by almost 50% from 8:00 to 14:00 hours.

ii) Sample collection from umbilical cord fails, if there is delay in drawing the

sample.

ORIGINAL ARTICLE


ACKNOWLEDGMENT: We are extremely thankful to Dr. SARIB RASOOL KHAN – Managing

Director DR. V R K WMC, Teaching Hospital & Research Centre and Allied Hospitals, for

providing all the facilities for the research work.

Our sincere thanks to Dr. SIKANDER HUSSAIN – Professor –Dept. of Physiology for the

cooperation.

REFERENCES:

1. Saraiya.Rao.Chatterjee,Principles of Obs and Gyn forPGs , 2nd edition pg-33.

2. Williams, Obstetrics-21st Edn.

3. Harold Varley, Practical Clinical Biochemistry, 4th Edn ,pg no.585.

4. Harold Varley, Practical Clinical Biochemistry, 4th Edn. pg no. 472.

5. Kilbride, J., Baker,T.G., Parapia, L.A.,Khoury,S.A..Shuqaidef , S.W., & Jerwood, D.Anaemia

During Pregnancy as a Risk Factor for Iron Defeciency Anaemia in infancy. Int J

Epidemiol (1999) 28: 461- 468 .

6. J. Colomer, C. colomer ,D. Gutierrez, A. Jubert A. Nolosaco, J. Donat,

R.Fernandez- Delgado, F. Donat and C. Alavarez- Dardet. Anaemia During Pregnancy as

a Risk Factor for Infant Iron Deficiency. Paediatric & Perinatal Epidemiology 1990,4

(2).196 – 204.

7. Chitra Upadhyaya et al, Serum Iron, copper & Zinc status in Maternal & Cord blood, IJCB

, 2004, 48 – 52.

CASE REPORT


ENTEROCOCCAL BRAIN ABSCESS OF OTOGENIC ORIGIN: A CASE

REPORT

Dr. K. Vidyasagar, Dr. R. Ravikumar. Dr. Nupur Pruthi.

1. Non-PG Senior Resident, Department of Neuromicrobiology, NIMHANS, Hosur Road, Bangalore.

2. Professor and Head, Department of Neuromicrobiology, NIMHANS, Hosur Road, Bangalore.

3. Assistant professor, Department of Neurosurgery, NIMHANS, Hosur Road, Bangalore


Dr. R. Ravikumar MD,

Professor and Head, Department of Neuromicrobiology,

NIMHANS, Hosur Road, Bangalore-560029,


Ph: 09448073965.

ABSTRACT: Various aerobic and anaerobic bacteria have been reported as causative agents of

brain abscess but only a few cases of enterococcal brain abscesses have been reported. We

report a case of enterococcal brain abscess of otogenic origin in a 35 year old male who was

known case of chronic suppurative otitis media (CSOM) and cholesteotoma of the right ear. The

abscess material culture yielded an isolate which was identified as Enterococcus faecium by

standard biochemical reaction. The isolate was sensitive to penicillin, ampicillin, gentamicin,

vancomycin, ofloxacin, lincomycin, and cloxacillin.

KEY-WORDS: Brain abscess, Enterococcus faecium, Computerized tomography

INTRODUCTION: Despite the advent of modern neurosurgical techniques, new antibiotics and

new powerful imaging technologies, brain abscess remains a potentially fatal central nervous

system (CNS) infection.1-4Brain abscess is a relatively uncommon infection with an incidence of

0.3-1.3/100,000 persons per year 1. Most of these cases occur in association with the

predisposing conditions such as otitis media, sinusitis, or presence of pyogenic infections in

other parts of the body. Dental infections are associated with around 2% of the brain abscesses.2

The causative pathogens of bacterial brain abscess vary with time period, geographic

distribution, age, underlying medical and/or surgical conditions and mode of infection. A large

number of Gram positive cocci, Gram negative aerobic bacilli, anaerobes and Mycobacterium

tuberculosis have been reported as the causative agents of bacterial brain abscess.1-4The

commonest organisms causing brain abscess following an otogenic source include

Staphylococcus aureus, Streptococcus pneumoniae, H. influenzae, Escherichia.coli, Proteus and

Pseudomonas species. Very few studies have reported Enterococcus species as one of the

causative agents of brain abscesses2-4.

We report a rare case of enterococcalbrain abscess of otogenic origin in a 35 years old

male which was managed successfully with surgical drainage and antibiotics.

CASE HISTORY: A 35-year old male patient presented to the Department of Neurosurgery with

three days of headache, giddiness and vomiting. The patient was a known case of CSOM and

cholesteotoma of right ear for the past three years having ear discharge and ear pain. The

patient underwent radical mastoidectomy with excision of cholesteotoma. On third post op day

CASE REPORT


patient developed headache, vomiting and giddiness with blurring of vision with no h/o fever,

seizures or limb weakness. At time of admission patient was conscious, had no fever and neck

stiffness. Neurological examination revealed left hemi paresis with grade two power, bilateral

papilledema, nystagmus and right cerebellar dysfunction. Cardiovascular, respiratory and

abdominal examinations were found to be normal.

His white blood cell (WBC) count was 13000/mm3 with 70% neutrophils. The

erythrocyte sedimentation rate (ESR) was 10mm/hr. Biochemical parameters were within

normal limits. CT of brain showed right cerebro-pontine angle cistern enhancing lesion with

loculation of size 4.4 × 3.5 × 3.0 cm2 with mass effect on fourth ventricle. Intracranial mass or

abscess was suspected as the probable diagnosis and craniotomy was performed and excision of

right cerebro-pontine angle abscess with EVD placement was done. Abscess material was

processed in the lab. Gram stain of the smear showed plenty of pus cells and Gram positive cocci

in pairs and short chain along with Gram negativebacilli. ZN stain showed no acid fast bacilli.

Abscess material was cultured on blood agar, MacConkey agar, thioglycollate broth and

anaerobic blood agar aerobically and anaerobically. A culture was also put up in LJ medium.

Culture yielded a bacterium which was identified as Enterococcus faecium by standard

biochemical reactions)6.

LJ medium showed no growth after eight weeks of incubation. The isolate was sensitive

to penicillin, ampicillin, gentamicin, vancomycin, ofloxacin, lincomycin and cloxacillin by disc

diffusion method. Patient was treated with iv ampicillin, iv gentamicin and metronidazole iv for

3 weeks. After three weeks of antibiotic therapy he was discharged without any neurological

deficit. The patient on follow up visits was doing well with no residual neurological deficit and

marked improvement in the radiological findings on a follow-up CT scan(fig1 B&C).

CASE REPORT


DISCUSSION: There have been many advances with respect to the diagnosis and management

of brain abscess, resulting in a corresponding increase of survival rates. However its incidence is

high, approximately 5% per million people, and the number of immuno-deficient hosts having

high risk of opportunistic infections might be increasing. This disease continues to be one of the

most common neurosurgical diseases[1-5].

Regarding portal of entry, brain abscess is almost always secondary to a focus of

suppuration elsewhere in the body or may develop either by a contiguous focus of infection,

head trauma or hematogenous spread from a distant focus.1-5 Thus the predisposing factors for

the development of brain abscess include infections of the middle ear, mastoid, paranasal

sinuses, orbit, face, scalp penetrating skull injury, intracranial surgery including insertion of

ventriculo-peritoneal shunts5-6.

A previous study conducted by Malik et al.6from Mumbai showed that in 47 cases of

brain abscess, the primary focus of infection could be established in 37 cases (78.7%) and

otogenic source was the commonest in 34% cases.

Another prospective study of pattern of brain abscess reported from India7 showed

chronic suppurative otitis media to be the commonest predisposing factor in 48% of patients.

The location and number of abscesses depends upon the predisposing factors. The temporal

abscess and the cerebellum are the commonest sites following otogenic source as observed in

the present case. The list of bacteria causing brain abscesses is very large. It includes Gram

negative aerobic bacilli like Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli,

Salmonella species, Proteus species, Klebsiella oxytoca, Haemophilus influenzae, Pasturella

species, Vibrio cholerae non 01; Gram positive bacteria like Staphylococcus aureus, other

Staphylococcus species, Streptococcus pneumoniae, Enterococcus species, Viridans

streptococci, other Streptococcal species. The anaerobic organisms reported are Bacteroides

species, Fusobacterium species, Peptostreptococcus and Propionibacterium species.1-4

The commonest organisms causing brain abscess following an otogenic source include


Pseudomonas species.1-7 Very few studies have reported Enterococcus species as one of the

causative agents of brain abscesses in India.

Kurien et al.2in 1993 reported Enterococcus faecalis as one of the causative agents of

brain abscesses in India, while studying 153 cases of brain abscesses.

In the year 2002, Park et al.4from Korea reported a case of otogenic brain abscess due to

Enterococcusfaecium.

A recent case report from India by Mohanty et al. 3 in the year 2005 reported a brain

abscess due to Enterococcus avium in a 19-year-old man with chronic otitis media since

childhood.

Enterococcus faecalis and Enterococcus faecium are responsible for most enterococcal

infections in humans, while Enterococcus gallinarum, Enterococcus avium and Enterococcus

casseliflavus are not frequently reported8.Enterococciare clearly unusual etiological agents of

brain abscess, and they account for 0.3–4% of reported cases of brain abscess9.Based on a

clinical spectrum of symptoms and findings, enterococcal brain abscess can be found in two

clinical forms postoperative and spontaneous. Postoperative brain abscess appears as a

nosocomial infection usually associated with neurosurgical procedures and shunt devices10. Our

patient had CSOM and also underwent radical mastoidectomy with excision of cholesteotoma

which was considered as risk factors for his enterococcal brain abscess. For most clinical

microbiological laboratories, the primary method of identifying Enterococcus species strains

CASE REPORT


relies on phenotypic characterization [10]. The treatment of enterococcal brain abscess includes

administration of appropriate antibiotics that have in vitro activity against the strain, and can

efficiently penetrate the cerebrospinal fluid, in addition to the elimination of the predisposing

factors if necessary10.

We would like to stress that a high index of suspicion, timely diagnostic support by CT

scan, surgical intervention and vigorous antimicrobial therapy are crucial for better outcome.

REFERENCES:

1. Lu CH, Chang WN, Lin YC, Tsai NW, Liliang PC, Su TM, et al. Bacterial brain abscess:

microbiological features, epidemiological trends, therapeutic outcomes. QJM. 2002;

95:501–09.

2. Kurien M, Job A, Mathew J, Chandy M. Otogenic intracranial abscess. Concurrent

craniotomy and mastoidectomy- Changing trends in a developing country. Arch

Otolaryngol Head Neck Surg. 1998; 124:1353–56.

3. Mohanty S, Dhawan B, Kapil A, Das BK, Pandey P, Gupta A. Brain abscess due to

Enterococcus avium. Am J Med Sci. 2005; 329:161–62.

4. Park SY, Min JH, Ryu JW, Ko YS. Enterococcal otogenic brain abscess. Korean J


5. Sung DJ, Ealaan K, Chang YL, Kim IS, Son EIK, Kim DW, et al. Clinical features and

surgical treatment of brain abscess. J Korean Neurosurg Soc. 2007; 41:391–96.

6. Malik S, Joshi SM, Kandoth PW, Vengsarkar US. Experience with brain abscesses.

Indian Pediatr. 1994; 31:661–66.

7. Lakshmi V, Rao RR, Dinkar I. Bacteriology of brain abscess--observations on 50

cases. J Med Microbiol. 1993; 38:187–90.

8. Sood S, Malhotra M, Das BK, Kapil A. Enterococcal infections & antimicrobial

resistance. Indian J Med Res. 2008; 128: 111-21.

9. Kurup A, TeeW, Loo I, Lin R. Infection of central nervous system by motile

Enterococcus: First case report. J Clin Microbiol.2001; 39:820-22.

10. Murray BE.The life and times of the Enterococcus. ClinMicrobiol Rev.1990;3: 46-65.

CASE REPORT


MYOFIBROBLASTIC SARCOMA: A CASE REPORT Dr. Rithesh. K. B, Dr. Nandesh Shetty, Dr. Sumukh. M, Dr. Ashish Shetty. Dr. Raghavendra. P

1. Assistant Professor, Department of OMFS, A. J. Institute of Dental Sciences, Kuntikana, Mangalore.

2. Head of the Department, Department of OMFS, A. J. Institute of Dental Sciences, Kuntikana, Mangalore.

3. Post Graduate Student, Department of OMFS, A. J. Institute of Dental Sciences, Kuntikana, Mangalore.


5. Assistant Professor, Department of Pedodontics, A. J. Institute of Dental Sciences, Kuntikana, Mangalore.


Dr. Sumukh. M,

Dept. of Oral & Maxillofacial Surgery,

A. J. Institute of Dental Sciences, N.H 17,

Kuntikana, Mangalore-575004,


Ph: 09886809202.

ABSTRACT: Myofibroblastic Sarcoma is a rare or uncommon neoplasm characterized by

myofibroblastic proliferation. The tumour may present as single or multiple nodules of soft

tissue, bone, or internal organs. When encountered in the jaws, the lesions exhibit clinical and

radiographic features suggestive of several odontogenic and non-odontogenic neoplasms.

Myofibroblastic Sarcoma of the jaws are usually well-demarcated, but sometimes can be poorly

delineated or infiltrated that may result in misdiagnosis and mistreatment1. A painless,

enlarging mass is the most common clinical presentation, but a definitive diagnosis requires

both histopathological and immunohistochemical analyses. In this paper we are going to discuss

a case of 64 years old male with Myofibroblastic Sarcoma of left side of face. The patient

underwent excision of the lesion in toto with reconstruction of the floor of the orbit using

prolene mesh.

KEYWORDS: Myofibroblastic Sarcoma, Myofibroma, Maxilla, Alveolus, Floor of Orbit, Prolene

mesh.

INTRODUCTION: Defining neoplastic Myofibroblastic Sarcoma (MS) as a distinct entity was

controversial. With increasing case reports, it became clear that Myofibroma was a distinct

entity in soft tissue sarcomas. Even though only low-grade Myofibroma was classified as a

distinct entity in the newly published World Health Organization classification of soft tissue

tumours, intermediate- and high-grade Myofibroma cases were documented in the literature.

Some cases of MYOFIBROBLASTIC SARCOMA were easy to misdiagnose as reactive lesions

because of the common existence of myofibroblasts in reactive granuloma. In addition, the

frequent exhibition of bland cytologic features in MYOFIBROBLASTIC SARCOMA is an important

factor in persuading pathologists toward a benign diagnosis. MYOFIBROBLASTIC SARCOMA,

especially low-grade MYOFIBROBLASTIC SARCOMA, is easily confused with myofibroblasts

composing nodular fasciitis because of their morphologic similarity and the overlapping

immunophenotype.

MYOFIBROBLASTIC SARCOMA is a common mesenchymal neoplasm that occurs most

frequently in the uterus and gastrointestinal tract. The occurrence of primary

MYOFIBROBLASTIC SARCOMA in the oral soft tissues or jawbones is very unusual. 1) Only 31

cases have been reported in the literature.2) Among cases of oral soft tissue MYOFIBROBLASTIC

CASE REPORT


SARCOMA, six arose in the cheek, five in the gingiva, five in the tongue and the remainder were

located in the floor of the mouth, soft palate, hard palate, mandibular alveolar mucosa, posterior

maxillary soft tissue and maxillary sinus. Among the jawbone lesion cases, six occurred in the

mandible and four in the maxilla2.

This paper discusses an unusual case of primary MYOFIBROBLASTIC SARCOMA of the

oral cavity, which arose in the maxillary buttress and had the growth pattern of a polyp.

DESCRIPTION OF CASE: A 64-year-old Male patient visited the Department of Oral & Maxillo-

facial Surgery at A. J. Institute of Dental Sciences, Mangalore with the chief complaint of a

swelling over the left side of the face region since 2 months duration. Swelling was insidious in

onset, initially small in size and associated with pain which was mild in intensity and continuous

type. Extent

Anteriorly: Left lateral aspect of the nose.

Posteriorly: 3 cm in front of the tragus.

Superiorly: Infraorbital rim

Inferiorly: Line joining corner of the mouth to tragus of the ear on the left side.

Size: 5 cm x 4 cm.

Patient had previously visited a dentist with complaints of pain and swelling and

underwent extraction of the two upper left molars as they were mobile. After extraction

swelling rapidly increased in size to its present size. Pain was moderate type and not subsiding

with medications. Patient is hypertensive and is on medication. On examination bucco-palatal

expansion was noted in the upper left molar region and 1st premolar region. Physical

examination revealed a firm swollen region, which showed tenderness, pain at palpation.

Surface was smooth, irregular in shape with ill defined margin with normal overlying skin.

Gingival swellings extended from the left maxillary canine to the 3rd molar. However, the patient

had not experienced any symptoms. On radiographic examination an extensive radiolucent

lesion with sclerotic borders was revealed above the left maxillary canine and molar region.

Root resorption of involved teeth was observed with grade III mobility of the 2nd and 3rd molar

teeth for which patient was treated with extraction and Incision & Drainage was done for the

swelling as the swelling was believed to be a periodontal abscess. On cross-sectional view of

occlusal projection expansion of buccal and palatal cortical bone of the maxilla with partial

resorption of buccal cortical bone was observed. Skin over the swelling was normal in

appearance but stretched. Obliteration of the nasolabial fold was seen. Watery discharge was

seen from the left eye.

Provisional diagnosis was Peripheral Ossifying Fibroma, Fibrosarcoma, Osteosarcoma.

Incisional biopsy was performed under local anaesthesia with adrenaline (1:200000) and the

sample was sent to Department of oral pathology for histopathological examination.

Histopathological examination suggested the lesion to be Osteosarcoma (Chondroblastic

Variant).

Patient was admitted in our hospital and all the necessary blood investigations were

carried out along with ECG, ECHO, Chest X ray and C. T. Scan of the Head. After obtaining a

medical clearance, the patient was taken up for Tumour excision under general anesthesia.

Reconstruction of the orbital floor was done using prolene mesh which was suture using 3.0

vicryl. Intra orally suturing was done using 3.0 vicryl and skin suturing using 5.0 prolene. The

excised tumour was then sent for histopathological examination.

Furthermore, patient was advised for therapeutic radiotherapy.

CASE REPORT


HISTO PATHOLOGICAL ASSESSMENT: Sections show a cellular spindle cell tumour arranged

in intersecting fascicles and slight swirling striform and whorl-like pattern. The tumour cells are

spindly to lump to stellate shaped showing mild pleomorphism, with vesicular nucleus some

showing conspicuous nucleolus and ill-defined pale eosinophilic cytoplasm. Focal nuclear

hyperchromasia is also seen. The stroma is myxoid at places and contains many thin walled

dilated and congested blood vessels. Large ares of hemorrhage are also seen in the studied

sections. Mitosis is low. A sparse chronic inflammatory infiltrate is also seen. Tumor tissue is

seen infiltrating the surgical resected margin.

Histological features are suggestive of low grade malignant SPINDLE CELL SARCOMA.

Immunohistochemistry for further evaluation and confirmation of histopathological changes

(CD34, S- 100 CD 99, Desmin, Actin).

IMMUNOPHENOTYPING REPORT:

SMA : Positive in some of the tumour cells.

Desmin : Negative in tumour cells.

S-100 : Negative in tumour cells.

CD99 : Negative in tumour cells.


IMPRESSION: With above features, Myofibroblastic Sarcoma has to be considered.

DISCUSSION: Myofibroblasts are modified fibroblasts, which can occur in normal tissues (e.g.

periodontal ligaments), reparative granulation tissue and reactive soft-tissue lesions. The cause

of Myofibroma is presently unknown. A number of authors have suggested that the tumors are

inherited in an autosomal dominant or alternatively in an autosomal recessive trait. However,

its low familial incidence suggests that there are probably factors other than genetics that play

an important role in the cause of this disease7.They are, however, also a principal cell type in

benign and malignant soft-tissue tumours. Myofibroblasts are spindle-shaped or stellate cells

with ovoid pale nucleus and distinct nucleolus. The cytoplasm is usually amphophilic and there

are indistinct cell borders. Ultrastructurally, myofibroblasts can be distinguished from

fibroblasts and smooth muscle cells by the findings of indentation of nucleus, presence of

peripheral or subplasmalemmal bundles of thin cytoplasmic filaments, termed stress fibres, and

a distinctive cell-stromal attachment termed fibronexus4. Myofibroblastic Sarcoma is a well

defined malignant tumour composed of myofibroblasts. It can occur at any age with slight male

predominance; the tumour size varies from 1.5 cm to 17 cm. MYOFIBROBLASTIC SARCOMA can

arise in soft tissues of various anatomic sites, including extremities, trunk (e.g. retroperitoneum,

breast and heart) and genital tract, but there is a predilection for the head and neck region. Oral

cavity (especially tongue, cheek and gingiva), nasal cavity, salivary glands and bones (e.g.

maxilla and mandible) can be affected. Grossly, most cases were described as firm, gray-white

coloured tumours with ill-defined margins. Histologically, the tumour cells show diffuse

fascicular or storiform growth pattern and they infiltrate surrounding tissues (e.g. skeletal

muscle). The cytological and ultrastructural characteristics of neoplastic cells are consistent

with myofibroblasts (described above). Increased mitotic activity of tumour cells and tumour

necrosis is associated with more aggressive behaviour of MYOFIBROBLASTIC SARCOMA5.

Tumour cells in MYOFIBROBLASTIC SARCOMA show a variable immunophenotype: actin

positive/desmin negative, actin negative/desmin positive, and actin positive/desmin positive

CASE REPORT


cases. In addition, neoplastic cells can express fibronectin, calponin, CD 34, CD 99 and CD 117,

whereas S-100 protein, epithelial markers and h-caldesmon are negative. MYOFIBROBLASTIC

SARCOMA is usually a tumour of low grade malignancy, prone to local recurrence (about 30% in

general), even after many years5. However, metastases to lungs have been also reported.

Therefore, close clinical follow-up of the patient is mandatory. Differential diagnosis of

MYOFIBROBLASTIC SARCOMA includes reactive myofibroblastic lesions, benign

myofibroblastic lesions and other Myofibroblastic Sarcomas. In these cases,

immunohistochemistry is not helpful and the differential diagnosis is based on careful

examination of the slides stained with hematoxylin-eosin. On the other hand, many

histogenetically different spindle-cell tumours can be distinguished from MYOFIBROBLASTIC

SARCOMA using immunohistochemistry. Nodular fasciitis is a rapidly growing lesion,

histologically with variable cellularity and myxoid stroma. It is less cellular and uniform than

MYOFIBROBLASTIC SARCOMA. Although mitoses can be present, the cells lack nuclear atypia,

which is usually present in MYOFIBROBLASTIC SARCOMA. Fibromatoses are composed of

uniform, collagen-producing myofibroblasts without nuclear pleomorphism. Inflammatory

myofibroblastic tumour (IMT) is histologically characterized by fasciitis-like, fascicular and

sclerosing areas with a prominent chronic inflammatory infiltrate with numerous plasma cells.

In addition, anaplastic lymphoma kinase (ALK) can be immunohistochemically detected in 30–

40% of Inflammatory myofibroblastic tumours6. The inflammatory infiltration in the presented

case of MYOFIBROBLASTIC SARCOMA was, however, due to tumour ulceration. High grade

Myofibroblastic Sarcoma is often difficult to distinguish from other high grade sarcomas. This

diagnosis should be established in those cases, where the presence of myofibroblasts is

confirmed by electronmicroscopy. Histogenetically different spindle-cell tumours can be

distinguished from MYOFIBROBLASTIC SARCOMA using immuno-histochemistry. Spindle-cell

carcinoma shows positivity for cytokeratins, fibrosarcoma is SMA negative, leiomyosarcoma has

a different microscopic appearance and shows desmin and h-caldesmon positivity. Spindle-cell

rhabdomyosarcoma shows SCMA positivity, angiosarcoma shows positivity for endothelial

markers (e.g. F VIII, CD 31 and CD 34) and malignant peripheral nerve sheath tumour shows at

least focal positivity for S-100 protein. In summary, MYOFIBROBLASTIC SARCOMA is a well-

defined myofibroblastic malignancy with predilection for head and neck region, which is prone

to local recurrency, rather than metastasing. For the diagnosis, a careful examination of

routinely stained slides is crucial. Immunohistochemistry can be useful in differential diagnosis

from some other spindle cell lesions and tumours. Electronmicroscopic examination can

support the diagnosis of MYOFIBROBLASTIC SARCOMA by proving the origin of tumour cells.

LEGENGS:

1. Frontal pre -operative photograph.

2. Birds eye view pre – operative photograph.

3. Intra oral lesion pre – operative photograph.

4. Intra operative photograph after excision of the lesion.

5. Excised lesion in toto.

6. Frontal view Post operative photograph.

7. Birds eye view Post operative photograph.

8. Histopathology Photograph.

9. C. T. Scan Pre opertive sub mento vertex view.

10. Occlual Radiograph

CASE REPORT


CASE REPORT


ACKNOWLEDGEMENTS:

Our sincere gratitude to Dr. Vinay Kumar Hegde, General Practitioner, Moodbidri, Dr. Aravind,

Consultant Pathologist, A. J. Hospital & Research Hospital, Mangalore and Department of Oral

Pathology, A. J. Institute of Dental Sciences, Mangalore.

REFERENCES:

1. Chiu-Kwan Poon and Po-Cheung Kwan. Myofibroma of the Mandible: A Case Report.

Chin J Oral Maxillofac Surg 16: 156-165, September 2005.

2. Hideki Mizutani, Iwai Tohnai, Makoto Yambe and Minoru Veda. LEIOMYOSARCOMA OF

THE MAXILLARY GINGIVA: A CASE REPORT. Nagoya J. Med. Sci. 165 - 170, 1995.

3. Nada O. Binmadi, Harold Packman, John C. Papadimitriou and Mark Scheper Oral

Inflammatory Myofibroblastic Tumor: Case Report and Review of Literature. The Open

Dentistry Journal, 2011, 5, 66-70.

4. Eyden, B. P.: The fibronexus in reactive and tumoral myofibroblasts: further

characterisation by electron microscopy. Histol. Histopathol., 16, 2001, s. 57–70.

5. Mentzel, T., Dry, S., Katenkamp, D., Fletcher, C. D.: Low-grade myofibroblastic sarcoma:

analysis of 18 cases in the spectrum of myofibroblastic 1tumors. Am. J. Surg. Pathol., 22,

1998, s. 1228–1238.

6. Li, X. Q., Hisaoka, M., Shi, D. R., Zhu, X. Z., Hashimoto, H.: Expression of anaplastic

lymphoma kinase in soft tissue tumors: an immunohistochemical and molecular study of

249 cases. Hum.1 Pathol., 35, 2004, s. 711–721.

7. Jin-Soo Kim, Sung-Eun Kim, Jae-Duk Kim. Myofibroma of the mandible: A case report.

Korean Journal of Oral and Maxillofacial Radiology 2006; 36 : 211-5.

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/July-Sep 2012 Page 264

INDIRECT BONDING WITH NEW TRANSFER TRAY - LIGHT TRAY

Dr. R. Satish, Dr. T. Srinivasan, Dr. R. Suresh, Dr. Sujith sivarajan

1. Associate Professor, Department of Orthodontics, Adhiparasakthi Dental College and Hospital.

Melmaruvathur, Tamil Nadu.

2. Reader, Department of Orthodontics, Adhiparasakthi Dental College and Hospital. Melmaruvathur, Tamil

Nadu.

3. Senior lecturer, Department of Orthodontics, Adhiparasakthi Dental College and Hospital. Melmaruvathur,

Tamil Nadu.


Tamil Nadu.


Dr. R. Satish,

Adhiparasakthi Dental College and Hospital,

Melmaruvathur, Kanchipuram District,

Tamilnadu, India-603319,

E-mail: [email protected], Ph: 91 09444183900

ABSTRACT: BACKGROUND: Indirect bonding is a technique in which orthodontic brackets are

transferred from dental casts onto the dentition using a transfer tray. The aim of this paper is to

describe a simple and efficient procedure of indirect bonding. The transfer tray used here is

Light tray (Ivoclar), light polymerised resin composite special tray material, which is used to

fabricate customized trays for fixed and removable implant-restorations. This light tray has

many advantages when compared with similar trays for indirect bonding.

KEYWORDS: Indirect bonding, light tray

INTRODUCTION: Traditional bracket placement involves hand placing each bracket directly in

the mouth. Accurate direct bracket placement is very difficult for even the most experienced

orthodontist. Indirect bonding has been an exciting advancement in orthodontics. It has great

benefit to the patient as it improves patient comfort, reduces the amount of time in the dental

chair, improves the accuracy of bracket placement, and reduces treatment time. Indirect

Bonding of brackets using light-curing transfer trays,(Fig.1), has several advantages like easy

mouldable, fast and easy working, accurate adaptation, stability of shape immediately after

polymerization and excellent elastic memory. Light trays can be cured by Light curing unit for 3

minutes or exposing to direct day light for 5 minutes.

Fig .1 Light Tray.

ORIGINAL ARTICLE


LABORATARY PROCEDURE: The indirect bonding technique starts by taking impressions of

the patient teeth. The impressions are used to make a stone model of the teeth, (Fig.2). The

brackets are secured to the stone model with water soluble glue (fevi stick,Fig.3). Use wax to

block and prevent adapting light tray in to the bracket wings and slots. Adapt the Light tray over

the brackets mounted on the patient cast from labial to lingual surface. Trim the excess tray

material with a wax knife, (Fig.4). Light cure the tray for 4 minutes, (Fig.5). Soak the working

model with the custom transfer tray in warm water for a minimum of one hour to dissolve

water soluble glue from the bracket base and release the custom tray from the model.

Fig.2. Model with markings of Bracket Position.

Fig.3 The brackets are fixed with water soluble glue.

ORIGINAL ARTICLE


Fig.4. Adaptation of Light tray over the brackets.

Fig.5. Light curing the Light tray.

Fig.6. Light tray with the brackets.

ORIGINAL ARTICLE


CLINICAL APPLICATION: Apply bonding agent and light cure adhesive on the brackets in

transfer tray. Etch the teeth and apply the bonding agent. Keep a dry field. Place the tray in the

mouth and the adhesive part of the tray pressed on to the teeth with fingers. Light cure the

adhesive for 20 seconds for each bracket, (Fig.7). Remove the tray and cure all the brackets for

10 seconds. Remove any excess adhesive from the teeth surface, (Fig.8).

Fig .7. Light tray with brackets on the teeth

Fig .8. After the removal of the light tray

CONCLUSION: Indirect bonding offers many advantages combined with safety, especially the

exact positioning of brackets. One of the main problems, however, is their transfer to the mouth

with precision and sufficient adhesion. Currently, there are various transfer trays for indirect

bonding available—opaque, translucent silicone-based polymer, and thermoplastic transfer

devices. The technique described in this article serves to simplify tray fabrication. This is

accomplished by using Light tray. The Light tray is easier to adapt, stability of shape

immediately after polymerization, excellent elastic memory, easy to trim, less bulky, easy to

transfer than other types, extremely cheap and cost effective. Light tray- transfer trays offer an

accurate bracket positioning and hence it could be treated as one of the preferable methods of

bracket placement.

ORIGINAL ARTICLE


REFERENCES:

1. Gottlieb, E.L.; Nelson, A.H.; and Vogels, D.S.III: 1996 JCO Study of Orthodontic

Diagnosis and Treatment Procedures, Part I: Results and trends. J. Clin. Orthod.

30:615-630, 1996.

2. White, L.W.: An expedited indirect bonding technique. J. Clin. Orthod. 35: 36-41,

January 2001.

3. Bishara, S.E.; Gordan, V.V.; VonWald, L; Olson, M.E.: Effect of an acidic primer on

shear bond strength of orthodontic brackets, Am. J. Orthod. and Dentofacial

Orthop. 114: 243-247, September 1998.

4. Miles PG: Indirect bonding with a flowable light-cured adhesive. J Clin Orthod

36:646, 2002

5. Sondhi A. Effective and efficient indirect bonding: The Sondhi

6. method. Semin Orthod ;13:43-57 2007

BRIEF COMMUNICATION


MODIFIED PERIODONTAL EXPLORER FOR EXPANSION SCREW

ACTIVATION

Dr. T. Srinivasan, Dr. R. Satish, Dr. R. Suresh, Dr. Sujith Sivarajan


Nadu.




Tamil Nadu.


Tamil Nadu.


Dr. T. Srinivasan,




E-mail: [email protected], Ph: 91 09841611886.

INTRODUCTION: Accidents with expansion screw activation keys are reported in the

literature1,2. A simple method to prevent such accident is to use a modified periodontal explorer

as a key for expansion screw activation. A no.17 periodontal explorer (fig 1) is cut at its first

terminal bend (fig 2). The second section is bent more vertically to the long axis of the shaft (fig

3). This part which is tapered and stiff enough to activate the screw is tried extra orally into the

screw. It is further trimmed in such a way that only a mm of instrument can project through the

screw hole (fig 4). Now a safe key for activating the maxillary expansion screw is ready to use

(fig 5). Once the patient’s parent or guardian successfully repeat the activation procedure in

office, the instrument can be given to them for home use.

BRIEF COMMUNICATION


BRIEF COMMUNICATION


REFERENCES:

1. Nazif MM, Ready MA. Accidental swallowing of orthodontic expansion key: report of two

cases. ASDC J Dent child 1983; 50:126-127

2. Sfondrini MF, Cacciafesta V, Lena A. Accidental ingestion of a rapid palatal expander. J

Clin Orthod 2003; 37: 201-202

ORIGINAL ARTICLE


INCIDENTAL RADIOGRAPHIC FINDINGS AND THEIR RESTORATIVE

IMPLICATIONS R. Sridevi, Sai Laxman Bharadwaj B, R. Thirumalai Prabhu

1. Senior lecturer, Department of Prosthodontics, Adhiparasakthi Dental College and Hospital. Melmaruvathur,

Tamil Nadu.

2. Intern, Department of Orthodontics, Adhiparasakthi Dental College and Hospital. Melmaruvathur, Tamil

Nadu.


Nadu.


Dr. R. Sridevi,

A-11, Laxmi Apartments,

Meenambal ST, Melmaruvathur, ,

Tamilnadu, India,


ABSTRACT: Radiographs are an irreplaceable diagnostic tool, especially in dealing with

dentofacial hard tissues. Guidelines like the ALARA require professionals to limit the number of

radiographs prescribed to patient, thereby minimizing radiation dose. On the other hand, for

prosthetic evaluation, a latest radiograph has the potential to uncover new findings that can

alter the treatment planning sequence or affect the outcome of the planned treatment. This

review article discusses ten such radiographs. The significant findings in each radiograph have

been highlighted and treatment protocols tailored to the same. The aim of this article is to help

the reader adopt a meticulous approach and a keen eye for detecting problems, and emphasizes

the efficacy of radiographs in patient evaluation for restorative care.

KEYWORDS: Incidental, Findings, Treatment, Interpretation

INTRODUCTION: Dental clinics here in our country are teeming with patients keeping dental

personnel on a tight schedule. Efficient practice in this scenario demands a good balance

between speed, time management and prescribing what is needed and best for the patient.

Frequently patients present for prosthetic rehabilitation with radiographs taken during

previous treatment sittings and we often avoid prescribing a new one. Considering the

possibility of incidental findings, it is wise practice to prescribe a new radiograph during

abutment evaluation. This additional measure avoids unnecessary failures and the need for

prosthetic retreatment like the removal and re-fabrication of fixed bridges which can cause

considerable damage to both tooth structure and the patients’ wallet.

All the radiographs reviewed here, presented to the Prosthodontic clinic in our

institution for rehabilitation. A thorough perusal of this article will tell us how, and bring to

light a multitude of possibilities and occurrences during diagnostic radiography; for what the

mind does not know, the eyes do not see!

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue

Radiograph 1 – RESIDUAL ROOT FRAGMENT

Fracture of a root during exodontia, particularly long,divergent ones is a common

complication 1. The edentulous area in this radiograph reveals the presence of a root fragment

following extraction of the maxillary left second premolar. This incidental finding is familiar

even with novice dental practitioners and cannot be missed. The fragment in thi

more than 5mm in length.

Current guidelines suggest that a root fragment of up to 5mm can be left in situ in a

healthy patient provided there is no evidence of apical pathology

Radiograph 2 – ADJACENT TOOTH PATHOLOGY

In endodontic practice, pulp sensibility testing of the tooth in question is corroborated

with the response of control teeth which are usually adjacent teeth. These tests are indirect and

subject to false positive and false negative readings

interpretation of radiographic findings are an invaluable adjunct to pulp sensibility testing.

In the above radiograph, exposed to evaluate 26 for crown placement, a periapical lesion was

identified in relation to 25. Clinical exami

Class I composite filling, tenderness to percussion and poor response to electric pulp testing

when compared to the contra lateral 15. Endodontic treatment of 25 prior to restoration of 26

was considered prudent to avoid patient discomfort and minimize the number of prosthetic

visits.

ORIGINAL ARTICLE

Journal of Evolution of Medical and Dental Sciences/Volume1/ Issue3/July-Sep 2012

RESIDUAL ROOT FRAGMENT

Fig 1


. The edentulous area in this radiograph reveals the presence of a root fragment


even with novice dental practitioners and cannot be missed. The fragment in this radiograph is


healthy patient provided there is no evidence of apical pathology2.

ADJACENT TOOTH PATHOLOGY

Fig 2

endodontic practice, pulp sensibility testing of the tooth in question is corroborated


subject to false positive and false negative readings3. In such cases, careful evaluation and



identified in relation to 25. Clinical examination was positive for the presence of an occlusal



prudent to avoid patient discomfort and minimize the number of prosthetic

2012 Page 273




s radiograph is




careful evaluation and



nation was positive for the presence of an occlusal




ORIGINAL ARTICLE


Radiograph 3 – MISSED ROOTS

The root canal treated tooth approximating the maxillary right first molar in this

radiograph shows clear evidence of two

The case notes for the patient under reference reveal that this tooth was designated as

15. However, obtaining the past dental history elicits extraction of the upper second premolars

for orthodontic purposes. A maxillary firs

palatal roots, whereas a maxillary second premolar has a single root with a single canal

effect the tooth in question was a first premolar and was scheduled for orthograde retreatment.

This radiograph is significant for two other findings

1. The orientation dot has been positioned mesio

2. The restorative margin in the first premolar is at the level of the interdental bone

distally due to tipping. Adjunctive periodontal therapy is imminent to ensure healthy

placement of crown margins for long

Radiograph 4 – CORONAL SEAL

1

2

ORIGINAL ARTICLE


Fig 3


radiograph shows clear evidence of two root outlines (white arrows)



for orthodontic purposes. A maxillary first premolar has two canals one each in buccal and



h is significant for two other findings

The orientation dot has been positioned mesio-apical instead of mesio-occlusal

The restorative margin in the first premolar is at the level of the interdental bone


placement of crown margins for long-term success.

CORONAL SEAL

Fig 4

2012 Page 274




t premolar has two canals one each in buccal and

palatal roots, whereas a maxillary second premolar has a single root with a single canal 4. In


occlusal



ORIGINAL ARTICLE


Hermetic apical seal for eras has been considered the gold standard for endodontic

success. Contemporary concepts stress that both the coronal and apical seal play an equal role

in determining the same. Coronal seal refers to the protection rendered

restoration (direct or indirect). If the coronal seal is not intact, leakage through the dentinal

tubules can establish reinfection within three months in the canal system leading to failure

The temporary restoration shown in the r

portion adequately. Though marginal discrepancies can be detected clinically on facial and

lingual aspects, the presence and extent of such defects in the approximal regions are detected

with relative ease and precision on radiographs during follow

in this radiograph is a victim of proximal (distal) under preparation and an over contoured

crown (arrow).The necessary adjustments have to done and the crown has to be replaced at

earliest.

Radiograph 5 – ROOT FRACTURE

This is a pretreatment radiograph for a maxillary anterior diastema closure.

Transverse root fractures can occur in the coronal, middle and apical third. Apical third

fractures are usually asymptomatic,

approach for treatment6.

Apical root fractures are by and large detected on radiographs as depicted here in tooth 22.

Prosthetic treatment planning for such teeth involves

1. Eliciting the history of trauma

2. Thorough sensibility testing for all the teeth in the segment

3. Adjuvant endodontic therapy where mandatory

4. In case these teeth are to be used as fixed partial denture abutments, it should be borne

in mind that there is an effective reduction in pericemental area available for support,

especially in a weak abutment like the lateral incisor.

ORIGINAL ARTICLE




in determining the same. Coronal seal refers to the protection rendered by a post endodontic



The temporary restoration shown in the radiograph does not seal and cover the coronal



precision on radiographs during follow-up visits. Also, the restored tooth



ROOT FRACTURE

Fig 5



fractures are usually asymptomatic, exhibit no mobility and advocate a wait and watch



Eliciting the history of trauma

Thorough sensibility testing for all the teeth in the segment

Adjuvant endodontic therapy where mandatory

In case these teeth are to be used as fixed partial denture abutments, it should be borne

effective reduction in pericemental area available for support,


2012 Page 275



by a post endodontic


tubules can establish reinfection within three months in the canal system leading to failure 5.

adiograph does not seal and cover the coronal



up visits. Also, the restored tooth


crown (arrow).The necessary adjustments have to done and the crown has to be replaced at the



exhibit no mobility and advocate a wait and watch




ORIGINAL ARTICLE


Radiograph 6 – CYSTIC LESIONS

Fig 6

Fig 7

Cystic lesions in the jaws are generally incidental findings on radiographs. The extent

and the nature of the lesion determine the prognosis. Henceforth, it is wise to subject these

lesions to histopathological examination before harping on a treatment plan for the patient.

The periapical radiograph and the ortho-pantomograph are those of two different

patients. The anterior maxillary lesion in the periapical (Fig 6) revealed a residual cyst. The

right mandibular posterior lesion in the panoramic view (Fig 7) turned out to be an odontogenic

keratocyst.

Significance – Residual cyst can expand and interfere with the fit of a prosthesis7, and

the presence of this multilocular odontogenic keratocyst presents an absolute contraindication

to implant placement or immediate replacement with fixed bridges owing to their aggressive

behavior and high recurrence rate 8. The residual cyst has to be thoroughly enucleated and

following the period of healing definitive prosthesis can be fabricated. As far as the Gorlins cyst

goes, it demands radical treatment and an extended follow up period to ensure complete

regression of the lesion before any form of definitive rehabilitation is planned.

ORIGINAL ARTICLE


Radiograph 7 – FURCATION INVOLVEMENT

Fig 8

The pulp and the periodontium have an embryologic, anatomic and functional

interrelationship. When the two are involved in disease simultaneously it is known as an endo-

perio lesion which classically can be demonstrated by furcation involvement of an

endodontically compromised or previously root treated tooth.

The radiograph depicts a Class III furcation involvement in 36 and has the potential to be

treated by surgical periodontal therapy9, but a close examination of the radiograph reveals

1) Poor quality endodontic therapy

2) Apical overextension of gutta percha in mesial root

3) Grossly destroyed coronal tooth structure

4) Class I restorations in the adjacent teeth

Taking into account all the above factors, the consensus was to extract the tooth and replace

with a fixed partial denture with support from 35 and 37.

Radiograph 8 – POST LENGTH

Fig 9

Anterior teeth are strategically located and designed to withstand the lateral forces. Post

endodontic restoration of extensively damaged crowns warrants the use of a post for retention

of the core.

ORIGINAL ARTICLE


In selecting posts for anterior teeth, it is vital that the post should be long enough to satisfy

clinical requirements without jeopardizing the root integrity10. The standard parameters are11,

1) The post should be 2/3rd the length of the root

2) The length of the post can also equal the coronal length of the tooth

3) The post should extend into one half the length of the root embedded in its supporting

bone.

In this patient the core in 22 is supported by a screwed post that does not extend to the

adequate depth. The bone levels are well below normal and the post stops at the level of

alveolar support. Short, stiff posts transfer forces to the unsupported root extending above the

alveolus and can cause root fracture11. It was decided to use only the central incisor 21 as a

terminal abutment to restore the edentulous area and follow up on the prognosis of the lateral

incisor.

Radiograph 9 – ANKYLOSED TOOTH

Fig 10

The patient presented for single unit restoration of root canal treated 26.

Accidental finding includes ankylosed maxillary left second premolar as evident in the absence

of a distinct periodontal ligament space, definitive pulp canals and chamber and infraoccluded

position.

Ankylosis is a pathologic fusion of the cementum or dentin of a tooth root to the alveolar

bone12. Adults, with their slower rate of replacement resorption may retain an ankylosed tooth

for many years with minimal treatment or minor cosmetic modifications13. At present, there are

no guidelines in the dental literature for the treatment of ankylosis14. The parameters that

influence treatment in this case include

1) Adult presentation and diagnosis of ankylosis

2) Mild infraocclusion

3) Considerable rotation and misplaced proximal contacts which necessitates pulp therapy

before preparation for full coverage restorations.

4) An adjacent root treated molar

Therefore, it was decided to restore the molar with a full metal coverage crown combined with a

minimal preparation onlay restoration on 25 to restore function.

CONCLUSION: A patient’s radiograph is an indicator of both past and current disease

experience. Dental professionals should aim at absorbing as much information as possible from

ORIGINAL ARTICLE


a given radiograph, for, this information may possess the power to reroute our original

treatment plan in lieu of the patient’s best interests.

An incidental finding is one that accompanies and does not constitute the major reason

for exposing the radiograph. Majority of these findings can be attributed to iatrogenic causes

except for pathologies like cysts and fractures. Timely identification of these errors can best

avoid irreversible damage to the dentition.

REFERENCES :

1. Peterson. Ellis. Hupp. Tucker: Ch 11 Prevention and management of surgical

complication in Contemporary oral and maxillofacial surgery, 4 ed, Pg 221-237

2. Abhay N Dhatarkar: Ch 13 in Exodontia Practice 1ed, Pg 129 – 134

3. V Gopikrishna et al; Assessment of pulp vitality – A review. International Journal of

Pediatric Dentistry 2009, Vol 19: 3-15.

4. T.R Pitt Ford, Ch 3 in Endodontics- Problem Solving In Clinical Practice, Pg 33-35

5. B A Begotka et al, The importance of coronal seal following root canal treatment.

Virginia Association Dental Journal, 1996, Oct-Dec, 73(4); 8-10

6. J.O Andreasen and F.M Andresen: Ch 12 Root fractures in Text Book and Color Atlas of

Traumatic Injuries to the teeth 4ed, pg 337-371

7. Cawson and Odell: Cysts of the jaws in Essentials of Oral Pathology and Medicine 7ed,

Pg 102-128

8. Nakamura et al: Marsupilization of Odontogenic Keratocysts – Long term follow up

analysis of the effect and changes in growth characteristics, Oral Surgery Oral Medicine

Oral Pathology Radiology Endodontology, 2002 Vol 94: 543-553.

9. Murray Arlin, Oral Health 1987 Vol 77(5): 29-34

What this article tells us?

To always consider the possibility of spotting pathologies on

routine radiography

Why is it important?

The preservation of that which remains is of utmost importance

than the meticulous replacement of that which has been lost.

How can we identify them?

A thorough knowledge combined with adequate experience

Where to learn these skills from?

Practice is the key.

It is the onus of every practitioner to keep himself up-to-date on

changing trends in treatment planning and diagnosis and apply

them on a daily basis.

ORIGINAL ARTICLE


10. Goodacre CJ et al: The Prosthodontic Management of Endodontically treated teeth – A

literature review II – Maintaining the apical seal, Journal of Prosthetic Dentistry 4:51,

1995

11. Stephen Cohen, Ch 21 Restoration of Endodontically treated teeth in Pathways of the

Pulp, Pg 786 – 821

12. William Biederman et al, Etiology and treatment of tooth ankylosis, American Journal of

Orthodontics, Vol 48(9): 670–684

13. Ebeleseder KA, Friehs S, et al, A study of replanted permanent teeth in different age

groups. Endod Dent Traumatol 14(6):274-8, 1998

14. Moffat MA et al , Intentional surgical repositioning of ankylosed permanent maxillary

incisor Dental Traumatology 2002; 18: 222–226

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Page 69

USE OF TRADITIONAL MEDICINE IN FEVER

Purabi Phukan

1. Associate Professor, Department of Community Medicine, Srinivasa Institute of Medical Sciences and Research

Centre, Mangalore- 574146


Dr Purabi Phukan,


Department of Community Medicine,

Srinivasa Institute of Medical Sciences and Research Centre,

Mangalore- 574146,

Karnataka, India.


INTRODUCTION:

Malaria is the most common cause of fever in India and is an age old problem in India

claiming thousands of life over the years 1,2. WHO launched its first ever comprehensive traditional

Medicine strategy in 2002 strategy to assist countries to gather and preserve knowledge on such

practices with the hope to develop a good database for finding antimalarial properties in future in

wake of drug resistance. Majority of the rural and tribal in rural areas have vast store of knowledge

and practice of traditional medicines as it is cheaper and easily accessible to them 3 4 5. Traditional

Medicine often becomes the first source of treatment for these communities. The WHO estimated

that 80% of the world’s population use botanical medicines for their primary health care needs,

malaria treatment inclusive6. The current study was therefore undertaken with an objective to find

out the knowledge and practices of traditional medicines among rural and tribal communities for

fever and the factors influencing such practices.

KEY WORDS: Malaria, Traditional Medicine, Fever, Ethnopharmacology

MATERIAL & METHODS:

A community based cross-sectional study was undertaken from June 2009 to May 2010 in

Rani Community Development Block which is the Rural Field practice area of Gauhati Medical

College, Assam. The Block has 96 villages with total population of 86,539 and literacy rate is 66.8%

(2001 Census). The block has 18% tribal population residing in 36 villages.

Considering expected frequency as 50%, by using Epi Info Version 7 sample size was

calculated to be 300 (95% confidence level, confidence limits of 5.65%). To get a representative

population, the households were selected by Proportionate Probability Stratified Random Sampling

technique from 16 villages. The 16 villages together formed a uniform composition, firstly in terms

of tribal and non-tribal study subjects and secondly in terms of easier and more difficult access to

health services. Stratification was done based WHO Protocols and methods of malaria situation

analysis 6. Head of the household was interviewed and data was collected in a pre-tested and

predesigned proforma regarding socio-demographic characteristics, knowledge and practices of

SHORT COMMUNICATION


Page 70

traditional medicines in fever and in known malaria, factors influencing their use. Also the herbs

and plants that are used was identified and recorded. However the pharmacological property of

these plants and herbs are out of the scope of this study and review of Botanical Plants literature

was done to find out available data on its use and medicinal properties. Statistical Analysis of the

data was subjected to descriptive analysis and Epi Info Version7.

RESULTS:

The Socio demographic profile of the study population is shown in Table 1. Among the 150

tribal and 150 non-tribal households visited it was found that literacy level of head of the

household was 82.7% and 92.6% respectively, with total literacy rate of 87.7%. According to

occupation of the head of the families it was found that majority are cultivators (51.2%) among the

tribal and businessman (40.7%) among the non-tribal communities and 24 % and 12.6% of the

tribal and non-tribal families are living below poverty line (income less than Rs 228.9 per capita per

month at 1993-94 prices). The respondents belonged to the age group of 19 -59 years, of which,

among the tribal 61.4% are males and 38.6% are females while among the non-tribal respondents,

72% are males and 28% are females. Majority of the tribal respondents belonged to Hindu (82.4%)

and rest were Christian (21.3%) whereas among the non-tribal respondents majority were Hindu

(86%) and the rest Muslim (14%).

Table 2 shows that knowledge and practice of traditional medicine. Out of the 300

households visited only 49 (16.3%) households knew of traditional medicines used in fever. Out of

these 49 households, majority, 38 (25.3%) belonged to the tribal community while 11 (7.3%)

belonged to non-tribal community. However, out of the 49 households, only 8 (5.3%) of the tribal

households and 3 (2%) of the non-tribal households are currently involved in collection and

preparation and distribution of the medicine prepared from the herbs. The names of the herbs and

plants used and the mode of preparation and administration was demonstrated and explained by

them.

The remaining 251 (83.7%) of the respondents did not have any faith in traditional

medicines for treatment of malaria and they neither had any knowledge of these remedies. Further,

it must be mentioned that although use of traditional medicines was reported by 49 households, it

is usually used as an initial management; if fever does not improve in next 2-3 days then they opt

for allopathic medicines.

Table 3 shows the common factors influencing the practice of traditional medicines for

fever. However, 40 (81.6%) respondents, 32 (84.2%) tribal and 8 (72.7%) non-tribal respondents

said they would also prefer to use traditional medicines as an adjunct to antimalarials if diagnosed

as malaria fever.

In this study 6 botanical plants that are practiced in the study area were identified and

recorded. Table 4 shows the different plants and herbs that were identified. These are Murraya

koenijii, Vitex negundo, Centella asiatica, Azadiracta indica, Ocimum sanctum/Ocimum basilicum

and a plant known as Tupurilata or Panipanta locally (scientific name unknown) are identified to be

used for treatment of fever and malaria as home remedy.

It was found that in case of the plant Tupurilata (local name), it was made into a thin paste

mixed with coconut oil and is applied over the scalp of infants and young children with high fever

when parents fear to giving allopathic medicines because they believe them to be having adverse

SHORT COMMUNICATION


Page 71

side effects. The other plants and herbs like Narasingha, Pasotia are grinded together applied on

scalp or body to get relief from headache and bodyache associated with fever. Whereas Manikmoni,

Neem and Tulsi taken orally in the treatment of persistent fever for young children as well as adults

by grinding and mixing them together and making a decoction and taken orally to get relief from

fever.

DISCUSSION:

The results of this study revealed that knowledge of traditional medicines was present only

in 49 (16.3%) of the respondents while only 11 (3.6%) practiced it in their homes recently. Similar

result was found in another study where 2.1% of the tribal community used local herbs for

treatment of malaria7. This value is comparatively less than the findings in other studies in Assam

where initial treatment through traditional healer (Vaidya) was found in 39.2% 8. The remaining

97% of the respondents did not have any knowledge about these traditional medicines used nor

believed that they can be helpful in malaria treatment.

The decreasing knowledge and practice of traditional medicines may be due to increased

malaria awareness campaigns in recent years and also due to high literacy rate of the study

population.

However in this study none of the respondents said that they will depend solely on TM if

fever is known to be due to malaria which is a positive finding in this study. After initial home

management if fever does not improve in 2-3 days than they opt for allopathic treatment from

doctor. This shows that access to early diagnostic facility would prevent the morbidity and

mortality that occurs due to delay in diagnosis. The factors like severity of fever, associated

symptoms of jaundice, infants and young children with persistent fever and fever in elderly people

and fear of side effects of the antipyretics and anti-malarials influenced the use of traditional

medicine. They are of the opinion that these medicines are safer to give to infants rather than

antimalarials as they seen side effects after using these. Similar finding was observed in Nigeria9.

Affordability of medicines was not a factor as they were aware of the free antimalarials available at

the health center.

Regarding the medicinal value of the plants used it was found that some of them indeed

were found to be having some benefit in treatment of fever and even in malaria.

Ocimum sanctum, locally known as “Tulosi” was found to be having many properties

including antipyretic and anti-malarial activity against P. falciparum and P vivax 10, 11, 12.

Similar use for fever and cough was also found in Arunachal Pradesh among Khamti tribes

in Lohit District13 and in rural area of Tamil Nadu14. In another study insecticidal property of tulsi

was also found15.

Azadirachta indica, locally known as “neem” was also found to exhibit antimalarial activity

by inhibiting the growth of P. falciparum 16and even against drug resistant strains of P. falciparum 17, 18.

Vitex negundo, locally known a “pasotia” meaning five leaved plant, Ayurveda it is called

nirgundi and in the west known as Chastetree, has proved to be useful in fever, spleen enlargement

and convulsion14 and in malaria19. Besides this it was also found to have insecticidal and pesticidal

properties by other studies 20, 21, 22.

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Centella asciatica, locally known as “manikmoni”, was also found to be useful malarial fever 23, 24, 25.

Murraya koenigii, locally known as “Narasingha” in this study area was also found to be

having anti-inflammatory property and hepatoprotective26.

A study in Africa has shown that traditional medicine can reduce 1 million malaria deaths.

In rural Tanzania a study about traditional Masai medicine showed 48% children already had

knowledge about these plants which have been preserved in the UN database for future reference27.

“Tupurilata” was not found in any database and it is a new plant found in this study which needs to

be studied. B N Prakash, a researcher with the foundation for the revitalization of Local Health

Tradition, based in Bangalore found Guduchi (Tinospore coeditdia) to have shown to reduce

malaria related deaths by 5 to 10 times.

CONCLUSION:

The study indicates that knowledge and practices regarding traditional medicines for

malaria or fever has significantly declined in the study population. The study indicates that delay in

malaria diagnosis may be one of the causes of depending on traditional medicine which can be

improved by making easier access to early diagnosis. That the use of traditional medicines does

more damage than good does not hold good in the current scenario when many studies did reveal

their usefulness. But certain remedies which have not been tested for efficacy is not encouraged so

vigorous research on the efficacy of traditional plants on malaria treatment should be carried out to

ascertain their usefulness. Ethno-pharmacological studies are encouraged to determine the

usefulness these traditional remedies, as few of these were found to be having some anti-malarial

property. The commonly used plants are brought out in this study along with their use. For this

purpose a book called “Traditional medicines and plants and malaria” by Merlin Wilcox, Gerard

Bodeker and Phillipe Rasanova provides guidelines on how to conduct such studies.

TM practice is an established health care system in India and is fast growing importance in

the western world. India can therefore contribute immensely for development and research for

alternative malaria treatment.

ACKNOWLEDGEMENT:

I thank, Dr R Sarma, Professor, Department of Community Medicine, Gauhati Medical

College, for her guidance pertaining to this work. I also would like to thank Ms. M Baruah, Lecturer

Botany, Arya Vidyapeeth College and Dr N D Bendegeri, Professor and Head, Department of

Community Medicine, KBNIMS for providing their valuable suggestions in preparation of this paper

for publication.

REFERENCES:

1. (Dhiman RC, Pillai CR, Subbaroa SK. Investigation of malaria outbreak in Bahraich district,

Uttar Pradesh. Malaria Research Center (ICMR), Delhi, India. Indian J of Med. Res. May 2001;

113:186-91.

2. C D Alert. Some important outbreaks of malaria in India during 2000. Jan 2001; 5:1.

3. WHO. Traditional Medicine Strategy 2003-2005. Geneva. Document: WHO/EDM/TRM/

2002.1.

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Page 73

4. Pulok K. Mukherjee and Atul Wahile. Integrated approaches towards drug development

from Ayurveda and other Indian system of medicines. Journal of Ethnopharmacology; 2006;

103: 25–35.

5. Merlin Willcox. Traditional herbal medicines for malaria. BMJ. 2004; 329 (7475):1156

6. Protocols and methods for malaria situation analysis. WHO, HIV/AIDS, Tuberculosis,

Malaria. Roll Back Malaria. July 2003. Trial Edition. Pg.1-88. (WHO/HTM/RBM/ 2003.47)

7. V Soan, Gyan Chand. Proceedings of National Symposium on Tribal Health. Knowledge,

Attitude and Practices towards Malaria in Tribal Community of Baigachak Area, Dindori

District (MP), Pg-75-78 (http://www.rmrct.org/files_rmrc_web/centre's_publications/

NSTH_06/NSTH06_9.V.Soan.pdf)

8. Chaturvedi HK, Mahanta J and Pandey A. Treatment-seeking for febrile illness in north-east

India: an epidemiological study in the malaria endemic zone. Malaria Journal.

17 December 2009; 8:301 (doi:10.1186/1475-2875-8-301)

9. Erhun W O, Agbani E.O and Adesanya S.O. Malaria Prevention: Knowledge, Attitude and

Practice in a Southwestern Nigerian Community. African Journal of Biomedical Research;

2005; 8: 25 - 29.

10. Pandey BP, Anita. In: Economic Botany; 1990. p. 294 (Published by Chand and Company

Ltd., Ramnagar, New Delhi.

11. P. Prakash and Neelu Gupta. Therapeutic uses of Ocimum sanctum Linn. (TULSI) with a note

on Eugenol and its pharmacological action: A Short Review. Indian J Physiol Pharmacol

2005; 49 (2): 125–131

12. Savitri Godhwani, J.L. Godhwani and D.S. Vyas. Ocimum sanctum: An experimental study

evaluating its anti-inflammatory, analgesic and antipyretic activity in animals. Journal of

Ethnopharmacology. November 1987; 21(2): 153-163

13. Hui Tag, AK Das, Hari Loyi. Anti-inflammatory palnts used by Khamti tribes in Lohit District

of Auranachal Pradesh, India. Natural Product Radiance. 2007; 6(4):334-340.

14. Chellaiah Muthu, Muniappan Ayyanar, Nagappan Raja and Savarimuthu Ignacimuthu.

Medicinal plants used by traditional healers in Kancheepuram District of Tamil Nadu, India.

Journal of Ethnobiology and Ethnomedicine; 2006, 2:43 doi:10.1186/1746-4269-2-43).

(available online at: http://www.ethnobiomed.com/content/2/1/43)

15. Ocimum sanctum. The Indian home remedy. In: Current Medical Scene, March-April 1992;

(Edited and published by S. Rajeshwari, Cipla Ltd., Bombay Central, Bombay.

16. Rochanakij, S., Thebtaranonth, Y., Yenjal, C. H. and Yuthavong, Y. Nimbolide, a constituent of

Azadirachta indica inhibits Plasmodium falciparum in culture. Southeast Asian J. Trop. Med.

Public Health; 1985; 16: 66–72.

17. Kausik Biswas, Ishita Chattopadhyay, Ranajit K Banerjee and Uday Bandopadhyay.

Biological activities and medicinal properties of neem (Azadirachta indica). Curent Science;

82(11):1336-1345.

18. Badani, L., Deolankar, R. P., Kulkarni, M. M., Nagsampgi, B. A. and Wagh, U. V. Biological

activities and medicinal properties of neem. Indian J. Malariol.; 1987; 24: 111–117.

19. agnus-castus.co.uk. [homepage]. Agnus castus (Vitex negundo). (available from

http://www.herb-agnus-castus.co.uk)

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Page 74

20. Vishal R Tandon. Review article: Medicinal Uses and biological properties of Vitex negundo.

NISCAIR Online Periodicals Repositories (NOPR). 2005; 4 (3): 162-165.

21. Hebbalkar DS, Hebbalkar GD, Sharma RN, Joshi VS, Bhat VS. Mosquito repellent activity of

oils from Vitex negundo Linn. leaves. Indian J Med Research; 1992; 95:200–203.

22. Krishnan Kannathasan & Annadurai Senthilkumar & Manivachagam Chandrasekaran &

Venugopalan Venkatesalu. Differential larvicidal efficacy of four species of Vitex against

Culex quinquefasciatus larvae. Parasitol Res; 2007; 101:1721–1723.

23. Nima D. Namsaa, M. Mandal and S. Tangjang. Anti-malarial herbal remedies of northeast

India, Assam: An ethnobotanical survey. Journal of Ethnopharmacology. Article. In Press-

Corrected Proof. 2010).

24. Sakshi Singh, Asmita Gautam, Abhimanyu Sharma and Amla Batra. Centella asiatica (L.): A

plant with immense medical potential but threatened. International Journal of

Pharmaceutical Sciences Review and Research. 2010; 4(2). Article 003 (Available online at

www.globalresearchonline.net).

25. Rahmatullah Mohammad, Ferdausi Dilara, Mollik Haque Ariful Md., Jahan Rownak,

Chowdhury H. Majeedul, Haque Mozammel Wahid, A survey of medicinal plants used by

Kavirajes of Chalna Area, Khulna District, Bangladesh. Afr. J. Trad. 2010; 7(2): 91-97

26. Bitterroot restoration [homepage]. Herbal Medicine> Medicinal Plants-Murraya koenijii.

27. IRIN: AFRICA: Turning to traditional medicines in fight against malaria. [Homepage]. IRIN:

The humanitarian news and analysis. A service of the UN Office for the co-ordination of

Humanitarian Affairs). (available at: http://www.irinnews.org)

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* fisherman, silkworm rearing, selling household produce like betel nuts and vegetables,

agricultural labourer, income from house rent and income from pension.

Table 1. Socio-demographic profile of the study population

Socio demographic Tribal (150) Non-tribal (150) Total (300)

profile No. (%) No. (%) No. (%)

Religion

Hindu 118 (78.7%) 129 (86%) 247 (82.4%)

Muslim - - 21 (14%) 21 (14%)

Christian 32 (21.3%) - - 32 (21.3%)

Sex

Male 92 (61.4%) 108 (72%) 200 (66.7%)

Female 58 (38.6%) 42 (28%) 100 (33.3%)

Age range (years)

19-28 15 (10.0%) 9 (6.0%) 24 (8.0%)

29-38 44 (29.2%) 49 (32.7%) 93 (31.0%)

39-48 52 (34.8%) 52 (34.8%) 104 (34.7%)

49-58 28 (18.8%) 26 (17.3%) 54 (18.0%)

>59+ 11 (7.2%) 14 (9.2%) 25 (8.4%)

Education Level

Illiterate 26 (17.3%) 11 (7.4%) 37 (12.4%)

Primary School 56 (37.3%) 35 (23.3%) 91 (30.4%)

High School 44 (29.3%) 57 (38.0%) 101 (33.7%)

HSCL passed 16 (10.7%) 21 (14.0%) 37 (12.4%)

HS passed & above 8 (5.4%) 26 (17.3%) 34 (11.4%)

Occupation

Cultivator 77 (51.2%) 47 (31.3%) 124 (41.3%)

Daily wage earner 62 (41.3%) 19 (12.7%) 81 (27%)

Skilled labour 5 (3.3%) 2 (1.3%) 7 (2.3)

Service 26 (17.3%) 37 (24.7%) 63 (21%)

Business 10 (6.6%) 61 (40.7%) 71 (23.7%)

Others* 17 (11.3%) 8 (5.3%) 25 (8.4%)

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Table 2. Head of household having knowledge and practice of traditional medicine in fever

Traditional

Medicine

Tribal

(n=150)

Non-tribal

(n=150)

Total

(N=300)

No. % No. % No. %

Current knowledge Yes 38 25.3 11 7.3 49 16.3

No 112 74.7 139 92.7 251 83.7

Practicing within household Yes 8 5.3 3 2 11 3.6

No 142 94.7 147 98 289 96.3

Table 3: Reason for use of traditional medicines in fever

Variables Tribal

(n=38)

Nontribal

(n=11)

Total

(N=49)

Very high fever in young children 29 76.3 2 18.1 31 63.3

Fever associated with jaundice 10 26.3 2 18.1 12 24.5

Fear of side effects of allopathic drugs 20 52.6 10 90.9 30 61.2

Use side by side with allopathic treatment 32 84.2 8 72.7 40 81.6

Side effects of Antimalarials drugs 20 52.6 10 90.9 30 61.2

Fever in Elderly with poor physical status 10 26.3 4 36.4 14 28.6

*Multiple responses

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Table 4- Showing information collected about the botanical plants used.

Local name Scientific name Parts of plants

used.

Mode of use

Panipanta/

Tupurilata

Unknown leaf is the useful

part.

Leaf is made to a thin paste, after

mixing with oil and applied to the

scalp

Narasingha Murraya koenijia leaf and stem Leaves are eaten directly or by

boiling in water and making a paste

Pasotia Vitex negundo leaf

Leaves are eaten directly as

vegetable or boiled and thin paste

made

Manikmoni Centella asiatica leaf A paste of the leaves are made and

given empty stomach.

Mahaneem Azadiracta indica leaves, stem and

roots

Boiled in water and the water is

given to drink

Tulsi Ocimum sanctum/

Ocimum basilicum

leaves Leaves are eaten directly.

CASE REPORT


UNUSUAL LOCATION OF CYSTICERCOSIS LESION PRESENTATION

Dr. V. Geeta, Dr. Parimla Devi, Dr. A. Sirisha, Dr. Rama Devi, Dr. Jijiya Bai, Dr. Shravan Kumar


2. Associate Professor, Department of Pathology, Gandhi Medical College, Secunderabad-6



5. Professor and HOD, Department of Pathology, Gandhi Medical College, Secunderabad-6

6. Professor, Department of Pathology, Gandhi Medical College, Secunderabad-6


Dr. V. Geeta,




Secunderabad-6


INTRODUCTION:

Cysticercosis in humans is exclusively caused by larvae of T.solium which have predilection

for skeletal muscle, eyes, and central nervous system. In literature head and neck manifestations of

Cysticercosis is reported as soft tissue swellings at sub mental area, cheek as well as tongue1-4.

Cysticercosis presenting as a nodule or mass on neck is a very rare occurance5. The diagnosis was

usually made on Histo pathologic examination. The ensuing clinical disorder is named after the

organism at this larval stage, cysticercosis cellulose Larva of pork tapeworm Taenia solium.

KEY WORDS: Cysticercosis, T.solium

CASE HISTORY:

A 21 years male presented with a painless solitary nodular swelling on right side of the

upper neck of 2 years duration. The nodule was gradually increasing in size, associated with

anxiety, easy fatigability, palpitations, decreased appetite and weight loss.

Local examination revealed 2 x 2 cm round, smooth swelling present on right side of neck at the

level of Thyroid cartilage and anterior to the upper 1/3rd of sternocleido mastoid muscle and on

palpation the swelling is cystic, non tender, firm in consistency, not moving with deglutition and on

protrusion of tongue.

Skin over the swelling was non pinchable. No local rise in temperature. Swelling was mobile

both horizontally and vertically, not attached to the underlying muscle. General and systematic

examination within normal limits.

Clinical Diagnosis made was

1) Benign cystic swelling of right neck.

CASE REPORT


2) Sebaceous cyst

3) Lipoma

4) TB lymph node

5) Aberrant thyroid

6) Salivary gland

FNAC: S/o ‘?’ necrotic lymph node, complex cyst or parasitic cyst.

U/S: S/o ‘?’ necrotic lymph node

Excision of the cyst was done and sent for HPE

The Histopathologic examination revealed ‘Cysticercosis Cellulose’ characterized by a scolex

and epithelium lined by tortuous body and continuous with outer cystic layer. Cyst enclosed by a

fibrous capsule infiltrated with lymphocytes, plasma cells and eosinophils. Figure.1

The post operative period was uneventful.

DISCUSSION:

Taenia solium passes its life cycle in two hosts. The definitive host is human who harbors

the adult worm and intermediate host in pig which harbors the larval stage. The adult worm lives in

the small intestine of man. Usually one adult worm is present which lives for years. It is about 3

meters long with proglotids, the gravid segments with about 50000 eggs in each gravid segment.

The worm sheds gravid segments laden with eggs in the stools which infect pigs on reaching the

alimentary canal of the intermediate host penetrate the gut wall and reach systemic circulation and

are lodged in different organs and muscles. They develop in to larvae referred as cysticercosis

Human being are infected through eating under cooked contaminated pork or infected vegetables.

Adult worms shed gravid segment laden with eggs in the stool, which re infect pigs. Thus

completing the cycle. Autoinfection of man may occur by contaminated fingers or by reversal of

peristaltic movements of intestine, the gravid segments are thrown back to the stomach and larvae

disseminate throughout the body via Arterio Venous Channels and lymphatics encysting in

subcutaneous tissue, striated muscle, brain and ocular tissue6.

Cysticercosis manifestations are different and depend on the location in the body and also

number of cysticercosis of a particular site and associated inflammatory response. 87%

cysticercosis cases – presents as solitary or multiple subcutaneous nodules on the trunk, upper

arm, neck, tongue, face and breast has been reported in this order of frequency.

In many patients involvement of central nervous system in the form of neuro Cysticercosis is

diagnosed when multiple cystic ring enhancing parenchymal lesions has been detected on CT Scan7.

We are not reporting this case because of its unusual site of presentation, but also the importance of

histopathologic examination is emphasized since neither the clinical examination nor history

suggested the diagnosis other than a benign lesion.

CASE REPORT


Photo micrographs showing cystic lesion containing parts of parasite and the cystic wall containing

granulation tissue with inflammatory reaction.

REFERENCES:

1. Kinnman J, Chi CH, Park JH. Cysticercosis in Otolaryngology. Arch Otolaryngol 1976;

102:144-7

2. Beaver PC, Jung RC, Cupp EW. Clinical Parasitology, 9 th edition. Philadelphia: Lea & Febiger,

1984.

3. Jain RK, Gupta OP, Aryya NC. Cysticercosis of the tongue. J Laryngol Otol 1989; 103:1227-8

4. Gupta SC and Gupta SC. Cysticercosis of the tongue. Ear Nose Throat J 1995;74:174-8

CASE REPORT


5. Cysticercosis of the neck-a report of unusual case. Danai Tanechpongfamb, dept.of oto rhino

laryngeology; Pathum thani Hospital, Journal of Medicine and health sciences, faculty of

medicine, srinakharin wirat university, Vol. 12, No.2, Aug-2005.

6. Park K. Epidemiology of Communicable diseases. In: Park K. Park's Textbook of Preventive

and Social Medicine. 16 th ed. New Delhi: M/s Banarsidas Bhanot Publishers, 2000; 229.

7. Smiti S, Sripathi H and Naik L. Unusual location of cysticercosis lesions in soft tissue –

Report of three cases. Ind J Radiol Imag 2003;13:157-8

ORIGINAL ARTICLE


CLINICO– EPIDEMIOLOGICAL PROFILE OF ROAD TRAFFIC INCIDENTS

ADMITTED AT A TERTIARY CARE HOSPITAL IN GARHWAL-

UTTARAKHAND

Sumeet Dixit, Praveen K. Tyagi, Amit K. Singh, Sudhir K. Gupta, Nidhi Malik

1. Dr. Sumeet Dixit, Assistant professor, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

2. Dr. Praveen K. Tyagi, Assistant professor, Department of General Surgery, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

3. Dr. Amit K. Singh, Associate professor, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

4. Dr. Sudhir K. Gupta, Associate professor, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)

5. Miss Nidhi Malik, Demonstrator, Department of Community Medicine, VCSGGMSRI– Srinagar, Pauri– Garhwal

(Uttarakhand)


Dr. Amit K. Singh,


(Community Medicine),

VCSG Govt. Medical College,

Srinagar – Garhwal, Uttarakhand,

India– 246174.


ABSTRACT:

BACKGROUND: The magnitude of Road traffic incidents and fatalities in India is alarming. In 2009,

4.22 lakh road traffic incidents and 1.27 lakh road traffic fatalities were reported. These numbers

translate into one road accident every minute and one road accident death every four minutes

METHODS: The study (based on Jorgensen and Abane model, 1999) was conducted over a period

of one year during April 2011 to March 2012, among 136 victims (including 33 drivers) of road

traffic incidents coming to Veer Chandra Singh Garhwali government medical college, Srinagar,

Garhwal. RESULTS: 136 victims including 33 drivers were interviewed who were brought to the

causality in the aforesaid period. 23 people were brought dead. There is clustering of cases from the

month of August to October when compared to other months of year. 40% of drivers were

drunk/or using some other substance at the time of accident. Only 12.1% of drivers were using seat

belts at the time of accident. 57.6% were having driving license and 54.5% were either refractive

error or hearing impairment or both. Human error, High speed, Lack of sleep, effect of Alcohol and

mechanical fault of vehicle were reasons of accident as told by the drivers CONCLUSIONS: During

August to October there is clustering of cases. This period coincides with “Char Dham Yatra” and

rainy season both. Special efforts should be done during this period. Strong vigilance of drivers for

ORIGINAL ARTICLE


alcohol use, presence of driving license, compulsory use of seat belts, and premedical checkup for

refractive errors may prove valuable and morbidity and mortality can be minimized.

KEY WORDS: Road Traffic Incident, Determinants, Hilly region

INTRODUCTION:

Road traffic incidents which are generally unintended and preventable are a common risk

every day to life that can happen to almost every one, anywhere. The problem of road traffic

incident is increasingly becoming a threat to public health and national development in many

developing countries. Road traffic incidents contribute to poverty by causing deaths, injuries,

disabilities, grief, lost of productivity and material damages. Road traffic incidents are the most

frequent causes of injury-related deaths world wide1. According to the World Report on Road

Traffic Injury Prevention2 traffic accidents account for about 3000 daily fatalities worldwide.

Statistical projections show that during the period between 2000 and 2020, fatalities related to

traffic incidents will decrease with about 30% in high income countries. The opposite pattern is

expected in developing countries, where traffic accidents are expected to increase at a fast rate in

the years to come. In developing countries the trend has reached an alarming state, but very little

attention is paid to the problem3. There is evidence that using minimum safety standards, crash

worthiness improvement in vehicles, seatbelts use laws and reduced alcohol use can substantially

reduce deaths on the road4. The magnitude of Road traffic incidents and fatalities in India is

alarming. In 2009, 4.22 lakh road traffic incidents and 1.27 lakh road traffic fatalities were

reported5.These numbers translate into one road incident every minute and one road incident

death every four minutes. However, this is an underestimate, as not all injuries are reported to the

police5. Hilly regions are prone for RTA and there are very few number of studies in such areas.

Therefore this study is under taken to identify the clinic – epidemiological profile of Road traffic

incidents amongst patients admitted at Base hospital, Srinagar - Garhwal and to assess the factors

associated with the causation of the same.

METHODOLOGY:

A model for traffic incident as inspired by the ecological model of a disease was developed

by Jorgensen and Abane (1999)6 who made a heuristic adjustment of this basic model to suit road

traffic accident analysis. The model is characterized by three main components:

1. The vehicle (corresponding to the vector in disease ecology) which describes vehicles into

its composition, age, technical conditions and safety equipments like seat belts in a car.

2. The environment, comprising the road system and the wider physical and built up

environment. The physical environment splits further into different aspects such as;

Daylight and climate (weather conditions and road conditions), Spatial conditions

(arrangements and Macro structures), Settlement pattern (Urban or rural / sparse or

populated area), situation of areas of residence and working areas, Principle of traffic

separation, topography and road constructions qualities.

3. The behavior of the population; including its characteristics such as age and sex ratio as

well as attitudes and general traffic behavior. And it goes further into driving behavior,

driving experience, driving style, risk compensation and risk driving (influence of alcohol

and drugs).

ORIGINAL ARTICLE


Superimposed on this model is a system of traffic laws, regulations and mode of enforcement

designed to ensure that the population adheres to the controls and regulations so as to maintain

some level of road safety i.e. traffic rules (speed restrictions, road signs), speed controls and

convictions for various road traffic offences6. Based on this model this cross sectional study was

done with the help a pretested questionnaire, in a tertiary care hospital in Garhwal. All cases of RTA

coming to the tertiary care hospital during March 2011 to February 2012 were included in the

study. Questions were asked for assessing various risk factors as per the above said model and data

entry was done on excel and analyzed thereafter.

ETHICAL CONSIDERATIONS:

Ethical clearance from institutional review board/ institutional ethical committee was taken

for the study. Written consent was sought from the all respondents. They were informed about the

nature and the purpose of the survey.

RESULTS:

During the study period a total of 136 individuals came for the medical assistance (Figure-

1).117 were males 19 were females. Out of them 33 were drivers of the vehicle, which got the

accident. The number of brought dead persons because of Road Traffic Incidents, in the aforesaid

period was 23. Out of the brought dead individuals 5 were drivers of the vehicle. Maximum number

of morbidity because of RTI is evident in the month of December. There is clustering of cases from

the month of August to October when compared to other months of year (Figure-1).

Most of the drivers were literate. Out of 33 drivers interviewed only 3 (9%) were illiterate.

Nearly 40% of drivers were drunk/or using some other substance at the time of accident.50% of

drivers were >40 years of age. 15.8% of drivers were less than 20 years of age. Most of the drivers

(51.5%) who met the accident were having driving experience of >5 years. 12.1% of drivers were

having driving experience of less than 1 year. Only 12.1% of drivers were using seat belts at the

time of incident. 57.6% were having driving license and 54.5% were either refractive error or

hearing impairment or both. Most of the respondents told that it was mistake of other drivers

which led to the accident. High speed, Lack of sleep, effect of Alcohol and mechanical fault of vehicle

were other reasons of accident as told by the drivers (Table-2). 78% of victims were brought to the

hospital with help of 108 helpline service. Rest 22 % were came either by themselves or by other

people (Figure-1).

ORIGINAL ARTICLE


Figure -1: Monthly distribution of RTI cases

Figure-2: Mode of transfer to the hospital

310

27

15 12 92

41

4 7 5

117

1 0 0 1 2 0 2 29

0 0 2

19

410

28

1712 11

4

50

4 7 7

136

0

20

40

60

80

100

120

140

160

No

of

case

s

Year- Month

Distribution of cases monthwise

Male

Female

Total

78%

15%

6%

1%

Mode of transfer to the hospital

108 helpline

Other people

self

other

ORIGINAL ARTICLE


Table-1: Clinico-epidemiological profile of RTI cases

*Human error: wrongful U-turn by other vehicle , Wrongful overtaking by un-coming vehicle

**Mechanical fault: break failure, burst tyre, and locked steering mechanism

Maximum number (47.8%) of RTI morbidity was because of polytrauma associated. And

upper limb injury was least responsible for the mortality.50% of accidents took place in the evening

Drivers interviewed Yes % age

Education(n=33)

Illiterate 03 9.1

Up to 5th std 13 39.4

5-12 th std 16 48.4

Graduate/Post graduate 01 3.1

Age(n=38,

Including the

brought dead

drivers)

<20 years 6 15.8

20-40 years 13 34.2

>40 years 19 50

Alcohol /other substance use at the time of accident( n=33) 13 39.4

Driving experience

( n=33)

<1 year 4 12.1

1-5 years 12 36.4

>5 years 17 51.5

Seat belt use( n=33) 4 12.1

Driving license( n=33) 19 57.6

Refractive error /Hearing impairment / both( n=33) 18 54.5

Cause as told by

driver( Multiple

answers could

be given)

Mistake of others/Human error*( n=33) 23 69.7

More speed 14 42.4

Lack of sleep 11 33.3

Alcohol use 09 27.3

Mechanical fault of the vehicle** 09 27.3

Others including environmental

conditions

04 12.1

ORIGINAL ARTICLE


hours. 72.7% of vehicles were older than 5 years of age. Fall from hill was the mode of accident in

most of the cases and the mortality and severe injuries were also more in fall from hillside, followed

by accident from the sides and head on collision.

Table -2: Epidemiological profile of RTI cases

DISCUSSION:

Maximum number of Morbidity because of RTI is evident in the month of December. It was

fall of a bus, from the hill side leading to higher toll in mortality and morbidity in month of

December. There is clustering of cases from the month of August to October when compared to

other months of year. “Char dham yatra” which lead to sudden increase in number of vehicles on

hillside and heavy rainy season both coincides with this period. These can be contributing factor for

such clustering of cases. Most of the drivers were literate. Out of 33 drivers interviewed only 3 (9%)

were illiterate. Substance use including drinking behavior was noticed in 39% of the drivers at the

Variable Number % age

Injury( n=136) Involved head 20 14.7

Upper limb 14 10.3

Lower limb 21 15.5

Abdomen 16 11.7

Multiple / polytrauma 65 47.8

Time of accident(N=38) 12pm -6 pm 14 36.8

6pm-9pm 19 50.0

9pm-6am 02 5.3

6am- 12 pm 03 7.9

Age of the vehicle(N=33) <5 years 09 27.3

>5 years 24 72.7

Type of

collision/accident(N=38)

Head on 04 10.5

From behind 02 5.3

From sides 07 18.4

Fall from hill 18 47.4

Other 07 18.4

ORIGINAL ARTICLE


time of accident. Experienced drivers (>5 years) met the accident in maximum number.

Overconfidence leading to recklessness can be the reasons for such happening. 77.9% drivers were

not using seat belt at the time of accident and when asked for the driving license only 42.4% could

not produce the same. 50% of drivers who met the accident were >40 years of age. In the elderly

visual impairment prevents adequate visual function, which may be responsible for the accident.

When examined, 54.5% were having either refractive error or hearing impairment or both. A study,

which examined the association between visual impairment and RTI among 1,428 drivers seen at

the accident and emergency department of a hospital in the United Arab Emirates, also identified

visual impairment to be significant risk factors7. Likewise Davidson in his examination of the

interrelationship between British drivers’ visual abilities, age and RTI histories found strongest

positive association between RTI variables and visual disabilities, among older drivers8. Most of the

respondents told that it was mistake of other drivers which led to the accident. High speed, Lack of

sleep, effect of Alcohol and mechanical fault of vehicle were other reasons of accident as told by the

drivers. Study by Asogwa et al9 showed that commercial drivers drive for hours without sleep and

food, until fatigue inevitably sets in and a crash may be the end result. Effect of alcohol or other

substances was also substantiated by Lemoineet al10. Maximum number (47.8%) of RTI morbidity

was because of polytrauma associated. And upper limb injury was least responsible for the

mortality. This is in contrast to the study by Biswas G11 who cited that the maximum (56.4%)

injuries were found on head and neck, followed by thorax (54.5%) and abdomen (44.5%). Other

studies12,13 also showed a high incidence of head injuries in their studies. 50% of accidents took

place in the evening hours. Fall from hill was the mode of accident in most of the cases and the

mortality and severe injuries were also maximum in such mode of accident followed by accident

from the sides and head on collision.

CONCLUSION:

During “Char Dham Yatra” period and rainy seasons there is clustering of cases. Special

efforts should be done during this period. Strong vigilance of drivers for alcohol use, presence of

driving license, compulsory use of seat belts, premedical checkup for refractive errors, must be

ensured. The role of 108 helpline14 cannot be ruled out and strengthening of this service can be of

paramount importance. All These measures may prove valuable and morbidity and mortality can be

minimized.

ACKNOWLEDGEMENT:

The author acknowledges medical social workers of department of community medicine,

Veer Chandra singh Garhwali govt. medical college, Srinagar, Garhwal for their work and support in

the study. The author also acknowledges the respondents who formed the building blocks for the

study.

REFERENCES:

1. Astrom, J. S, Kent, M.P. and Jovin, R. D. (2006) Signatures of Four Generations of Road Safety

Planning in Nairobi City, Kenya In: Journal of Eastern African Research and Development.

Vo. l20, pp. 186-201.

ORIGINAL ARTICLE


2. Peden, M. (Ed), (2004), World Report on Road Traffic Injury Prevention. World Health

Organisation, Geneva.

3. Odero, W., Garner, P. and Zwi, A. (1997). Road traffic injuries in the developing countries: a

comprehensive review of epidemiological studies. Journal of Tropical Medicine and

International Health. 2(5), 445-460.

4. Leon, S.R. (1996).Reducing death on the Road.The effects of minimum safety standards,

Unpublicised crash test, seat belts and alcohol. Am J Public Health; 86(1):31-3.

5. Road Accidents in India, 2009. Transport Research Wing, Ministry of Road Transport &

Highways, Government Of India, New Delhi.

6. Jorgensen, S. H., and Abane, A. M. (1999). A comparative study of urban traffic accidents in

developing and developed countries: Empirical observations and problems from Trondheim

(Norway) and Accra (Ghana). Bulletin of Ghana Geographical Association. No. 21, 113-128.

7. Bener A, Ahmad MF, El-Tawil MS, Al- Bakre S. Visual impairment and motor vehicle

accident. Middle East Journal of Emergency Medicine. 2004; 4: 1-9

8. Davidson PA. Inter-relationships between British drivers’ visual abilities, age and road

accident histories. Opthalmic and Physiological Optics. 1985; 5:195-204.

9. Asogwa SE. Kola nut and road traffic accidents in Nigeria. American Journal of Public Health.

1978; 68:1228.

10. Lemoine P, Ohayon M. Abuse of psychotropic drugs during driving. Encephale. 1996; 22:1-6.

11. Biswas G, Verma SK, Sharma JJ, Aggarwal NK. Pattern of Road Traffic Accidents in North

East Delhi. Journal of Forensic Medicine & Toxicology.2003; 20(1):27-32.

12. Sahdev P, Laeque MD, Singh B and Dogra TD. Road Traffic Accidents in Delhi, causes, injury

pattern and incidence of preventable deaths. Accid Anal Prev 1994; 26:12-18.

13. Salgado MSL, Colombage SM. Analysis of fatalities in road accidents. For Sci Int .1998;

36:91-96.

14. In Uttarakhand, Emergency helpline Number “108″ to tackle disaster calls, complaints.

Available at http://www.indiahillstoday.com/2010/10/12/in-uttarakhand-emergency-

helpline-number-108-to-tackle-disaster-calls-complaints/

ORIGINAL ARTICLE


A STUDY ON EVALUATION OF APPROPRIATE USAGE OF FRESH FROZEN

PLASMA (FFP)

Dr. V. Geeta, Dr. I. Srilakshmi, Dr. A. Krishnayya, Dr. Lakshmi, Dr. Poornima, Dr. O. Shravan Kumar,

Dr. P. Jijiya Bai




4. Blood bank Medical Officer, Gandhi Medical College, Secunderabad, AP.

5. Post Graduate Student, Department of Pathology, Gandhi Medical College, Secunderabad, AP.

6. Professor & HOD, Department of Pathology, Gandhi Medical College, Secunderabad, AP.

CORRESPONDING AUTHOR-

Dr. V. Geeta,




Secunderabad, AP.


ABSTRACT:

The term FFP refers to the fluid portion of 1 unit of human blood that has been centrifuged,

separated & frozen solid at -18°C or colder within 8hrs of collection. The indications for transfusing

FFP are very limited, as it can cause unpredictable adverse reactions. A retrospective study of FFP

transfusion was carried out at the blood bank-Gandhi Medical College for a period of 6 months; i.e

January 2011–July 2011 for various indications. We evaluated 840 patients who received 1534

units of FFP and classified them as appropriate, clinically appropriate and inappropriate. In our

study appropriate and clinically appropriate transfusions of FFP were about 61%- a good

proportion of FFP transfusions were justified but 39% were of without any appropriate indication.

KEY WORDS: Fresh Frozen Plasma, Centrifugation, Adverse Reactions

INTRODUCTION:

The use of FFP has increased due to multiple factors, possibly increased acceptance of the

concept of component therapy.FFP contains the labile as well as stable components of the

coagulation , fibrinolytic & complement system; the proteins(that maintain oncotic pressure &

modulate immunity) and fats, carbohydrates & minerals are present in concentrations similar to

those in circulation. The most labile coagulation factors are preserved for 1 yr if FFP is kept at -30°

C or below. The FFP should be administered as soon as possible after thawing & in any event within

12 hrs if kept at 2-6°C.

ORIGINAL ARTICLE


Contents of 1 unit of FFP prepared from 450ml of whole blood

Plasma : 175-230ml

All Coagulation Factors : 1 i.u/ml of each factor including factors V

& VIII)

Fibrinogen : 200-400 mgm

INDICATIONS OF FFP:

� Active bleeding,

� Liver diseases

� Disseminated intravascular coagulation (DIC)

� Thrombotic Thrombocytopenic Purpura (TTP)

� Coagulopathy in massive transfusion

� Familial Factor V deficiency

� Deficiency of Factors II, VII, IX, X

� Antithrombin III deficiency

� Congenital or Acquired coagulation factor deficiency1

DOSAGE OF FFP:

About 10ml/Kg body wt. Post transfusion assessment of levels of APTT, PT & fibrinogen is

done for monitoring the effect of FFP2. Plasma should be ABO compatible with the recipient blood.

AIMS & OBJECTIVES:

Evaluation of appropriate usage of FFP in a period of 6 months (January 2011- June 2011)

in Gandhi Hospital.

MATERIALS & METHOD:

A Retrospective study was conducted at Gandhi Hospital Blood bank for a period of

6months (January 2011-june 2011). We evaluated 840 patients, who received 1534 units of FFP &

classified them as 1.Appropriate; 2.Inappropriate; 3. Clinically appropriate.

Table: 1- SEX RATIO (M: F ratio- 1:1.5)

SEX MALE FEMALE TOTAL

No. of patients 382 458 840

% 45.5% 54.5% 100%

Table: 2- AGE GROUP

AGE

GROUP

JAN FEB MARCH APRIL MAY JUNE TOTAL JAN

0-20 33 35 36 34 28 56 222 26.7%

21-40 71 44 49 68 74 91 397 21-40

41-60&

ABOVE

31 39 30 25 24 62 211 31

ORIGINAL ARTICLE


Table: 3- Guidelines-British Committee for Standard Hematology3

SNO CLINICAL

CONDITIONS

TOTAL

REQUIREMENT

APPROPRI

ATE

CLINICALY

APPROPRIATE

INAPPROP

RIATE

%

1. Liver Diseases 152 ---- 152 ---- 18%

2. DIC 84 ---- 84 ---- 10%

3. Hemophilia 168 168 ---- ---- 20%

4. Sepsis + Burns 168 60 ---- 108 20%

5. Cardiac

surgeries

168 ---- ---- 168 20%

6. Snakebite 80 50 ---- 30 9.5%

7. Others 20 ---- ---- ---- 2.5%

8. Total 840 278 236 306

Table: 4- Total patients-840 ; Total units-1534

BLOOD

GROUP

O+ve B+ve AB+ve A+ve O-ve A-ve B-ve AB-ve

No. of

Patients

338 227 48 168 13 6 20 2

Percentage 40.9

%

27.3

%

5.9% 20% 1.7% 0.9% 2.8% 0.5%

RESULTS:

• Total patients who received FFP are 840, out of which males were 382 and females we 558

(table:1)

• Age group ranging from 0-20 years constitute 26.4%; 21-40 years 47.2%; 41-60 years

26.2% (table:2)

• Depending upon the conditions patients received FFP have been divided into 8 groups

according to the guidelines provided by British Committee for Standard Hematology3

(table:3)

• Out of 840 patients, conditions like liver diseases, disseminated intravascular coagulation

are clinically appropriate (where there is active bleeding leading to coagulopathy) and

hemophilia, sepsis, burns, rheumatic heart diseases, snake bite and shock are considered to

be appropriate (the term appropriate is limited to the treatment of coagulation protein

deficiency, for which specific factor concentrates are un available or undesirable)-(table:3)

• No.of units of FFP transfused are 1534 in six months period. Of this 40.9% are transfused to

O positive blood group (table: 4).

DISCUSSION:

� FFP is efficacious for treatment of Deficiencies of factors II, V, VII, IX, X & XI.

� Reversal of warfarin effects: Patients who are anticoagulated with warfarin are deficient in

functional vitamin K dependent coagulation factors II, VII, IX, X as well as protein C & S. FFP

can be used to achieve immediate hemostasis.

ORIGINAL ARTICLE


� Massive Blood Transfusion: In patients with documented blood clotting abnormalities,

prolonged APTT, INR after huge blood loss requiring 4 or more units of packed red cells-

FFP is commonly recommended.

� FFP can be used as a source of Antithrombin III in patients who are deficient of this

inhibitor & undergoing surgery or who require heparin for the treatment of thrombosis.

� FFP useful in infants with secondary immunodeficiency associated with severe protein

losing enteropathy, FFP can be used as a source of immunoglobulin for children & adults

with human immunodeficiency.

� FFP is used in treatment of Thrombotic thrombocytopenic purpura.

ASSOSIATED RISKS:

• Anaphylactoid reactions

• Alloimmunisation

• Transfusion related acute lung injury (TRALI): antibodies against the patients granulocytes

may cause leucocyte aggregation in pulmonary vessels leading to TRALI4

• Increase in infections

• Excess usage-Hypervolemia & cardiac failure (The guidelines set by British Committee for

Standard Hematology was followed in our study). 3

Approximately 60% FFP used are inappropriate according to Kakkar et al 5, but clinically

apparent cases like liver diseases, coronary bypass surgeries reduced the inappropriate usage to

28%. Severe liver disease6, 7, 8 is one of the most common clinical indications for transfusion of FFP.

Patients with liver diseases have several abnormalities that can lead to bleeding like coagulopathy,

Disseminated Intravascular Coagulation (DIC), Thrombosis. According to Consten et al9 & LA

Harker et al10 in cardiac surgery 11 post operative bleeding due to residual effects of heparin may be

corrected with transfusion of FFP.

CONCLUSION:

In our study appropriate & clinically appropriate transfusions of FFP were about 61%. It is

desirable that educational programmes be arranged for doctors regarding appropriate usage of

FFP.

Blood bank associations & Hematologists should more firmly adhere to the guidelines.

In our institution 61%, a good proportion of FFP transfusions were justified and 39% were

used without any appropriate indications.

ACKNOWLEDGEMENT:

I extend my special thanks to all the technical staff off blood bank and the personnel of

record room of Gandhi Hospital for helping me in collecting the necessary data.

REFERENCES:

1. NIH consensus conference: Fresh frozen plasma: indications and risk JAMA1985; 253:551-

3.

2. Snyder AJ, Gotschall JL and Menitove JE. Why is fresh frozen plasma transfused?

Transfusion1986; 26:107-12.

ORIGINAL ARTICLE


3. British Committee for standards in Hematology, blood transfusion Task force. Guidelines for

the use of Fresh frozen plasma, cryoprecipitate and cryo supernatant.TransfusionMed1992;

2:57-63.

4. Nordhagen R, Conradi M, Dromtort SM. Pulmonary reaction associated with transfusion of

plasma containing anti-Vb. VOXSANG. 1986; 5:`102-8 (Pubmed)

5. Kakkar N, Kaur R and Dhanoa J. Improvement in fresh frozen plasma transfusion practice:

results of an outcome audit. Transfus Med 2004; 14231-5.

6. Schofield WN, Rubin GL and Dean MG. Appropriateness of platelet, fresh frozen plasma and

cryoprecipitate transfusion in New South Wales public hospital. Med J Aust 2003; 178:117-

21.

7. Spector I, Corn M and Ticktin HE. Effect of plasma transfusion on the prothrombin time and

clotting factors in liver disease. Eng J Med 1966; 275: 1032-7.

8. Mannucci PM, Franchi F, Dioguardi N. Correction of abnormal coagulation in chronic liver

disease by combined use of fresh frozen plasma and prothrombin complex concentrates.

Lancet 1976; 2: 542-5.

9. Consten E, Henny CP, Eijsman L, Donglemant DA, Van Oers MH. The routine use of fresh

frozen plasma in operations with coronary bypass surgery is not justified. J thorac

Cardiovasc Surg 1996; 112:162-7.

10. LA Harker, TW Malpass, HE Branson, EA 2d Hessel and SJ Slichter. Mechanism of abnormal

bleeding in patients undergoing coronary bypass surgeries. Acquired transient platelet

dysfunction associated with selective Alpha granule release. Blood 1980; 56: 824-34.

11. Wilhelmi M, Franke U, Cohmert T, Weber P, Kaukemuller J, Fisher S, et al. Coronary artery

by pass grafting surgery with out the routine application of blood products: Is it feasible?

Eur J Cardiothorac Surg 2001; 19: 657-61

CASE REPORT


Page 96

PALATAL PLEOMORPHIC ADENOMA WITH FLORID SQUAMOUS METAPLASIA: A

POTENTIAL DIAGNOSTIC PITFALL

Abdul Hakeem Attar, Mandakini B. T, Azhar Fatima



3. Lecturer, Unanai College


Dr Abdul Hakeem Attar,

C/o Abdul Azeem Attar,

Shameem Masala,

Attar Gazar, Gulbarga.


ABSTRACT:

Pleomorphic adenoma is the most common benign tumor occurring in the major

and minor salivary glands. We report a case of pleomorphic adenoma with extensive

squamous metaplasia in the palate of a 20 year old man. The dimensions of the tumor were

3x2x2cm. More than 75% 0f the epithelial element in the tumor was composed of sheets of

squamous cells, with multiple keratin filled cysts. This case illustrates that pleomorphic

adenoma with squamous metaplasia presents a potential for misinterpretation as

mucoepidermoid carcinoma and squamous cell carcinoma. We discuss the various pitfalls

and the features that are helpful in distinguishing between these lesions.

KEY WORDS: Pleomorphic adenoma, Squamous metaplasia

INTRODUCTION:

Pleomorphic adenoma is the most common benign tumor occurring in the major or

minor salivary glands. [1] The tumor is characterized by epithelial and modified

myoepithelial elements intermingled with tissue of mucoid, myxoid or chondroid

appearance. It has a wide spectrum of morphological patterns, [2] squamous cells, oncocytes,

sebaceous cells, bone, adipose tissue and crystalline materials can be found in the tumor.

We report a benign salivary gland tumor with a predominant and extensive squamous

component. The features are those of a pleomorphic adenoma with florid squamous

metaplasia. This case illustrates the difficulty of making a correct diagnosis in the initial

tissue specimen and we discuss the diagnostic pitfalls of this pathological entity.

CASE PRESENTATION (CLINICAL DETAILS):

A 20 year old patient presented with complaint of swelling in the oral cavity since

two years. The swelling was painless and progressively increasing in size .Physical

examination showed a firm nodule of 4x4cm in diameter on the left side of the hard palate

and anterior part of soft palate.

CASE REPORT


Page 97

CYTOLOGICAL FINDINGS:

Fine needle aspiration was done and demonstrated some clusters of squamous cells,

with some of the cells showing keratinizing cytoplasm .Also seen some clusters of cells with

features suggestive of glandular differentiation .Differential diagnosis of well differentiated

squamous cell carcinoma & pleomorphic adenoma was made .

GROSS / HISTOPATHOLOGICAL FINDINGS:

Surgical resection was done. Gross specimen comprised of well circumscribed, well

encapsulated mass, grey white in color and measured 3x3x2cm .No cystic area, hemorrhage

or necrosis was seen .Histological examination showed a well encapsulated tumor more

than 75% of epithelial element in the tumor was composed of squamous cells with multiple

keratin filled cysts. The rest of areas showed features of conventional pleomorphic

adenoma.

DISCUSSION:

Histological diversity is the hallmark of pleomorphic adenoma. [3] Histological

patterns vary considerably between different parts of same tumor. [3] Focal squamous

metaplasia is found in about 25% of pleomorphic adenoma. Rarely focal squamous

metaplasia is reported. [4] Squamous metaplasia is commonly associated with repair

following infarction and necrosis of the salivary gland. In the present case necrosis was not

seen and squamous cells were detected in FNA biopsy as well as in the resection specimen.

squamous metaplasia has been noted in non-neoplastic entities like chronic sialadenitis,

necrotizing sialometaplasia, lymphothelial cysts occurring in the vicinity of salivary gland .

Potential for misdiagnosis of pleomorphic adenoma as mucoepidermoid carcinoma and

squamous cell carcinoma have been reported. In our case also the features misinterpreted

as mucoepidermoid & squamous cell carcinoma. To avoid misinterpretation of pleomorphic

adenoma with squamous metaplasia as mucoepidermoid carcinoma on cytology, a close

scrutiny for fragments of chondromyxoid stroma – a characteristic feature for pleomorphic

adenoma. In our case also on reviewing the slides again after histological diagnosis we could

find occasional tiny fragments of stroma . Also keratinization especially of the extracellular

type is rare in mucoepidermoid carcinoma. How ever even if the features diagnostic of

pleomorphic adenoma are identified, the differential diagnosis may still includes a

mucoepidermoid carcinoma arising in a preexisting pleomorphic adenoma.

CONCLUSION:

We have reported a case of palatal pleomorphic adenoma with florid squamous

metaplasia and with potential pitfalls in the diagnosis.

ACKNOWLEDGEMENT:

The work was indeed a mammoth task to accomplish and would not have been

possible without active co-operation, constant strategic support and encouragement by our

CASE REPORT


Page 98

beloved – PRESIDENT- (Khaja Bandanawaz Institute of Medical Sciences)—DR.SYED SHAH

KHUSRO HUSSAINI.

REFERENCES:

1. Spiro RH. Salivary neoplasms : overview . Head Neck Surg 1986; 8 :177-84

2. Waldron CA. Mixed Tumor ( pleomorphic adenoma ) and myoepithelioma. In : Ellis

GL, Auclair PL, Gnepp PR. Eds . Surgical pathology of salivary glands. Philadelphia :

Saunders , 1999; 165-86

3. Das DK. Anim JT. Pleomorphic adenoma of salivary glands. Cytopathology 2005 : 16:

65-70

4. Lam KY, Ng IOL, Chan GSW. Palatal pleomorphic adenoma with florid squamous

metalasia . J Oral Pathol Med. 1998; 27: 407-10.

CASE REPORT


Page 99

Fig 1- Photograph showing swelling in the palate

Fig 2- Gross photograph showing well circumscribed tumor

CASE REPORT


Page 100

Fig 3- Photomicrograph showing squamous cells with keratin pearls. (H&E, 400X)

CASE REPORT


Page 101

Fig 4- Photomicrograph showing conventional pleomorphic adenoma (H&E, 400X)

CASE REPORT


CUTANEOUS NECROTISING VASCULITIS – THERAPEUTIC FACT-A CASE

REPORT



Kerala.



Dr. Kiran D R.,






ABSTRACT: INTRODUCTION: Mixed connective tissue disorder, unlike other connective tissue

disorders have a milder course. MTCD with only necrotizing cutaneous vasculitis without organ

damage respond well to Immunosuppresents and Steroids. CASE REPORT: Middle aged Young

lady presented with multiple non healing large pressure sores and multiple nonblanchable

purpuric lesions. She was bedridden, anaemic and with significant weight loss. All her major

organ functions were normal. Her U1 RNP Antibody is positive and Skin Biopsy showed

positive direct fluorescent test for IgG. She responded well to immunosuppresants and steroids.

CONCLUSION: This patient who presented with MTCD, with predominant necrotizing

cutaneous vasculitis and without major organ involvement showed good recovery and

responded well to cyclophosphamide pulse therapy, daily azathioprine and good wound care.

KEY WORDS: Necrotising Vasculitis, MCTD, U1 RNP Antibody, Immunosuppresants

INTRODUCTION:

Vasculitis is not a disease but rather a disease process (from Merck manual).Here we

came across a MCTD with predominant necrotizing vasculitis involving only skin .This is been

reported so as to stress the fact that MTCD , unlike other connective tissue disorders has milder

course and necrotizing vasculitis confined to skin do well with immunosuppresives, steroids

and good wound care 5.

CASE REPORT:

Female patient aged 34 year old, presented with weight loss( more than 10%), lethargy

and multiple non healing open ulcers associated with necrotic base over pressure bearing areas

predominantly confined to extensor areas of limbs of one year duration. She had intermittent,

moderate grade fever without cough and rashes. She was bed ridden due to sever nonhealing

disabling ulcers over the pressure bearing areas and joint contractures.

On examination, Patient is thin built and poorly nourished.

Multiple non blanchable purpuric lesions, multiple depigmented lesions on face and loss of scalp

hair.

Pallor present, Febrile, Tachycardia present.

Systemic examination– Normal.

CASE REPORT


Investigations: Hb 6gm/dl, WBC -8200, Eosinophils increased, Platelet count- 80,000, ESR-110,

CRP elevated,

LFT and RENAL FUNCTION: Normal

Urine Routine: Normal, No albumin or microscopic Haematuria

ECG: WNL

Echo: No pericardial fluid, EF – 60%, Normal Function.

PFT: Normal curve, No features of interstitial pattern.

Chest X Ray: CP angles free and normal, lung parenchyma normal, No Infiltrates.

USG Abdomen: NO Organomegaly, pelvis normal.

Stool examination: No occult blood.

CT brain: Normal study.

NCS: Normal.

Ophthalmological Examination: Visual Aquity-6/6, Fundus –Normal.

ANA positive, RA Factor negative

ANCA negative, U1 RNP Antibody positive,

Skin Biopsy – direct fluorescent test positive for IgG, Complements were normal ,

HIV 1&2 negative, Hepatitis B & C Negative.

Diagnosis of MCTD was made with above findings.

TREATMENT GIVEN:

Patient was started with steroids, monthly pulse therapy of Cyclophosphamide and daily

2mg of Azathioprine. Other general conditions maintained with blood transfusion and

supportive care. Wounds were been taken care of by debridement and allowed them to go for

healing by secondary intention. Some of the wounds healed in one setting, but others required

2-3 attempts. Finally in six months duration all wounds healed well and now patient is

ambulatory, self dependant with only Azathioprine daily.

ACKNOWLEDGEMENT:



It gives pleasure to express my sense of gratitude to my professor Dr Palaniswamy for

his guidance, encouragement and constant source of inspiration during case management.


DISCUSSION:

MCTD also known as Sharp’s syndrome an undifferentiated connective tissue disease.

MCTD a combined feature of scleroderma, myositis, SLE and Rheumatoid Arthritis (with some

source adding polymyositis, dermatomyositis and inclusion body myositis) and is thus

considered as overlap syndrome. MCTD commonly causes joint swelling, malaise, Raynaud’s

phenomenon, Sjogren’s syndrome, muscle inflammation and sclerodactyly. Distinguishing lab

characteristics are positive speckled ANA and an anti U1RNP antibody. It is associated with HLA

DR-41.

Vasculitis induced injury to blood vessel may lead to increased vascular permeability,

vessel weakening that cause aneurysm formation, haemorrhage and intimal proliferation,

thrombosis that result in obstruction and local ischemia2. It is critical to distinguish vasculitis

occurring as a primary autoimmune disorder from vasculitis secondary to infection, drugs,

malignancy or connective tissue disease such as SLE/ RA. Much of the diagnostic work up in a

CASE REPORT


patient with suspected vasculitis is directed at excluding secondary causes that can mimic

vasculitis3.

Immunoglobulin finding may be helpful in diagnosing MTCD. Indirect Immuno

fluroscent test – Presence high titre of IgG against U1RNP as the only autoantibody support

MTCD. The fluroscent auto nuclear antibody test typically reveals a speckled pattern of staining

on HEP-2 substrate. Recent studies revealed that antibody directed to an appropriate specific

epitop on 70 kd are specifically associated with MTCD than other anti 70 k antibody. Direct

Immuno fluroscent test- Performed on lesional skin of patients with MTCD, this may reveal

epidermal nuclear IgG staining. The staining is thought to be related to high titres U1RNP

antibody in the patient seen. In some cases Lupus Band test may be positive (linear deposition

of Ig, Fibrin and/or compliment components present at the basement membrane) 4.

Treatment option includes corticosteroids, Immunosuppressive drugs to reduce the

inflammation. Cyclophosphamide may be in severe vasculitis. Dramatic remission seen in

patient with alternate day corticosteroid treatment with continuation of cyclophosphamide.

Later corticosteroid was discontinued. Mean duration of remission was 22 months. No patient

showed recurrence of disease during treatment with cytotoxic agents5. IV cyclophosphamide is

better than oral and recommended at least six months. Substitution of Azathioprine after

remission with cyclophosphamide did not increase the rate of relapse.

Newer treatment approach includes deoxysperagualin, achieved a high rate of disease

remission and permitted prednisolone reduction. Other newer Immunosuppresives are

Leflunamide, TNF antagonists – Infliximab and ENBREL. Colchicine not that much effective in

skin va sculitis, but some showed improvement. Development of plasma exchange including

semi specific immunoabsorption with L-tryptophan or Protein A columns to remove ANCA

without depletion of non Ig plasma proteins and appear of comparable efficacy to plasma

exchange6.

CONCLUSION:

MCTD, although called as overlap syndrome, here we came across MCTD without major

organ involvement, without associated other connective tissue diseases. Predominant

presentation was confined to skin as necrotizing cutaneous vasculitis. The disease here showed

a chronic disabling course which provided enough time to treat with Pulse cyclophosphamide

therapy, daily Azathioprine and good wound care. MCTD without predominant organ

dysfunction and confined to skin manifestation as a good prognosis with regular treatment than

the systemic vasculitis or MCTD with other connective diseases, which has mixed results to the

regular treatment.

REFERENCES:

1 Aringer M, Steiner G, Smolen JS (Aug-03). “Does MCTD exist? Yes.” Rheumatic disease clinical

North America. 31(3): 411-29.

2 Mandell BF, Hoffman G.S. Differrentiating the Vasculitis. Rheumatic disease clinical North

America (1994); 20:409-42.

3 Hunder G. Vasculitis Diagnosis and therapy. Am. J Med: 1996; 100(22):375-455

4 H Ihn, K Yamane, N Yazawa, M Kuba, M Fujimoto, S Sato, K Kikuchi and K Tamaki; Distribution

of antigen specificity of Anti U1RNP antibody in patient with systemic sclerosis. Clinical

Experimental Immunology(1999)117(2);383-387.

5 FauciAS,Katz P,Haynes BF, Wolf SM:Cyclophosphamide therapy for sever necrotizing

vasculitis(1979) vol 301:235- 238.

CASE REPORT


6 Jayne D (2000)Evidence based treatment of systemic vasculitis. Rheumatology(Oxford)

39:585-595.

ABBREVIATIONS:

MCTD: Mixed Connective Tissue Disease

HLA: Human Leucocyte Antigen

SLE: Systemic Lupus Erythematosis

RA: Rheumatoid Arthritis

RNP: Ribosomal Neucleo Protein

ANA: Anti Nuclear Antibody

ANCA: Anti Nuclear Cytoplasmic Antibody

Post Treatment- Healed cutaneous Vasculitis on face, Post Healed Hypopigmented Lesion

CASE REPORT


PLASMA CELL LEUKEMIA- LIGHT CHAIN SECRETORY TYPE, WITH

PRIMARY AMYLOIDOSIS



Kerala.



Dr. Kiran D R.,






ABSTRACT:

INTRODUCTION: Secondary PCL (Plasma Cell Leukemia), arising from multiple myeloma is

aggressive and rare variant of multiple myeloma. It is known that AL (Amyloid Light Chain)

type of Amyloidosis is primary amyloidosis occurring in multiple myeloma. Attempt to report

this case of secondary PCL of light chain secretory type with primary amyloidosis. Emphasis

given to this report is so as to highlight the helpful prognostic tools in this rare variety.

CASE REPORT: 60 year old female presenting with Hepatosplenomegaly, severe anemia,

bleeding manifestations and fever. She had pancytopenia with ESR of 170. Peripheral smear

showed plenty of plasma cells >20% and bone marrow biopsy showed mature to immature

plasma cells, plenty in number. Skull X ray showing multiple punched out lesions.

Electrophoresis was normal, abdominal wall fat stained positive for Congo Red and Serum Free

Light Chain Assay was positive. Diagnosed as PCL of light chain secretory type. CONCLUSION:

PCL itself, high plasma cell labeling index, increased LDH, increased serum

β2microglobulin,renal indices like increased serum creatinine, organomegaly, non secretory

variety-all carry bad prognostic signs.

KEY WORDS: PCL, Primary Amyloidosis, Light chain, Punched out bone lesions

INTRODUCTION:

It is known that incidence of PCL is <1 / million cases and 2% of multiple myeloma1. It is

an aggressive and rare presentation of multiple myeloma2. It has features of acute leukemia and

multiple myeloma.PCL usually arises from myeloma having IgD or IgE as M component. PCL,

arising from pre existing multiple myeloma of light chain secretory type associated with AL

(Amyloid Light chain) type of Amyloidosis is very rare. Since there are no large trials on

treatment of patients with PCL, we here make an attempt report this case.

CASE REPORT:

A 60 years old female patient presented with history of fever and epistaxis of one month

duration. On examination she was Febrile, having tachycardia and pallor. She had no

generalized lymphadenopathy but had moderate Hepatosplenomegaly. She had sternal

tenderness.

CASE REPORT


INVESTIGATIONS:

WBC count – 1, 22,000

Hb-2.8mg/dl

Platelet count – 80,000

ESR- 170

Renal and Liver function tests are normal

Serum calcium: 12 mg/dl

Serum uric acid: normal

Serum LDH: 310u/L

Serum β2 microglobulin: 3.1mg/L

Serum Electrophoresis showed no M band

Serum Free Light Chain Assay: detected

Urine Bence Jones protein: Negative

Peripheral Smear Report: RBC showed hypochromia and anisocytosis. Neutrophils were

decreased in number. A large number of plasma cells were seen .Immature and abnormal

plasma cells were seen in plenty. A good number of binucleated plasma cells also seen.

Immature cells exceeded 20%. Platelets grossly decreased in number.

Bone Marrow Aspiration Report: Hypercellularmarrow.RBC precursors were reduced in

number and were normopoietic. Granulocytic precursors were also reduced in number. Each

field showed sheets of plasma cells. Many of the plasma cells were atypical. Some of them were

rounded, some had nuclear abnormalities and some were binucleated. A large number of

plasma blasts were also seen. Megakaryocytes were reduced in number.

Flow Cytometry of Bone Marrow Aspirate: Showed intense positivity for CD 38 and the

presence of cytoplasmic kappa light chains.

Abdominal fat stained positive for Congo Red.

Skull X-ray showed multiple punched out lesions.

Our patient was diagnosed to have primary PCL – light chain type with Primary Amyloidosis,

based on peripheral smear, bone marrow and flow cytometric analysis.

Treatment: Patient was given supportive treatment. Prednisolone and Melphelan were started.

Patient expired in two months after diagnosis.

DISCUSSION:

Plasma cell leukemia is a lymphoproliferative disorder. It is a rare monoclonal

neoplasm having B lymphocyte lineage. It is one of the aggressive human neoplasms accounting

for 2-4% of all cases of plasma cell diseases3. Rarity of PCL can be accessed from the fact that at

M.D. Anderson cancer centre, 27 patients with PCL were seen in 20 year period whereas at

Policlinico-Sanmateo in Italy, 15 cases were seen in 15 years, both representing 2-5% of total

cases of multiple myeloma seen at these centers. Incidence of PCL is less than 1 case per million

population1. Presentation may be primary, secondary – evolving from an existing case of

multiple myeloma as part of the terminal phase of the disease or denova. Sixty to seventy

percent cases are primary. PCL is of two types, Secretory and non-secretory. No M protein is

detected in the non secretory type of PCL4.

WHO criteria to diagnose PCL are - Plasma cells constitute more than 20% of cells in the

peripheral blood with an absolute plasma cell count of more than 2 X 109 / litre.

Lab findings: There is overlap between cells of multiple myeloma and Primary PCL. PCL plasma

cells more frequently express the CD 20 antigen than those of multiple myeloma and they often

CASE REPORT


lack CD 56 antigen which is present on the majority of myeloma cells. CD 56 is important in

anchoring plasma cells to bone marrow stroma and its expression is associated with poor

prognosis. CD 28 is more frequently expressed on malignant plasma cells in secondary than in

primary PCL. Acquisition of CD 28 is associated with increased proliferative rate and disease

progression. PCL is derived from terminally differentiated B cells and the malignant cells stain

positive for mature B cell markers (CD38 and PCA1, Prostate Cancer Antigen 1)5.

In 80% of PCL patients, using FISH (Flourescent In Situ Hybridisation) technique- losses in long

arm of chromosome 13 (13 Q) and deletion of one of the homologous chromosome 13

(Monosomy 13). In 80% of cases, loses on chromosome 16 also occur. Overexpression of

PRAD1/cyclinD1 (Parathyroid associated Neoplasia gene) also present (help in controlling cell

cycle). PCL is more frequent in light chain (Bence Jones’s protein) or IgD myeloma and less in

IgA or IgG myeloma. Hypercalcaemia and increased LDH are known bad prognostic signs of

disease 6. PCL is an extremely aggressive disease with no standard treatment regimen so far

due to the rarity of the disease. Median survival is 2-8 months, prognosis is very poor.

Regimens includes MP, (Melphelan, Prednisolone) VAD (Vincristine, Doxorubicin,

Dexamethasone) TD (Thalidomide, Dexamethasone) VBAP (Vincristine, Carmustine,

Adriamycin, Prednisolone) 7. Case reports regarding long time survival after autologous bone

marrow transplantation or stem cell transplantation also exists but again there is no long term

prospective data on a large number of patients. We presented this case for its rarity.

CONCLUSION:

PCL itself has aggressive course, short survival time, high plasma cell labeling index,

expression of CD 28, Cyclin, PRAD 1 indicate high proliferation. Lytic bone lesion is more

common in multiple myeloma than PCL. Biochemical parameters like increased serum

creatinine, LDH, Serum β2microglobulin and calcium have poor prognosis. Amyloidosis

associated multiple myeloma indicate tumor burden. Non secretory variety has got bad

prognosis. So above mentioned prognostic tools may help to judge the severity of the tumour

burden in a PCL case and act accordingly

ABBREVIATIONS:

PCL: Plasma Cell Leukemia

LDH: Lactate Dehydrogenase

CD: Cluster Differentiating

AL: Amyloid Light

ACKNOWLEDGEMENT:



It gives me pleasure to express my sense of gratitude to my Professor Dr Palaniswamy,

for their guidance, encouragement and constant source of inspiration during case management.


CASE REPORT


Skull X Ray PA view- Showing punched out lesions

Skull X Ray Lateral view- Showing punched out lesions

REFERENCES:

1. Kosma MA, Gale RP. Plasma Cell Leukemia.SeminHaematology 1987.24; 202-8

2. DimopoulasMA,PalumboA,DelasalleKB,AlexanianR.Primary Plasma Cell leikamia.Br

Journal Hematol 1994;88;754-9.

3. Chan SM, George T, Cherry AM,Medeiras BC(2009) Complete remission of primary PCL

Bortezomito, Doxorubicin and Dexamethasone; a case report; cases 12: 1186/1757-

1626-2.

4. ShindoT,Yumoto Y, Yoshida M, Okuda T; Non Secretory Primary Plasma Cell Leukemia

successfully treated with VAD and MP therapy.RhinshoKetsueki; 2002;43; 107-11

5. Badhe BA, Basu D, Toe P Ch,Dutta TK, Ghotekar LH; Plasma Cell Leukemia; a case report.

Indian Journal Pathology Microbiology 2003; 46; 484-7.

6. Voutsadakis IA; Plasma Cell Leukemia. Hama 2000; 3:82-9.

7. Suzuki M, Kawauchi K, Sugiyama H, Yasuyama M, Watanabe H. Primary Plasma Cell

Leukemia; a case report of successful responder to a combination of Vincristine,

Doxorubicin and Dexamethasone. ActaHematol 1989; 82:95-7.

ORIGINAL ARTICLE


ANTI-CONVULSANT ACTIVITY OF GANAXOLONE ALONE AND IN

COMPARISON WITH STANDARD ANTI-EPILEPTIC DRUGS IN

RODENT MODELS

Mr. S.K. Subhani Basha, Dr .B. L. Kudagi, Dr. R. Pravin Kumar

1. Tutor, Department of Pharmacology, Narayana Medical College, Nellore.

2. Professor & H.O.D., Department of Pharmacology, Narayana Medical College, Nellore.

3. PG Student, Department of Pharmacology, Narayana Medical College, Nellore.


Dr .B. L. Kudagi,

Professor & H.O.D.,

Department of Pharmacology,

Narayana Medical College,

Nellore.


ABSTRACT:

BACKGROUND: Presently, treatment of epilepsy with standard anti-epileptic drugs is

associated with a number of shortcomings inviting us to study newer agents that would

overcome these problems or search for the drugs or substances, which would enhance the

efficacy or reduce the dose or toxicity of these standard anti-epileptic drugs. Ganaxolone

(GNX) (3α-hydroxy-3β-methyl-5α-pregnan-20-one), a synthetic analog of the endogenous

neurosteroid allopregnanolone and a positive allosteric modulator of GABAA receptors, may

represent a new treatment approach for epilepsy. AIM: To evaluate the effect of Ganaxolone

on maximal electroshock (MES) induced and Pentylenetetrazol (PTZ) induced convulsions

and also their effect in combination with conventional antiepileptic drugs (CAEDs).

MATERIAL AND METHODS: Wister strain albino rats weighing 200-250 gm were used.

Effects of Ganaxolone (5 &10 mg/kg) alone and in combination with standard drugs were

studied in MES and PTZ induced seizure models. Abolition of tonic hind limb extension was

an index of anticonvulsant activity in MES, while for PTZ seizures; failure to observe clonus

for 5sec duration for 30min was the index. Following that, percentage inhibition was

calculated. STATISTICS: ANOVA followed by Newman-Keuls Multiple Comparison Test was

used for analysis of data between the groups. RESULTS: In MES seizures, significant anti-

epileptic activity was observed with 10mg of Ganaxolone compared to control group but

has less activity when compared to that of Phenobarbitone. In PTZ induced convulsions, the

anti-epileptic effect of Sodium Valproate was higher than Ganaxolone, but both were

statistically significant as compared to control. In PTZ-induced seizures, augmented effects

were obtained when Ganaxolone was combined with sodium valproate i.e. 55%.

CONCLUSIONS: The results provide a lead for potential benefit of adding Ganaxolone to

Sodium Valproate in the treatment of epilepsy, which needs to be explored further.

KEYWORDS: Seizures, Ganaxolone, Phenobarbitone, Sodium Valproate, Pentylenetetrazol,

Hydoxypropyl-β-Cyclodextrin, GABA.